GP Small Group education – April/May 2015

Antibiotics – Resistance

is futile

Acknowledgements This material was prepared by the Clinical Quality and Education team with help gratefully received from:

Topic preparation team

• Ben Hudson Small Group Leader, GP

• Jeanette Hight Small Group Leader, Practice Nurse

• Tim Vincent Small Group Leader, Community Pharmacist

Others consulted

• Rosemary Ikram Consultant Microbiologist

• Steve Chambers Infectious Diseases Consultant, CBHB

• Ben Harris Medical Liaison, Infection Control Team, CSCL

• Andrew Meads Medical Director, Acute Demand

• Sharon Gardiner Antimicrobial Pharmacist CDHB

• Geraldine Wilson GP, Lecturer, University of Otago

• Paul Bridgford Team Leader, Reporting and Analysts, Pegasus Health

• Richard Everts Infectious Diseases Physician, Nelson

This clinical resource was prepared by the Clinical Quality and Education Team, Pegasus Health. Any statement of preference made is a

recommendation only. It is not intended to compel or unduly influence independent prescribing choices made by clinicians. References not

listed are available on request. All clinical documents produced by Pegasus Health are dated with the date they were originally produced or

updated, and reflect analysis of available evidence and practice that was current at that time. Any person accessing any clinical documents

must exercise their own clinical judgment on the validity and applicability of the information in the current environment, and to the individual

patient. The educational material developed for delivery at this education session remains the intellectual property of Pegasus Health. This

material is not to be redelivered, on sold to any individual or organisation, or made publicly available on any website or in any publication,

without written permission from Pegasus Health (Charitable) Ltd. Pegasus Health (Charitable) Ltd June 2013

Setting the scene

• “The time may come when penicillin can be bought by anyone in

the shops. Then there is the danger that the ignorant man may

easily underdose himself and by exposing his microbes to non-

lethal quantities of the drug, make them resistant.“

Alexander Fleming, from his Nobel Prize acceptance speech in 1945.

Worldwide antibiotic use (NZMJ)

National antibiotic use 2005-2012 (NZMJ)

Local antibiotic use

Case 1 – Fred

• 23 yr old

• Presents with a blocked nose and sore throat which started 4/7 ago, coughing with a small amount of yellow sputum

• Has a stag do to go to in 5/7 time

Fred asks for a course of antibiotics

Case 1

Does Fred need antibiotics?

How can we assess Fred’s health literacy?

What does the average patient know about

antibiotics, and potential harms?

How do you talk to patients about URTIs?

Adapted from Sinus and Allergy Health Partnership (SAHP) Otolaryngol Head Neck Surg. 2004;130(1 Suppl):1-45

What are Fred’s expectations?

How do you explain to Fred that an antibiotic is not needed?

“ So, doc – are you going to give me some antibiotics?”

Why do antibiotics get prescribed?

• Perceived pressure from patients

• Pressure on ourselves

• The patient has paid for a consult

• Work medical certificate is needed (otherwise the patient would not be attending)

• Uncertainty about diagnosis

• Because they’ve been prescribed for the same thing in the past

• Fear (patient’s and/or doctor’s)

• Because there is an infection that needs it

How can we change it so that

“Because there is an infection

that needs it”

is top of the list?

What about back pocket scripts?

• Do you use them?

• What discussion do you have with the patient?

• How do you use them? – Postdate them?

– Give them to the patient (40% will be dispensed)

– Give them to PN (28% will be dispensed)?

– Give them to the pharmacist?

• How do you let PN and pharmacist know that it is a back pocket script?

A few days later:

Fred returns:

• Anorexia

• Right-sided chest pain

• T 39.5C, RR 30, O2 sats 93%

We want to minimise unnecessary antibiotic use BUT how

do we ensure those who really need them get them?

Case 2 - Jane

• 53 yr old

• Mild varicose eczema

• Sore right lower leg 3/7 – now swollen, erythematous

• Feeling a bit flu-y

What else do you need to know?

Would you do any investigations?

Do you routinely do bloods?

Criteria for IV antimicrobials

IV therapy is indicated if patient has any of the following:

• Sepsis – clinical symptoms of infection (fever, sweats, chills or rigors) and at least 2 of the following: temperature: > 38 ºC or < 36 ºC

tachycardia > 90 beats per minute

tachypnoea > 20 breaths per minute

WBC count > 12 or < 4x109/L, or the presence of immature neutrophils

• Febrile neutropenia or immunosuppression

• Specific indications eg. endocarditis, meningitis, septic arthritis, osteomyelitis or abscess

• Oral route compromised

[Adapted from CDHB Antimicrobial Guidelines]

Acute Demand

In Canterbury we can use the “Acute Demand” service for cellulitis:

• This means being able to give IV antibiotics in General Practice –

or at the 24 Hour Surgery – without admitting the patient to

hospital.

• The practice is funded to give the antibiotics and follow up the

patient

What dose of oral flucloxacillin would

you prescribe for Jane?

• Why did you choose this dose?

• What patient factors would make you choose a

higher/lower dose?

• Oral flucloxacillin should be started without

delay. How do you ensure this?

• What if Jane can’t afford the script?

Case 3 - Joe

• 7 yr old

• Sent home from school with spots on his face

• Mum very upset at implication of lack of hygiene

How are you going to treat Joe?

What do you use for impetigo? Why?

• Oral antibiotics?

• Topical treatments?

• Combination of oral and topical antibiotics?

• What if a child refuses flucloxacillin?

Topical antibiotics Fusidic acid and mupirocin dispensed in Canterbury

(2006 to 2013)

-

5,000

10,000

15,000

20,000

25,000

30,000

2006 2007 2008 2009 2010 2011 2012 2013

15g

Tu

bes

Total

Fusidic acidCrm&Ointmnt

Mupirocin2%Crm

Why has there been such an increase in overall prescribing since 2006?

Decolonisation

• Prevention of infection is the ideal

• Use of antiseptic skin cleanser is important

• Can be considered for recurrent Staph skin infections

• Labour intensive, microbiologically effective in about 70% of

cases

Take home messages

• Is that antibiotic needed?

• If you prescribe, use an appropriate antibiotic & adequate dose

• NNT are high to prevent complications such as mastoiditis and pneumonia

• Antibiotics have significant risk of side effects

• There is no universally accepted treatment for impetigo

• “Bugs do not become resistant – we selectively breed them”

• Think about what you will change as a result of this round