1. New Antibiotic guidelines April 2013
Dr Fiona Donald
Consultant Microbiologist
Nottingham

2. Outline of talk New antibiotic guidelines, summary of changes
Update on antimicrobial resistance
A bit about Microbiology

3. Antimicrobial guidelines – Why?
Simple, informed decision approach to prescribing
Evidence based and using knowledge of local resistance rates and target organisms
Saves money?
Rational use of antibiotics leads to less antibiotic resistance and fewer side effects
Educational tool
Fewer phone calls to Microbiology

4. Changes to guidelines - overview
Updates to national guidance eg from HPA, CKS, SIGN and NICE
Aim to reduce use of agents which will induce C difficile disease ie cephalosporins and quinolones
Shorter courses are now recommended for some conditions
Trying to stay ahead of resistant organisms

5. Changes to guidelines 2013 New sections on: Dental abscess
Diverticulitis
Additional antibiotics for multi-resistant UTIs
Linezolid added as amber 2 agent
Mastitis and breast abscess
Gonorrhoea

6. Changes to guidelines 2013 Updates on:
Community acquired pneumonia – add clarithromycin to amoxicillin
Whooping cough
Pelvic inflammatory disease/gonorrhoea – IM ceftriaxone, not cefixime
MRSA treatment and decolonisation
Meningococcal prophylaxis, ciprofloxacin now recommended
Shingles age to consider treatment now 50 yrs

7. Use of antibiotics
Antibiotics are essential to modern medicine but their abuse leads to resistance.
A single course of antibiotics in primary care leads to bacterial resistance to that antibiotic (BMJ 18th May 2010).
All staff who prescribe have a responsibility to their patients and for public health to prescribe optimally

8. Antibiotic side effects
Many
Skin, GI, CNS, drug interactions
Clostridium difficile infection
Cephalosporins, penicillins, quinolones, macrolides
Colonisation/infection with resistant bugs
MRSA
ESBL coliforms (NDM)
Candida (thrush)

9. Antibiotic Resistance
Has been called one of the worlds most pressing public health problems
In the US the annual cost of treating infections caused by just 6 types of multi-resistant bacteria exceeded the yearly cost of treating influenza
November 2009 EU/USA summit announced a task force to deal with the problem (BMJ 22nd May 2010)
Goal of developing 10 new antibiotics by 2020 (10 x 20 initiative, IDSA)

10. Local resistance patterns
But remember sampling bias

11. Local resistance patterns
Bur remember sampling bias

12. Local resistance patterns
But remember sampling bias

13. Local resistance patterns

14. Local resistance patterns

15. What can be done?
Rationalisation of prescribing of antibiotics in hospital and the community, use of guidelines
Good infection control practices
Education of the public
Rationalisation of the veterinary usage of antimicrobials, banning of antimicrobial growth promoters
Prevention of disease e.g. vaccination
Development of new antimicrobials or other drugs to beat bacteria

16. Antibiotic Resistant Superbugs
ESBL producing coliforms
Most often seen in community urine samples
Cause of UTI and sepsis
Only one reliable antibiotic available to treat infections, IV meropenem
Hardly any oral options
New strain NDM-1even more resistant

17. ESBL E.coli laboratory data
2008/09:
551 urines positive with ESBL E coli
257 NUH
294 GP/community
49 blood cultures (vs 469 non- ESBL E coli)
Currently around 9% of community acquired E coli bacteraemias are multi-resistant

18. New UTI antibiotics Fosfomycin and
Pivmecillinam (a type of penicillin)
Classified as Amber 2 agents
May be prescribed on the advice of a Medical Microbiologist
Used for oral treatment of multi-resistant UTI when no other oral option available

19. Diagnosis of UTI
Uncomplicated UTI in community – no need to send sample.
Send sample if no response to short course of first line treatment
If complicated UTI (eg pregnancy, loin pain, fever, catheter) send sample before treatment

20. Culture – chromogenic agar

21. Urine culture in men and women >65 years
Asymptomatic bacteriuria is common – one third of >65 yrs
Do not send for culture on the basis of a positive urine dip unless symptomatic
Do not treat asymptomatic bacteriuria, it does not reduce symptomatic episodes or mortality but does increase side effects and resistance rates

22. Urine culture in people with long-term catheters
Urine dipsticks are NOT useful, as catheters will normally become colonised with bacteria
Do not send urine for culture unless there are symptoms of infection
Do not treat asymptomatic bacteriuria in the presence of a catheter
Do not routinely give antibiotic prophylaxis for catheter changes

23. Clinical microbiology service
Based at QMC A floor West Block
All samples come here approx 800,000 per year
One third from GPs, two thirds from acute trusts
Sample processing and reporting carried out by biomedical scientists
Medical microbiologists provide the clinical leadership and interaction with clinicians

26. Gram-stain Gram-positive cocci Gram-negative cocci
Gram-positive bacilli
Gram-negative
bacilli

27. Role of Clinical Microbiology
Diagnose infections
From samples sent to us
By clinical discussion and seeing patients
Provide results on specimens
Electronically reported
Selected results are telephoned
Generate a discussion about a patient

28. Role of Clinical Microbiology
Surveillance
Data provided to local infection prevention and control teams
Locally to HPU and CCDC - particularly notifiable diseases
Nationally to HPA, CDSC, DH
Advice on diagnosis and treatment of infections

29. Further information Full guideline available at www.nottsapc.nhs.uk
Microbiology website at NUH
NUH antibiotic guidelines
Health Protection Agency/ (now Public Health England) website