Steve McCormick Lead 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 RiskMedium RiskLow Risk Fluoroquinolones Ampicillin/Amoxicillin Aminoglycosides Cephalosporins Co-trimoxazole Metronidazole Co-amoxiclav Clindamycin Macrolides Tazocin Tetracyclines Trimethoprim Rifampicin Vancomycin

Formulary First line Antibiotics Amoxicillin Flucloxacillin Phenoxymethylpenicillin Macrolides Tetracyclines Metronidazole Nitrofurantoin Trimethoprim

HPS 2013

Audit of management of commonly encountered infection in primary care Number of consultations by infection

Path of least resistance VT Dr Gail Haddock, GP NHS Highland

SAPG homepage

Primary 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 relapse 8 Antibiotics to prevent Quinsy NNT >4000 4B- Antibiotics to prevent Otitis media NNT 200 2A+ phenoxymethylpenicillin 5B- 500 mg QDS 1G BD 6A+ (QDS when severe 7D ) 10 days 8A- Penicillin Allergy: Clarithromycin mg 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 (0.41 to 1.38) Antibiotic prescription (0.14 to 0.60) Intention to consult (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