Steve McCormickLead Antimicrobial Pharmacist NHS Lanarkshire

Antimicrobial use is a National priority

• Scottish Antimicrobial Prescribing Group• Local Antimicrobial Management Team• Healthcare Environment Inspectorate

Definition of antimicrobial stewardship

• “Prudent prescribing is not to prescribe as few antibiotics as possible but to identify that small group of patients who really need antibiotic treatment and then explain, reassure and educate the large group of patients who don’t.

British Journal of General Practice 2009, 50:567

Stewardship: Prudent Prescribing

• Is an antibiotic required?– Only use when clearly indicated, not self limiting (viral) infections

• Select appropriate agent from local antimicrobial policy– Minimise collateral damage/risk to patient

• Prescribe optimal dosage for shortest duration – Maximise effect but minimise selective pressure

• Ask specialist/micro for advice if suspect resistance– Access unedited antibiogram/C+S results

Antimicrobial Prescribing Policies

• New empirical Antimicrobial policies for hospitals and primary care in place in all NHS Boards

• Evidence based guidance on empirical treatment of common infections now with HAI focus

• Promote use of narrow spectrum agents and restrict agents associated with Clostridium difficile.

Risk of C. difficile infection

High Risk Medium Risk Low Risk

Fluoroquinolones Ampicillin/Amoxicillin

Aminoglycosides

Cephalosporins Co-trimoxazole MetronidazoleCo-amoxiclavClindamycin

MacrolidesTazocin

TetracyclinesTrimethoprimRifampicin

Vancomycin

Formulary First line Antibiotics

• Amoxicillin

• Flucloxacillin

• Phenoxymethylpenicillin

• Macrolides

• Tetracyclines•• Metronidazole

• Nitrofurantoin

• Trimethoprim

HPS 2013

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Path of least resistance VT

• Dr Gail Haddock, GP NHS Highland

• http://youtu.be/m5N3dcPmxW0

SAPG homepagewww.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribing_Group__SAPG

Primary Care Antimicrobial GuidelinesPrimary Care Antimicrobial Guidelines

All NHS boards follow management of infection template from Health Protection Agency

Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours 2A+

If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) 3A- consider 2 or 3-day delayed or immediate antibiotics 1,A+ or rapid antigen test.RCT in <18yr olds shows 10d had lower relapse8

Antibiotics to prevent Quinsy NNT >4000 4B- Antibiotics to prevent Otitis media NNT 2002A+

phenoxymethylpenicillin5B-

500 mg QDS 1G BD

6A+

(QDS when severe

7D)

10 days

8A-

Penicillin Allergy:Clarithromycin

250-500mg BD

5 days

9A+

Guidance for acute sore throat

Public Awareness Campaigns

Patient Expectations+++

Booklet shared with parents in UK general practice

Francis et al BMJ 2010

Effect of the intervention on patient outcomes

Francis et al BMJ 2010

Intervention%

Control %

OR (95% CI) multi-level modelling

Reconsultation 12.9 16.2 0.75 (0.41 to 1.38)

Antibiotic prescription

19.5 40.8 0.29 (0.14 to 0.60)

Intention to consult

55.3 76.4 0.34 (0.20 to 0.57)

Delayed Scripts

• Delay for 48 hours prescription• “Leave behind reception if no better in 2

days”• Evidence to say – do work

Role of the AMT – Primary care

• Link in with Primary Care Prescribing Advisers who monitor prescribing using PRISMS

• Engage individual prescribers by feeding back meaningful data to promote reflection & discussion in order to influence future prescribing and promote compliance with policy

• Improve quality and reduce quantity of antimicrobial prescribing

Role of Individual Prescribers• Awareness of local antimicrobial prescribing policy

• Minimise use of non-policy antibiotics and inappropriate dosage or duration

• Patient education re self management of self limiting infections to avoid unnecessary use of antibiotics

• Especially vigilant on antibiotic use in high risk groups e.g. Elderly, Nursing Homes