Antibiotic guidelines

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Antibiotic guidelines

• Tony Elston
• Consultant Microbiologist

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Group 1

• 7 ways in which antibiotics are different

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Group 2

• The prescribing of antibiotics is the single
  most abused privilege that doctors enjoy. Doctors
  know little if anything about the scientific
  rationale for antibiotic prescribing yet have the
  arrogance to prescribe freely without a hint of a
  definite diagnosis and without consideration of
  the consequences
• ( Scott, 1997 ).

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Group 3

• Antibiotic policies are written for the failure
  of the educational process (Scott 1997 )

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Group 4

• When and how to prescribe in Colchester

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Group 5

• General bar/coffee shop/pick up joint chat to
  non-medic about antibiotics

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7 ways in which antibiotics are different

• Have a go !

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7 differences

• Most people take at some time
• Efficacy determined by previous population use
• Patients expectations
• Resistance is inevitable
• Veterinary use
• Growth promoter use
• Our efforts may be hindered by other countries

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Principles of infection

• Balance between organisms and host
• Host factors
• Non-specific
• Specific
• Pathogenic factors

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Host factors

• Non-specific
• Physical
• Chemical
• Cellular
• Specific
• Antibodies
• Complement
• Cellular

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Pathogen factors

• Adhesion
• Capsule
• Toxins

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Why infection ?

• Normal
• a balance
• Chaos theory
• Effects of inflammation
• Cytokines, swelling, spread
• Cascade
• Self perpetuating

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Where are antibiotics used?

• 50 man, 50 animals
• 50,000,000 prescriptions/year
• Hospitals vs community
• Up to 2 fold variation between districts

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Why worry ?

• Abs have allowed huge advances
• Better outcomes
• Abs select for resistance
• Resistant bacteria spread
• Resistance leads to clinical problems
• Costs

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The antimicrobial tug of war

• Clinical judgement vs guidelines
• Expectations vs reassurance
• Termination
• Prescription of an Ab should be seen as a serious
  step, similar to the prescription of steroids ..

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Dont keep taking the tablets

• How long ?
• How much ?

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Better prescribing

• Stop unnecessary use
• Shorten courses
• Avoid inappropriate broad spectrum use
• Avoid repeat prescriptions without evidence
• Avoid telephone prescribing
• Faster diagnosis

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Promoting better prescribing

• Evidence based guidelines
• Computer assisted prescribing
• Swifter diagnosis
• NICE guidelines
• Prescribing of antibiotics for self-limiting
  respiratory tract infections in adults and
  children in primary care
• http//guidance.nice.org.uk/CG69

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Educating public

• Antimicrobials cure serious diseases- not colds,
  coughs and sneezes
• Cherish your flora

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Resistance

• The battle between man and the microbe is
  escalating and the microbe is winning
• ( Burget and Burke, 1994 ).

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Resistance

• International problem
• WHO report
• House of Lords
• US UK governments have action plans
• Specialist Committee on Antimicrobial Resistance

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Increase in drug resistance

• More extensive use of antimicrobial agents
• Advancing medical procedures
• Increase in critically ill patients
• Animal feeds and aquaculture

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Prevention

• Basic infection control measures

• Ward cleaning
• Rational use of antibiotics
• Avoid patient overcrowding
• Minimise inter-ward transfers
• Adequate levels of staff
• Audit of policies

• Surveillance
• Hand washing
• Protective clothing
• Patient isolation
• Careful handling of linen
• Careful waste disposal
• Aseptic technique

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Department of Health Advisory Committee on
Antimicrobial Resistance and Healthcare
Associated Infection (ARHAI)

• November 2011 Start Smart Then Focus

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Start Smart is

• Do not start antibiotics in the absence of
  clinical evidence of bacterial infection
• If there is evidence/suspicion of bacterial
  infection, use local guidelines to initiate
  prompt effective antibiotic treatment
• Document on drug chart and in medical notes
  clinical indication, duration or review date,
  route and dose
• Obtain cultures first

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Then focus is

• Review the clinical diagnosis and the continuing
  need for antibiotics by 48 hours and make a clear
  plan of action - the Antimicrobial Prescribing
  Decision
• The five Antimicrobial Prescribing Decision
  options are Stop, Switch IV to Oral, Change,
  Continue and Outpatient Parenteral Antibiotic
  Therapy (OPAT).
• It is essential that the review and subsequent
  decision is clearly documented in the medical
  notes.

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National initiatives

• https//www.gov.uk/government/uploads/system/uploa
  ds/attachment_data/file/244058/20130902_UK_5_year_
  AMR_strategy.pdf
• https//www.gov.uk/government/uploads/system/uploa
  ds/attachment_data/file/138331/CMO_Annual_Report_V
  olume_2_2011.pdf
• http//www.rcgp.org.uk/clinical-and-research/targe
  t-antibiotics-toolkit.aspx