1. Training on use of antimicrobials in clinical practice 1

2. Training on use of antimicrobials in clinical practice 2 Contents Section One- Policy context: National and local strategic approaches 3 Section Two- Diagnosis of infection and clinical decision making12 Section Three- Prudent antimicrobial prescribing19 Section Four- Antimicrobial use in hospital29 Section Five- Antimicrobial use in primary care41 You can copy or reproduce the information in this training pack for use within NHSScotland and for educational purposes. You must not make a profit using information in this training pack. Commercial organisations must get our written permission before reproducing this training pack.

3. Section One Policy context: National and local strategic approaches 3

4. ScotMARAP Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) issued in 2008 Made recommendations for NHS Boards to address the growing problem of antimicrobial resistance 4 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

5. SAPG The Scottish Antimicrobial Prescribing Group (SAPG) was set up to ensure national delivery of ScotMARAP Members include representatives from regional NHS Boards, national NHS stakeholders (HPS, ISD, NES, QIS) and Scottish Government 5 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

6. Antimicrobials and HAI Healthcare Associated Infection (HAI) is currently a priority area for all NHS Boards The Healthcare Environment Inspectorate was set up in 2009 to ensure Boards complied with Infection Control Standards Antimicrobial prescribing is included within the standards 6 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

7. Antimicrobial Management Teams (AMT) Core activities: Develop and implement local antimicrobial policies for hospital and primary care Monitor antimicrobial use at local level– antibiotic usage data and compliance with antimicrobial policy Ensure clinical staff educated and trained in use of antimicrobials Feed back data on antimicrobial use and surveillance to prescribers 7 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

8. 8 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

9. NHS your name AMT Lead doctor – Consultant Microbiologist – Antimicrobial Pharmacist – Prevention and Control of Infection representative – Primary Care representative - 9 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

10. Antimicrobial policies Separate policies for hospital and primary care Evidence-based guidance on empirical treatment of common infections Alternative choices for penicillin-allergic patients Antibiotic name, dose, frequency, route and duration Hospital – guidance on IV to oral switch therapy (IVOST) Must be reviewed by AMT annually. 10 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

11. NHS your name Antimicrobial Policies Details of access – booklets, intranet, posters Hospital policy – key features of presentation of information 11 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches

12. Section Two Diagnosis of infection and clinical decision making 12

13. 13 Diagnosis of infection Definition of sepsis and infection severity indicators Sepsis: Clinical symptoms of infection (pyrexia, sweats, chills, rigors) Plus – 2 or more of the SIRS* criteria:Temperature 38 °C Heart rate > 90 bpm Respiratory rate > 20/minute WCC 12 x 10 9 /L Severe sepsis: Sepsis + organ dysfunction/hypoperfusion (oliguria, confusion, acidosis, hypotension) Note: The above features may be masked in specific situations e.g. immunosuppression, The elderly and in patients on certain medications ( β -blockers, corticosteroids, etc.) *SIRS = Systematic Inflammatory Response Syndrome SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making

14. Microbiology samples Will a sample aid diagnosis and management of the suspected infection? What sample(s) are required? – blood culture, urine, sputum, wound swab? Take sample before starting empirical treatment (except suspected meningitis) In severe infections empirical treatment should be started without waiting for the microbiology results 14 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making

15. Interpreting Microbiology reports Is the microbiology report relevant? Does the patient need antibiotics? Which antibiotics should be used? Do I need to discuss this case with a microbiologist? 15 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making

16. Factors affecting choice of antibiotic Likely organism and site of infection Culture and sensitivity results Patient characteristics e.g. diseases, allergies, medication, renal/hepatic function, pregnancy, breastfeeding Infection/severity indicators Spectrum of antimicrobial activity Formulations available Relevant cautions/contra-indications/side effects Risk of C. difficile 16 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making

17. Section Three Prudent antimicrobial prescribing 17

18. Some facts about antibiotics 1/3 of hospital inpatients receive antibiotics 1/3 to ½ are inappropriate Up to 30% of all surgical prophylaxis is inappropriate Antimicrobials account for 30% of hospital pharmacy budgets Inappropriate use leads to resistance, C. difficile, increased morbidity & mortality, increased cost and litigation 18 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

19. Using antibiotics prudently Is an antibiotic required? What is optimum choice and duration? Minimise risk to patient – HAI, drug toxicity Document decision making Ask for advice if unsure 19 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

20. Requirements for medical notes Document indication for antibiotic treatment and antibiotic(s) prescribed Document duration or review date - unnecessarily long courses of antibiotics put patients at risk of HAI and antimicrobial resistance Document any advice received from microbiology or pharmacy. 20 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

21. Requirements for antibiotic prescriptions Correct choice of drug – as per local policy Correct dose – inadequate dosage results in ineffective treatment and selects for resistance Correct frequency – essential for effective treatment Correct duration – as per local policy 21 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

22. Duration of antibiotic treatment Duration depends on site of infection and infecting organism Antimicrobial policies always state recommended duration Most common infections do not require treatment for longer than 7 days Some exceptions are atypical pneumonias, endocarditis, UTIs in males, meningitis 22 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

23. Common problems with antibiotic prescribing and administration Wrong antibiotic – drug, dose, frequency, route, duration Penicillin-allergic patients prescribed a penicillin Empirical antibiotics not reviewed when microbiology results available Missed doses – can have serious consequences. 23 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

24. Problems caused by inappropriate use of antibiotics Patient: Drug toxicity or ineffective treatment Allergic and adverse reactions Healthcare associated infection – MRSA or C. difficile infection Population (society): Emerging antimicrobial resistance 24 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

25. Concordance Concordance with antibiotic treatment is important in reducing resistance Patients need information about antibiotics -course length, when to take, potential adverse effects, interactions with food or other medicines 25 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

26. Information on use of antimicrobials Local antimicrobial policy – intranet link Microbiology – names /phone & bleep numbers Antimicrobial pharmacist – name /phone & bleep number Infectious Diseases consultant – name /phone & bleep number 26 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing

27. Section Four Antimicrobial use in hospital 27

28. Indications for IV antibiotics Sepsis, severe sepsis or deteriorating clinical condition Febrile with neutropenia/immunosuppression Deep-seated/specific infections: bone/joint, moderate to severe cellulitis, deep abscess, endocarditis, meningitis Oral route compromised: vomiting, nil by mouth, severe diarrhoea, swallowing disorder, unconscious, malabsorption 28 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

29. IV to oral switch therapy (IVOST) policy Review patient daily If answer to all of following questions is NO, switch to oral route -Oral route compromised? -Continuing sepsis or deteriorating condition? -Special indication for IV therapy? -Antimicrobial only available in an IV formulation? 29 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

30. Gentamicin Indicated for treatment of gram negative infections and in surgical prophylaxis High or prolonged dosage can lead to renal or ototoxicity Dosage based on weight and renal function - on-line calculator should be used where possible. See local policy for details. 30 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

31. Gentamicin monitoring Blood sample should be taken 6-14 hours after first dose Level interpreted using a nomogram (Glasgow or Hartford) – see local policy for details Subsequent doses given every 24, 36 or 48 hours Seek advice from microbiology or Infectious Diseases before continuing treatment beyond 72 hours 31 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

32. Vancomycin First line agent for MRSA infections and may be used for surgical prophylaxis in patients at risk of MRSA Loading dose given based on body weight then subsequent doses based on renal function Must be administered by slow IV infusion to avoid shock-like syndrome and thrombophlebitis 32 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

33. Vancomycin monitoring Check level immediately before 3 rd or 4 th dose Target level is 10 -15 mg/L (15-20mg/L for severe infections) Seek advice from pharmacy or microbiology on dose adjustment. 33 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

34. Surgical prophylaxis Single dose antibiotic prophylaxis recommended in SIGN 104 List of procedures where prophylaxis is recommended Avoid cephalosporins where possible due to C. difficile risk Consult local policy for details 34 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

35. MRSA colonisation MRSA screening used to detect MRSA colonisation MRSA colonises skin and mucous membranes Colonisation presents risks for patients with open wounds and those undergoing surgical procedures Hospital patients who are MRSA positive may receive decolonisation therapy – disinfection of skin and nasal passages 35 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

36. Managing MRSA infection At one time up to 40% of Staph. aureus infections in UK were due to MRSA but this figure is falling Most common site is skin and soft tissues MRSA pneumonia, UTI and bacteraemia are less common First line treatment is IV vancomycin Alternatives include teicoplanin and linezolid – see local policy 36 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

37. C. difficile Gram positive, spore forming anaerobic bacillus which produces 2 main toxins, A and B Carried by 2% adults as part of normal large bowel flora and carriage increases with age C. difficile infection (CDI) is associated with significant morbidity and mortality Symptoms - diarrhoea with characteristic foul odour, abdominal pain, pyrexia, raised WCC and raised serum creatinine 37 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

38. Risk factors for C. difficile > 65 years of age Antibiotic exposure, especially ‘4C’ (clindamycin, cephalosporins, co-amoxiclav, ciprofloxacin) Prescription of proton pump inhibitors e.g. omeprazole, lansoprazole Serious underlying disease / surgery Prolonged hospital stay Inadequate cleaning of ward facilities and equipment Poor Hand Hygiene by patients and staff 38 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

39. Managing C. difficile Isolation with transmission based precautions Assess severity factors then prescribe either -Metronidazole 400mg TDS PO 10-14/7 (can be given IV if patient is NBM) or -Vancomycin 125mg QDS PO 10-14/7 (can only be given orally) 39 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

40. Useful Websites Scottish Antimicrobial Prescribing Group (SAPG): http://www.scottishmedicines.org.uk/smc/6616.html NES HAI portal: http://www.nes.scot.nhs.uk/hai Pause: http://www.pause-online.org.uk/ 40 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital

41. Section Five Antimicrobial use in primary care 41

42. explain the use of antibiotics in self-limiting conditions describe the value of patient information leaflets and delayed prescribing outline how primary care practice in use of antibiotics may influence healthcare associated infection and development of antimicrobial resistance identify local antibiotic choices for common infections explain the national prescribing indicators for antimicrobials and how these can be used to evaluate local practice identify the local availability of specialist advice on the use of antibiotics. 42 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Learning outcomes Section Five Antimicrobial use in primary care

43. Antimicrobials in primary care 80% of total antimicrobial use in humans is in primary care 60% of that is for respiratory infections Antibiotics are often prescribed for self-limiting viral infections 43 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

44. Upper respiratory tract infections (URTI) Most URTI are self-limiting and do not require antibiotics 92% of patients with acute rhino sinusitis are still prescribed antibiotics in primary care despite evidence that antibiotic therapy does not offer clinically significant benefit Antibiotics should be reserved for patients with severe or prolonged symptoms and evidence based criteria should be used to identify patients who are likely to benefit from treatment Doctors over-estimate patient demand for antibiotics Immediate prescriptions for conditions such as sore throats increase future consultations. 44 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

45. Strategies to reduce antibiotic use for URTIs Take detailed history, carry out full examination and ask directly about patient’s expectation for antibiotics. Do not prescribe antibiotics via telephone consultation. Reassure patients that antibiotics are not needed because they will make little difference to the symptoms and may have side-effects. Use a patient information leaflet to back up this advice. Consider using a delayed prescription if symptoms are not settling within a recognised time frame and give symptom management advice. Advise patients on the likely timescale for the illness: Acute otitis media – 4 DAYS Acute sore throat – 1 WEEK Acute rhino sinusitis – 2 ½ WEEKS Acute bronchitis – 3 WEEKS 45 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

46. Healthcare associated infections Healthcare associated infections (HAI) present in mainly in hospital and may also occur in the community in Care Homes and other long term care facilities Prescribing of antibiotics within primary care can influence development of HAI The development of C. difficile infection (CDI) can be driven by antibiotic use in the preceding 12 weeks, which is often in primary care Antibiotics associated with a high risk of CDI are cephalosporins, quinolones, clindamycin and co-amoxiclav Prescribers should follow the local antibiotic policy and where possible avoid the use of high risk antibiotics particularly in those patients over 65 years 46 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

47. Antimicrobial resistance Antibiotic use causes resistance through selective pressure Broad spectrum antibiotics select for resistant pathogens by eradicating natural flora Current problems with resistant organisms include: MRSA -methicillin resistant Staphylococcus aureus VRE - vancomycin resistant enterococci ESBL - extended spectrum betalactamase 47 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

48. Common infections: local antimicrobial policy choices Acute sore throat – Acute otitis media – Acute rhino sinusitis – Acute bronchitis – Exacerbation of COPD – Community acquired pneumonia – Urinary tract infection (women) – Cellulitis - 48 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

49. National prescribing indicators In 2009 a set of 41 prescribing indicators for antibacterials were developed within PRISMS Provide an overview of quantity and quality of antibacterial prescribing at NHS board, CHP and GP Practice level Can be used to identify outliers in terms of quantity of antibacterials prescribed and use of non- policy agents Total use of antibiotics is an example of a quantitative indicator Seasonal variation of quinolones is an example of a qualitative indicator 49 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

50. Information on use of antimicrobials Local antimicrobial policy – intranet link Microbiology – names /phone & bleep numbers Antimicrobial pharmacist – name /phone & bleep number Infectious Diseases consultant – name /phone & bleep number 50 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care

51. Useful resources on use of antibiotics in primary care Health Protection Agency guidance on primary care management of infections www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947340160 Scottish Antimicrobial Prescribing Group – Prudent antimicrobial use www.scottishmedicines.org.uk/files/sapg/Respiratory.pdf National Prescribing Centre Information on URTIs www.npci.org.uk/therapeutics/infect/commonresp/resources/pda_rti_general.pdf 51 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care