Speaker 5 - Dr Leong Combat AMR Primary Care

7/29/2019 Speaker 5 - Dr Leong Combat AMR Primary Care

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Combating AMR in

Primary Carepractical antimicrobial therapy forcommon infection in primary care setting

Dr Leong Kar NimMBBS (India) MRCP (Ireland)

Consultant Infectious Diseases

Infectious Disease Unit

Hospital Pulau Pinang


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Percentage of Abs usage

Acute bronchitis 78%

Acute phranyngitis 65%

Acute sinusitis 81%

Nonspecific URI 33%

Broad spectrum Abs 56%

Family Medicine 2006; 38(5):349-54


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Outpatient Antibiotic Use andPrevalence of Antibiotic-

Resistant Pneumococci inFrance and Germany: A

Sociocultural PerspectiveStephan Harbarth,* Werner Albrich, and Christian Brun-Buisson

The prevalence of penicillin-nonsusceptible pneumococci is sharply divided between France (43%) and

Germany (7%). These differences may be explained on different levels: antibiotic-prescribing practices for

respiratory tract infections; patient-demand factors and health-belief differences; social determinants,

including differing child-care practices; and differences in regulatory practices. Understanding these deter-

minants is crucial for the success of possible interventions. Finally, we emphasize the overarching impor-

tance of a sociocultural approach to preventing antibiotic resistance in the community.

Emerging Infectious Diseases Vol. 8, No. 12, December 2002


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Strep pneumo

sensitivity pattern in

Germany vs France


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Out patient antibiotic

utilization data

Figure 3. Outpatient antibiotic utilization (18,19), France and Germany,19851997. DDD, daily defined doses.


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Findings:

In Germany :

lower antibiotic consumption

narrow-spectrum antibiotics

higher dosing of amino-penicillins

better treatment compliance

Lower rates of resistant pneumococcus


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MANAGEMENT OF COMMONINFECTION IN PRIMARY CARE

SETTINGS

Adapted from CDC and UK guidelines


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Aim :

A simple, empirical approach to the treatment of common

infections which require antibiotics in outpatient setting

Promote the safe, effective and economic use of antibiotics

Minimise the emergence of bacterial resistance in the

community


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General principles:

Lower threshold for antibiotics in immunocompromised hosts

or those with multiple morbidities; consider culture and seek

advice

Prescribe an antibiotic only when there is likely to be a clearclinical benefit

Consider NO antibiotic strategy for acute self-limiting upper

respiratory tract infections


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Use narrow spectrum antibiotics when possible

Avoid broad spectrum antibiotics eg co-amoxiclav, quinolones

and cephalosporins

Avoid widespread use of topical antibiotics e.g. fusidic acid

Where a best guess therapy has failed or special

circumstances exist, seek advice from Physicians/ID/ClinicalMicrobiologists.


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Common RTI in Primary Care

Acute pharyngitis

Non specific URTI/ILI

Acute bacterial rhinosinusitis

Acute bronchitis


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Acute pharyngitis

Only 5-15% of adult cases of acute pharyngitis are caused by

GABHS (Group A -haemolytic strep)

Antibiotic therapy of GABHS hastens resolution by 1-2 days if

initiated within 2-3 days of symptom onset.

Centor criteria :

History of fever

Lack of cough

Tonsillar exudates

Tender anterior cervical adenopathy


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Patients with none or only one of these findings should NOT

be tested or treated for GABHS.

Rapid streptococcal antigen test (RAT) is recommended for

patients with two or more criteria, with antibiotic therapy only

if test is positive Treatment :

Penicillin V 500 mg1 gm QID 10 days

Clarithromycin 250-500 mg BD 5 days

Extended BL-BLI / FQ are not indicated


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Non specific URTI

The common cold is caused by viral pathogens eg rhinovirus,

parainfluenza, adenovirus, RSV and influenza

Bacterial rhino-sinusitis complicates only about 2% of cases.

Symptoms may last up to 14 days with an average of 7 to 11

days

Purulent nasal secretions do not predict bacterial sinusitis


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Common cold resolves without antibiotic treatment.

Treatment with an antibiotic does NOT shorten the duration

of illness nor prevent bacterial rhinosinusitis.

Patients with purulent green or yellow secretions do not

benefit from antibiotic treatment.

Cough suppressants have limited efficacy for relief of cough

Acute cough associated with the common cold may be

relieved by antihistamines and decongestants


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Suspected Influenza

Annual vaccination is essential for all those at risk ofinfluenza.

Pregnant (including 2 weeks post partum)

> 65 years

chronic respiratory disease (including COPD and asthma)

significant cardiovascular disease (not hypertension),immunocompromised

diabetes mellitus

chronic neurological

renal or liver disease Treat only at risk patientswithin 48 hours of onset or in a

care home where influenza is likely.

Oseltamivir 75 mg bd x 5 days

Zanamivir 10 mg BD (2 inhalations by diskhaler) x 5 days


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Acute bacterial rhino-sinusitis

Acute maxillary and ethmoid rhinosinusitis

Most cases of acute rhinosinusitis are due to uncomplicated

viral infections

Most rhinovirus colds last 7 to 11 days (J Clin Microbiol1997;

35:2864;JAMA 1967; 202:158).

Bacterial rhinosinusitis may be present if symptoms have beenpresent >7 days and there is localization to the maxillary sinus.


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Most patients will improve without antibiotic treatment.

About 81% of antibiotic-treated patients and 66% of controls

improved at 10-14 days (absolute benefit of 15%).

Patients with mild symptoms should NOT receive antibiotics.

Use a narrow spectrum agent that covers S. pneumoniae and

H. influenzae

Amoxicillin 500 mg TDS X 7 days

Doxycycline 100 mg BD X 7 days Consider second line agent if no improvement or worsening after

72 hours. Co amoxy Clav 625 mg TDS X 7 days


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Acute bronchitis

Acute coughing illness last for 3 weeks

Greater than 90% of cases of acute cough illness are non-

bacterial.

Viral etiologies include influenza, parainfluenza, RSV, and

adenovirus.

Bacterial agents include Bordatella pertussis, Mycoplasma

pneumoniae, and Chlamydophila pneumoniae.

Purulent sputum not predictive of bacterial infection.

>95% of patients with purulent sputum do not havepneumonia (J Chron Di1984; 37:215)


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Empiric antibiotic treatment is not indicated for acute

bronchitis.

Meta-analyses of randomized, controlled trials all concluded

that routine antibiotic treatment is not justified (BMJ

1998;316:906; Chest2006;129:95S-103S). Antibiotic treatment decreases transmission but has little

effect on symptom resolution.

If influenza therapy is considered, it should be initiated within

48 hours of symptom onset for clinical benefit.

Treatment:

Amoxycillin 500 mg TDS X 5 days

Doxycycline 200 mg stat and 100 mg OD X 5 days


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Acute exacerbation of COPD

Treat exacerbations promptly with antibiotics only if purulent

sputum and increased shortness of breath and/or increased

sputum volume

Risk factors for antibiotic resistant organisms (penicillin R)

include co-morbid disease, severe COPD, frequentexacerbations, antibiotics in last 3 months

Treatment: 5 days

Amoxicillin 500 mg TDS

Doxycyline 200 mg / 100 mg BD

Clarithromycin 500 mg BD

If resistance risk factors:

co-amoxiclav 625 mg TDS


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Urinary Tract Infection

Do not use prophylactic antibiotics for catheter changes unless

history of catheter-change-associated UTI

Do not treat asymptomatic bacteriuria; it is common but is

not associated with increased morbidity, especially elderlypatient

Catheter in situ: antibiotics will not eradicate asymptomatic

bacteriuria; only treat if systemically unwell or pyelonephritislikely


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UTI in women with severe symptoms (fever, dysuria and flank

pain): treat with empirical antibiotic

Women mild/or 2 symptoms: use dipstick to guide

treatment.

Nitrite & blood/leucocytes has 92% positive predictive value ; -ve nitrite, leucocytes, and blood has a 76% NPV

Men: send pre-treatment MSU culture OR if symptoms

mild/non-specific, useve nitrite and leucocytes to exclude

UTI

Empirical Therapy : 3-5 days in women ; in men 7 days

Co Amoxy Clav

Unasyn

Cefuroxime


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TIPS for not overusing

antibiotics in primary care Tell patients that antibiotic use increases the risk of an

antibiotic- resistant infection.

Identify and validate patient concerns.

Recommend specific symptomatic therapy.

Spend time answering questions and offer a contingency plan

if symptoms worsen.

Provide patient education materials on antibiotic resistance.


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REMEMBER:

Effective communication ismore important than an

antibiotic for patientsatisfaction.

Documents

Speaker 5 - Dr Leong Combat AMR Primary Care