1. Actions for Commissioning Teams QIPP and antibiotic prescribing – Slide Set September 2013

2. Introduction Aim - to provide CCGs and practices with an update on local prescribing activity in three QIPP topics identified by NICE that relate to antibiotic use: 1.Antibiotic prescribing, and in particular the use of broad-spectrum antibiotics quinolones, cephalosporins and co-amoxiclav 2.Three-day trimethoprim course for uncomplicated UTIs in women 3.Prescribing of minocycline for acne National prescribing comparators available, supporting all 3 topics – provided in accompanying data-pack at CCG and practice-level Data also compared with the West Midlands ‘aspirations’ for these prescribing comparators

3. Antibiotic prescribing in particular the use of broad-spectrum antibiotics quinolones, cephalosporins and co-amoxiclav Chief Medical Officer’s last annual report focussed on threat of antimicrobial resistance and infectious diseases 1last annual report –poor development pipeline for new drugs –need to preserve effectiveness of existing treatments Whilst antibiotic prescribing in England fell in late 1990’s, it has been rising in recent years 2 Antibiotic prescribing, especially broad-spectrum quinolones/cephalosporins, identified as QIPP topic by NICE 3 –Quins, cephs (and co-amoxiclav) associated with increased risk of C.difficile, MRSA and resistant UTIs 4 –NICE encourages organisations to review prescribing policies and prescribing data 1.Chief Medical Officer annual report: volume 2. 2013.Chief Medical Officer annual report: volume 2 2.National Antibiotics Charts. 2013. NHS Prescription Services.National Antibiotics Charts 3.Key therapeutic topics - Medicines management options for local implementation. 2013. NICEKey therapeutic topics - Medicines management options for local implementation. 4.Management of infection guidance for primary care for consultation & local adaptation. 2013. Health Protection England.Management of infection guidance for primary care for consultation & local adaptation.

4. Evidence: linking antibiotic prescribing in primary care and resistance Qualitative studies indicate GPs may perceive antibiotic resistance as a ‘theoretical’ or ‘minimal’ risk. When faced with an unwell patient, ‘societal’ antibiotic resistance may not be an important consideration But evidence shows antimicrobial prescribing at the individual patient level within primary care is associated with emergence of resistance to that antibiotic in that individual: Systematic review and meta-analysis by Costelloe et al (BMJ 2010;340:c2096) Results of meta-analysis of studies investigating antibiotics prescribed in primary care and risk of antimicrobial resistance in sampled bacteria: Authors also identified one prospective study that reported changes in resistance over time: –pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months Authors found evidence for higher rates of resistance with longer duration and multiple courses of antibiotics Authors concluded odds of resistance are greatest in month following treatment but may persist for up to 12 months Inappropriate use of antibiotics can put the individual patient at greater risk of resistant bacteria, and may make antibiotics less effective when they are really needed, at least in the short term. Urinary tract bacteria (5 studies) Respiratory tract bacteria (6 studies) Time after antibiotic treatment: 2 months12 months2 months12 months Odds Ratio for isolation of resistant bacteria (95% CI) 2.5 (2.1 to 2.9) 1.33 (1.2 to 1.5) 2.4 (1.4 to 3.9) 2.4 (1.3 to 4.5)

5. Targeting antibiotics in RTIs from NICE Clinical Guideline 69: Respiratory tract infections (2008)Clinical Guideline 69 Respiratory tract infections (RTIs) accounts for majority (60%) of antibiotic prescribing in primary care A ‘no antibiotic’ or ‘delayed antibiotic’ strategy should be agreed with patients for these, generally self-limiting, conditions –acute otitis media (typical duration of illness:4 days) –acute cough/acute bronchitis (3 weeks) –acute sore throat/acute pharyngitis/acute tonsillitis (1 week) –common cold (1 ½ weeks) –acute rhinosinusitis (2 ½ weeks) –acute cough/acute bronchitis (3 weeks) –Advise on natural history of the illness. Reassure that antibiotics are not needed immediately as will make little difference to symptoms and may have side effects, e.g. diarrhoea, vomiting rash. Advise to return if RTI worsens/prolonged; advise on symptom management Depending on patient preference and assessment of severity, the following patients can also be considered for an ‘immediate antibiotic prescribing’ strategy, in addition to ‘no prescribing’ or ‘delayed prescribing’ strategies: –bilateral acute otitis media in children younger than 2 years –acute otitis media in children with otorrhoea –acute sore throat/acute pharyngitis/acute tonsillitis if ≥ 3 Centor criteria (Centor criteria are: presence of tonsillar exudate; tender anterior cervical lymphadenopathy or lymphadenitis; history of fever; absence of cough)

6. Targeting antibiotics in RTIs (cont.) from NICE Clinical Guideline 69: Respiratory tract infections (2008)Clinical Guideline 69 Offer immediate antibiotics or further investigation or management for patients who: –are systemically very unwell –have symptoms/signs suggestive of serious illness and/or complications –includes pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital or intracranial complications –are at high risk of serious complications due to pre-existing comorbidity –includes significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, young children born prematurely –are >65 years with acute cough and two or more of the following, or > 80 years with acute cough and one or more of the following: –hospitalisation in previous year –type 1 or type 2 diabetes –history of congestive heart failure –current use of oral glucocorticoids.

7. Broad spectrum antibiotics Message from Health Protection England (HPE) is that generic antibiotics should be used if possible 1 Broad spectrum antibiotics (e.g. co-amoxiclav, quinolones, cephalosporins) should be avoided where narrow spectrum antibiotics are effective, as they increase the risk of C. difficile, MRSA and resistant UTIs Based on current HPE recommendations, 1 first-line use of broad spectrum antibiotics is limited to the following situations: –Acute prostatitis – either ciprofloxacin or orfloxacin –Acute pyelonephritis – either ciprofloxacin or co-amoxiclav –Upper UTI in children – co-amoxiclav 1.Management of infection guidance for primary care for consultation & local adaptation. 2013. Health Protection EnglandManagement of infection guidance for primary care for consultation & local adaptation.

8. Suggested resources European Antibiotic Awareness Resources for England (www.gov.uk) Online CPD Non Prescription Pads

9. Trimethoprim for uncomplicated UTIs in women UTIs – one of most common conditions seen in female patients in primary care Prescribing of trimethoprim for uncomplicated UTIs in (non- pregnant) women is one of NICE’s QIPP topics; promotes use of a 3-day course of trimethoprim (200 mg, twice daily) 1 Evidence suggests 3-day course of trimethoprim is no less effective than longer (5-10) day course 2 Nitrofurantoin (100 mg m/r) is alternative treatment listed in HPE guidance but is more expensive 1.Key therapeutic topics - Medicines management options for local implementation. 2013. NICEKey therapeutic topics - Medicines management options for local implementation. 2.Milo G, Katchman E, Paul M, Christiaens T, Baerheim A, Leibovici L. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004682. DOI: 10.1002/14651858.CD004682.pub2.

10. 1.Key therapeutic topics - Medicines management options for local implementation. 2013. NICEKey therapeutic topics - Medicines management options for local implementation. 2.Garner SE et al. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD002086Art. No.: CD002086 3.Time to say goodbye to minocycline? DTB Published Online First: 1 May 2013 doi:10.1136/dtb.2013.5.0176Time to say goodbye to minocycline? 4.Primary Care Dermatology Guidance – acne vulgaris. http://www.pcds.org.uk/clinical-guidance/acne-vulgarishttp://www.pcds.org.uk/clinical-guidance/acne-vulgaris Minocycline for acne Minocycline as oral treatment for acne included as QIPP topic by NICE in 2012 1 –Higher cost than other tetracyclines used in acne (e.g. oxytetracycline, doxycycline), but no clear evidence that more effective or better tolerated 2 Also potential for serious adverse events: –increased in risk of lupus compared with tetracyclines or no treatment (reported incidence of about 53 cases per 100,000 prescriptions of minocycline) 3 –Also increased risk of liver dysfunction and association with irreversible slate-grey skin pigmentation n.b. use of oral antibiotics is recommended where there is moderate inflammatory acne – topical agents preferred for milder forms of acne 4 DTB questioned if it is “time to say goodbye to minocycline?”, challenging med man committees to remove minocycline from formularies 3 Data from Keele indicate substantial decline in use in the past 12 months, but > 3-fold variation in the usage remains across CCGs

11. Other Reports Available from Keele for your CCG: Access your reports at www.centreformedicinesoptimisation.co.uk or e-mail medman@keele.ac.uk to subscribe. Follow us on Twitter @medmankeelewww.centreformedicinesoptimisation.co.uk medman@keele.ac.uk Keele’s monthly newsletter providing a roundup of developments relating to prescribing in primary care A number of cost-effective prescribing options for practices to consider across many therapeutic areas Quarterly financial overview presenting the “Top 20” BNF Chapters, Sections and Chemicals by spend and number of prescriptions This comprehensive spread sheet provides practices and CCGs with an update on prescribing activity across national and local prescribing indicators. Monthly update of local prescribing indicators at the CCG level, showing variation over time Quarterly update of key mental health prescribing indicators, compared across primary care and mental health trusts Comprehensive annual compendium of prescribing and healthcare information to support QIPP related to medicines use 11

12. Actions for Commissioning Teams website: www.centreformedicinesoptimisation.co.uk e-mail: medman@keele.ac.uk www.centreformedicinesoptimisation.co.ukmedman@keele.ac.uk