Bedfordshire Antimicrobial Prescribing Guidelines 2008

Managing Common Infections in Primary CareBedfordshire Antimicrobial Prescribing Guidelines 2008

QUIZ!

QUIZ (True/ False)

1. Clostridium Difficile• Is present in gut of one quarter of > 65 yr olds• Lies dormant without causing symptoms • Multiplies rapidly when normal gut flora disturbed,

producing toxins causing illness• Is usually spread on the hands of health workers• can form spores which can survive for long periods in

the environment• Can be eliminated from the hands by alcohol hand gel• Can be controlled partly by reducing use of broad

spectrum antibiotics

QUIZ

2. Antibiotic sensitivities Rank the following antibiotics in terms of % sensitivity (high to low – Bedford lab)

• E. Coli UTI: co-amoxiclav, trimethoprim, nitrofurantoin

• Strep pneumoniae middle ear discharge: Erythromycin, Doxycycline, Penicillin V

QUIZ: 3. Sore Throat

• List 5 indications for admitting a patient with a sore throat

TRUE OR FALSE:• Throat swabs should be routinely taken• Antibiotics prevent suppurative complications• Antibiotics should be given to patients on

immunosuppressive chemotherapy• Antibiotics prevent the development of rheumatic

fever and acute glomerulonephritis

QUIZ: 4. Sore Throat (cont)

The following patients should usually be prescribed antibiotics for sore throat by the GP:

• Recurrent tonsillitis• With an increased risk of severe infection (e.g. diabetes

or immunocompromised). • Who are at risk of immunosuppression (e.g. on disease-

modifying anti-rheumatic drugs [DMARDs], carbimazole). • With a history of valvular heart disease. • With a history of rheumatic fever.• With peritonsillar abscess

5. OTITIS MEDIA True/False

• 70% resolve within 3 days without antibiotics• Analgesics are the mainstay of treatment• For most patients frequency of side effects of

antibiotics are similar to frequency of benefitAntibiotics more likely to help the following

groups: • above 6 months of age • systemically unwell• Purulent discharge

6. OTITIS MEDIA True/False

• If a delayed prescription is offered, instructions should be to use if not improved after 48 hours

• Amoxicillin for 7 days is first line if antibiotics are used

• Preferred second line treatment (if recurrent) includes cefalosporins

• Trimethoprim is also a second line option

7. Acute Sinusitis True/False

• Reserve antibiotics for cases persisting more than 5 days in adults and 7 days in children

• Plain sinus x ray is useful in establishing a diagnosis

• Intranasal decongestants may have a short term benefit

8. Treatment Duration

How Long should antibiotics be used for:• Otitis Media• Uncomplicated pneumonia• Acute Sinusitis• Tonsillitis• Acute exacerbation of COPD• Uncomplicated lower UTI• Complicated UTI• Prostatitis• Epididymo-orchitis

9. Treatment Choice

Name 1st and 2nd choice antibiotics for:• Otitis Media• Uncomplicated pneumonia• Acute Sinusitis• Tonsillitis• Acute exacerbation of COPD• Uncomplicated lower UTI• Complicated UTI• Prostatitis• Epididymo-orchitis

10. Pelvic Inflammatory Disease

TRUE/ FALSE• A chlamydial swab of the cervix and

HVS should be taken prior to treatment• Should be treated before results of

swabs if unwell, using broad spectrum combination

Specify broad spectrum regime – name of antibiotics, dose, durations

11. Impetigo TRUE/ FALSE

• Topical therapy is preferred

• Bactroban is preferred choice of topical therapies

• Should be treated for 5 days if oral antibiotics are used

• Is caused by staphylococcus aureus or streptococcus pyogenes

12. Cellulitis TRUE/ FALSE

• Often involves both Staphylococcus aureus and streptococcus pyogenes

• Should be treated for 10 days

Name 3 possible treatment regimes (oral)

13. Dermatophyte infections- tinea capitis

TRUE/ FALSE

• Scalp scraping and hair root should be sent for fungal culture

• Topical imidazole creams are ineffective

• Should be referred to a dermatologist

• Oral Griseofulvin is recommended

14. Dermatophyte infections- tinea corporis/ cruris/ pedis

TRUE/ FALSE

• Skin scrapings should be routinely sent for fungal culture

• Topical imidazole creams are effective

• Should all be referred to a dermatologist

• Topical treatments should be continued for 1-2 weeks after clinical cure

15. Dermatophyte infections: fungal nail infections

TRUE/ FALSE • Nail clippings should be routinely sent

for fungal culture• Treat only positive nail clippings• Should not be treated if only symptoms

are cosmetic appearance• For toe nail infections treatment is

usually needed for 3 months

16. Antivirals

SHINGLES – TRUE/ FALSE

Oral antiviral are indicated in:• Healthy 50 year old man presenting within 24

hrs of appearance of rash on trunk• 24 year old with ophthalmic shingles rash for

48 hrs• 80 year old presenting with chest wall

shingles after 96 hours

ANSWERS

QUIZ (True/ False)

• 1. Clostridium Difficile• Is present in gut of one quarter of > 65 yr olds FALSE (1/3 of

over 65 yr olds)• Lies dormant without causing symptoms TRUE• Multiplies rapidly when normal gut flora disturbed, producing

toxins causing illness TRUE• Is usually spread on the hands of health workers TRUE• can form spores which can survive for long periods in the

environment TRUE• Can be eliminated from the hands by alcohol hand gel FALSE• Can be controlled partly by reducing use of broad spectrum

antibiotics TRUE

Consequences of high community prescribing

• MRSA: Staphylococcus aureus (SA) is a bacterium found on the skin of around 30% of the general population at any time causing no apparent ill effect. This is known as colonisation. SA infections of the skin may cause pimples or boils. However, inside the body, it can cause serious infections such as pneumonia, organ failure and death.

• MRSA (Methicillin-resistant SA) is a form of SA that is resistant to commonly used antibiotics. Individuals can be colonised with SA or MRSA and are carriers of the organisms, possibly passing them on to others through physical contact.

• Clostridium difficile (C.Diff):C.diff (Clostridium difficile) is a bacterium found in the gut of around a third of people aged 65 and over. It lies dormant causing no ill effect until the normal flora of the gut is disturbed (e.g. through taking antibiotics), when it can multiply and produce toxins. It then causes severe explosive diarrhoea. Spread may then occur via the hands of healthcare workers, or from contaminated objects or contaminated food. C.diff can form spores which can survive for long periods in the environment and be dispersed through the air.

Return to disease areas

2. Rank the following antibiotics in terms of % sensitivity (high to low – Bedford lab)

E. Coli UTI:

• nitrofurantoin 96%

• co-amoxiclav 94%

• Trimethoprim 73%

Strep pneumoniae middle ear discharge:

• Erythromycin & Penicillin V 96%

• Doxycycline 90%

QUIZ: 3. Sore Throat

5 indications for admitting a patient with a sore throat:– Stridor/ suspected epiglottitis/ upper airways obstruction– Suppurative complications – quinsy/ peri-tonsillar abscess– Suspected Kawasaki disease– Suspected diphtheria– Suspected Stevens-Johnson syndrome– Suspected Yersinial pharyngitis– Profoundly unwell/ severely dehydrated

• Throat swabs should be routinely taken FALSE• Antibiotics prevent suppurative complications FALSE• Antibiotics should be given to patients on

immunosuppressive chemotherapy TRUE• Antibiotics prevent the development of rheumatic fever

and acute glomerulonephritis FALSE

QUIZ: 4. Sore Throat (cont)

The following patients should usually be prescribed antibiotics for sore throat by the GP:

• Recurrent tonsillitis FALSE• With an increased risk of severe infection (e.g.

diabetes or immunocompromised). TRUE• Who are at risk of immunosuppression (e.g. on

disease-modifying anti-rheumatic drugs [DMARDs], carbimazole). TRUE

• With a history of valvular heart disease. TRUE• With a history of rheumatic fever. TRUE• With peritonsillar abscess FALSE (ADMIT)

5. OTITIS MEDIA True/False

• 70% resolve within 3 days without antibiotics FALSE – (80%)

• Analgesics are the mainstay of treatment TRUE• For most patients frequency of side effects of

antibiotics are similar to frequency of benefit TRUE

Antibiotics more likely to help the following groups: • above 6 months of age FALSE• systemically unwell TRUE• Purulent discharge TRUE

6. OTITIS MEDIA True/False

• If a delayed prescription is offered, instructions should be to use if not improved after 48 hours FALSE (72 hours)

• Amoxicillin for 7 days is first line if antibiotics are used FALSE (5 DAYS)

• Preferred second line treatment (if recurrent) includes cefalosporins FALSE

• Trimethoprim is also a second line option FALSE – CO-AMOXICLAV/ ERYTHROMYCIN/ CLARITHROMYCIN

Patient Decision Aids

Patient Decision Aids

7. Acute Sinusitis True/False

• Reserve antibiotics for cases persisting more than 5 days in adults and 7 days in children FALSE (7 days adults 10 days children)

• Plain sinus x ray is useful in establishing a diagnosis FALSE

• Intranasal decongestants may have a short term benefit TRUE

8. Treatment Duration

How Long should antibiotics be used for:• Otitis Media ZERO OR 5 DAYS• Uncomplicated pneumonia 7 DAYS• Acute Sinusitis ZERO OR 5 DAYS• Tonsillitis ZERO OR 10 DAYS• Acute exacerbation of COPD 5 DAYS• Uncomplicated lower UTI ZERO OR 3 DAYS• Complicated UTI 7 DAYS• Prostatitis 28 DAYS• Epididymo-orchitis 14 DAYS

9. Treatment Choice 1st and 2nd choice

• Otitis Media Amoxicillin, Erythromycin (Clarithromycin) (or None)

• Uncomplicated pneumonia Amoxicillin, Erythromycin (Clarithromycin)

• Acute Sinusitis Amoxicillin, Amoxicillin, Erythromycin (Clarithromycin) (or None)

• Tonsillitis Penicillin V, Amoxicillin, Amoxicillin, Erythromycin (Clarithromycin) or None

• Acute exacerbation of COPD co-amoxiclav, doxycycline• Uncomplicated lower UTI trimethoprim, nitrofurantoin MR• Complicated UTI nitrofurantoin MR, co-amoxiclav• Prostatitis Ofloxacin, doxycycline• Epididymo-orchitis doxycycline + cefixine, ofloxacin

10. Pelvic Inflammatory Disease TRUE/ FALSE

• A chlamydial swab of the cervix and HVS should be taken prior to treatment FALSE (also take cervical bacterial swab)

• Should be treated before results of swabs if unwell, using broad spectrum combination TRUE

Specify broad spectrum regime – name of antibiotics, dose, durations:

Cefixime 400mg one dose + doxycycline 100mg bd 14 days + metronidazole 400mg bd 14 days

11. Impetigo TRUE/ FALSE

• Topical therapy is preferred FALSE

• Bactroban is preferred choice of topical therapies FALSE (fusidate 5 days small lesions only)

• Should be treated for 5 days if oral antibiotics are used FALSE 7 days

• Is caused by staphylococcus aureus or streptococcus pyogenes FALSE only staph

12. Cellulitis TRUE/ FALSE

• Often involves both Staphylococcus aureus and streptococcus pyogenes TRUE

• Should be treated for 10 days TRUE

Name 3 possible treatment regimes (oral):

Amoxicillin 500mg tds + Flucloxacillin 500mg qds 10 days

Co-fluampicil 1-2 caps qds 10 days

Erythromycin 500mg qds 10 days (or Clarithromycin 500mg bd)

13. Dermatophyte infections- tinea capitis

TRUE/ FALSE • Scalp scraping and hair root should be

sent for fungal culture TRUE• Topical imidazole creams are

ineffective TRUE• Should be referred to a dermatologist

TRUE• Oral Griseofulvin is recommended

TRUE

14. Dermatophyte infections- tinea corporis/ cruris/ pedis

TRUE/ FALSE • Skin scrapings should be routinely sent for

fungal culture TRUE• Topical imidazole creams are effective TRUE• Should all be referred to a dermatologist

FALSE• Topical treatments should be continued for 1-

2 weeks after clinical cure TRUE

15. Dermatophyte infections: fungal nail infections

TRUE/ FALSE • Nail clippings should be routinely sent

for fungal culture TRUE• Treat only positive nail clippings TRUE• Should not be treated if only symptoms

are cosmetic appearance TRUE• For toe nail infections treatment is

usually needed for 3 months TRUE

16. Antivirals

SHINGLES – TRUE/ FALSE

Oral antiviral are indicated in:• Healthy 50 year old man presenting within 24

hrs of appearance of rash on trunk FALSE• 24 year old with ophthalmic shingles rash for

48 hrs TRUE• 80 year old presenting with chest wall

shingles after 96 hours FALSE

ANSWERS

Antibiotic Prescribing Figures

Resources

• myweb.tiscali.co.uk/bedpgme/AMG08.htm

• Clinical Knowledge Summaries cks.library.nhs.uk

• Local Antibiotic Guidelines & Other Resources myweb.tiscali.co.uk/bedpgme/Nurse%20Events/Antiobioticresources.htm

• NICE Respiratory Tract Infections www.nice.org.uk/Guidance/CG69

Care pathway for respiratory tract infections (RTIs)

• At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including:

• history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant

• risk factors, relevant comorbidities)• examination as needed to establish diagnosis.

Care pathway for respiratory tract infections (RTIs)

• Address patients’ or parents’/carers’ concerns and expectations when agreeing the use of the three antibiotic strategies:– no prescribing– delayed prescribing– immediate prescribing

No Antibiotics

• Agree a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis

• No antibiotic prescribing Offer patients:– reassurance that antibiotics are not needed

immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash

– a clinical review if the RTI worsens or becomes prolonged.

Delayed Antibiotics

• Delayed antibiotic prescribing• Offer patients:• reassurance that antibiotics are not needed

immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash

• advice about using the delayed prescription if symptoms do not settle or get significantly worse

• advice about re-consulting if symptoms get significantly worse despite using the delayed prescription.

• The delayed prescription with instructions can either be given to the patient or collected at a later date

Immediate prescribing

• Consider an immediate prescribing strategy for:• children younger than 2 years with bilateral acute

otitis media• children with otorrhoea who have acute otitis media• patients with acute sore throat/acute

pharyngitis/acute tonsillitis when three or more Centor criteria are present:– presence of tonsillar exudate– tender anterior cervical lymphadenopathy or lymphadenitis– history of fever– an absence of cough

Offer all patients

• advice about the usual natural history of the illness and average total illness length:– acute otitis media: 4 days– acute sore throat/acute pharyngitis/acute- tonsillitis: 1 week– common cold: 11/2 weeks– acute rhinosinusitis: 21/2 weeks– acute cough/acute bronchitis: 3 weeks

• advice about managing symptoms including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to ‘Feverish illness in children’

Time trends

Antibiotic prescription items per Item based Infections STARPUPCT Trends, Feb 2006 to June 2008

67.81

61.61

88.11

64.68

83.6882.49

65.0161.39

56.34

77.67

70.16

66.31

59.9556.12

60.2

67.56 67.36

73.12

58.85

63.12

77.4977.35

69.31

68.53

69.96

81.84

77.3

78.17

73.9

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Practice Variation (3 fold)

Antibacterial items per 1000 Infection based STAR PUsPractices in Bedfordshire PCT by Locality, June 2008

58.3

740

.90

52.2

442

.35

93.4

156

.26

49.5

163

.66

41.2

1

53.6

952

.24

47.7

361

.82

47.3

661

.93

70.9

042

.23

120.

0062

.20

54.4

269

.19

93.0

747

.53

55.5

5

71.6

767

.90

66.8

954

.80

78.6

945

.79

62.4

852

.03

55.1

183

.63

65.2

6

61.7

462

.63

72.3

6 78.2

570

.44

47.4

042

.89

60.6

471

.73

82.8

363

.80

51.2

772

.32

48.9

8 52.5

364

.08

55.3

8

50.5

742

.03

51.0

761

.90

56.6

2 62.7

258

.65

56.6

7

66.2

8

50.7

7

60.3

0

45.9

1

70.6

8

74.7

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Horizon Chiltern Vale Ivel Valley LB WMB

Cephalosporins

Cephalosporin prescription items per item-based infections STARPUPractices in Bedfordshire PCT, June 2008

0

10

20

30

40 Horizon Chiltern Vale Ivel Valley LB WMB

Quinolones

Quinolone prescription items per item-based infections STARPUPractices in Bedfordshire PCT, June 2008

0

10

20

30

40

Horizon Chiltern Vale Ivel Valley LB WMB

Variation in prescribing

• There is a large variation in prescribing between practices

• Why?

• What differs?