1. Quality Education for a Healthier Scotland Multidisciplinary ScRAP Scottish Reduction in Antibiotic Prescribing Programme Prescriber Learning Event “Reducing the unnecessary prescribing of antibiotics” “Can we ScRAP the unnecessary antibiotic prescription?” October 2013 edition

2. Quality Education for a Healthier Scotland Multidisciplinary What are the barriers to decreasing antibiotic use?

3. Quality Education for a Healthier Scotland Multidisciplinary Introduction & contents Aim of ScRAP Facilitator led DVD presentation & discussion session What will be covered: What are the barriers to decreasing antibiotic use? Resisting resistance – Presenting the evidence – Local prescribing data Patient expectations – Examining a typical patient consultation Managing complications – Targeted use of antibiotics – Myth busters – Alternative strategies – delayed prescriptions Event closure

4. Quality Education for a Healthier Scotland Multidisciplinary http://www.youtube.com/watch?v=m5N3dcPmxW0

5. Quality Education for a Healthier Scotland Multidisciplinary Resisting resistance – presenting the evidence

6. Quality Education for a Healthier Scotland Multidisciplinary

7. Quality Education for a Healthier Scotland Multidisciplinary

8. Quality Education for a Healthier Scotland Multidisciplinary ESAC data 2003 Surveillance of antimicrobial consumption in Europe, 2003 ESAC data 2010 Surveillance of antimicrobial consumption in Europe, 2010 Antibiotic usage at a European population level United Kingdom Sweden

9. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic resistance at a European population level Goossens et al. Lancet 2005; 365: 579-587 Outpatient antibiotic use in Europe and association with resistance: a cross-national database study

10. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic resistance at practice population level Butler et al. Br J Gen Pract 2007; 57, 785 Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices. Quartile 1Quartile 2Quartile 3Quartile 4Overall Ampicillin Year 1 %58.750.649.250.051.3 Year 7 %53.551.051.649.751.2 Reduction % (95% CI)5.2(2.9 to 7.4)-0.4 (-2.3 to 1.5)-2.4 (-4.1 to -0.7)0.3 (-1.4 to 2.0)0.0 (-0.9 to 1.0) Trimethoprim Year 1 %29.126.626.525.5 Year 7 %25.724.925.024.725.0 Reduction % (95% CI)3.4 (1.3 to 5.4)1.7 (0.1 to 3.3)1.5 (0.0 to 2.9)0.8 (-0.7 to 2.3)0.4 (-0.8 to 1.7) Reduction (%) in resistance to ampicillin & trimethoprim over a 7-year period, by quartile of reductions in total antibiotic prescribing

11. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic resistance at patient level Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic The effect is greatest in the month immediately after treatment but may persist for up to 12 months This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community Costelloe et al. BMJ 2010:340 c2090 Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis

12. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion What information did you already know? What information was new? What has the information added to your understanding of antimicrobial resistance? How do you think this might affect how you interact with patients in the future?

13. Quality Education for a Healthier Scotland Multidisciplinary Resisting resistance – local prescribing data

14. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

15. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

16. Quality Education for a Healthier Scotland Multidisciplinary Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

17. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion Antibiotic use at local level How does your antibiotic usage compare with other local practices in your health board? Was your antibiotic use higher or lower than you expected? How has your antibiotic usage changed over time? Was the change in your antibiotic usage more or less than you expected? Key points from local guidelines

18. Quality Education for a Healthier Scotland Multidisciplinary Patient expectations – e xamining a typical patient consultation

19. Quality Education for a Healthier Scotland Multidisciplinary Expectations – but whose are they really?

20. Quality Education for a Healthier Scotland Multidisciplinary Expectations – but whose are they really? Health care professionals over-estimate patient demand for antibiotics In patients with bronchitis, antibiotic prescribing had no effect on patient satisfaction scores Whereas careful physical examination did V Duijn et al. Br J Gen Pract. 2007 July 1; 57(540): 561–568. Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms

21. Quality Education for a Healthier Scotland Multidisciplinary Patient consultation video

22. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion ICE approach (Matthys et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing Br J Gen Pract. 2009 January 1; 59(558): 29–36) Examination and its role in patient satisfaction Treating concerns not desires Explanation – not a battle of wills Explanation – natural history of infection Safety net option Any changes to consultation technique?

23. Quality Education for a Healthier Scotland Multidisciplinary Managing complications – targeted use of antibiotics

24. Quality Education for a Healthier Scotland Multidisciplinary Targeted use of antibiotics The antibiotic revolution should be more focused... “Our mission is not to prescribe as few antibiotics as possible, but to identify that small group of patients who really need antibiotic treatment and to explain, reassure and educate the large group of patients who don’t.” Van Duijn et al. Br J Gen Pract. 2007 Jul;57(540):561-8. Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms

25. Quality Education for a Healthier Scotland Multidisciplinary Targeted use of antibiotics The following subgroups of patients in whom an immediate antibiotic strategy should be considered depending on clinical assessment of severity ; Bilateral acute otitis media in children younger than two years Acute otitis media in children with otorrhoea Acute sore throat / acute pharyngitis / acute tonsillitis where three or more Centor Criteria* are present A delayed prescription or no prescription strategy may also be considered National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) *Centor criteria Tonsillar exudate Tender anterior cervical lymphadenopathy History of fever Absence of cough

26. Quality Education for a Healthier Scotland Multidisciplinary Targeted use of antibiotics An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations: Systemically very unwell Symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) High risk of serious complications because of pre-existing comorbidity eg significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69)

27. Quality Education for a Healthier Scotland Multidisciplinary Targeted use of antibiotics If patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria:  Hospitalisation in previous year  Type 1 or type 2 diabetes  History of congestive heart failure  Current use of oral glucocorticoids For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69)

28. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion Does this information help you understand more clearly the place in therapy of antibiotics in respiratory tract infections? Are there instances where you have treated patients out with these criteria? Do you feel more confident in not prescribing an antibiotic out with the criteria?

29. Quality Education for a Healthier Scotland Multidisciplinary Managing complications – myth busters

30. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – value of antibiotics in RTI Without antibiotics 40% will resolve after 3 days and 90% after 7 days The NNT (Number Needed to Treat) was 6 to half pain at day 3 Acute sore throat Spinks et al. Antibiotics for sore throat. Cochrane database for systematic review issue 4 2006

31. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – value of antibiotics in RTI 80% resolve in 14 days with no antibiotics Antibiotics have a small benefit after 7 days of illness (NNT = 15) There was no additional benefit of antibiotics in older patients, more severe pain or longer duration of symptoms Acute Rhinosinusitis Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database for systematic reviews issue 2 2008

32. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – value of antibiotics in RTI 66% of children are better within 24 hours and antibiotics have no effect on symptoms 90% of children are better in 2 to 7 days and antibiotics have only a small effect on reducing pain by 16 hours (NNT =15) Acute Rhinosinusitis Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database for systematic reviews issue 2 2008

33. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – value of antibiotics in RTI Antibiotics reduced symptoms by only one day in an illness lasting up to 3 weeks Acute Cough / Bronchitis Fahey et al. Antibiotics for acute bronchitis. Cochrane database for systematic reviews issue 4 2004

34. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – value of antibiotics in RTI 66% of children are better within 24 hours and antibiotics have no effect on symptoms 90% of children are better in 2 to 7 days and antibiotics have only a small effect on reducing pain by 16 hours (NNT =15) Acute Otitis Media Sanders et al. Antibiotics for acute otitis media in children. Cochrane database for systematic reviews issue 1 2004

35. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – preventative value of antibiotics in RTI Overall NNT > 4000 to prevent one case of quinsy Centor score of 3 or 4 = 1:60 chance of quinsy Centor criteria: Tonsillar exudate Tender anterior cervical lymphadenopathy History of fever Absence of cough Sore throat and quinsy Peterson et al. Protective Effects of antibiotics.BMJ 2007;335:982-984 Centor et al. The diagnosis of Strep throat in adults in the emergency room. Med Decision Making 1981;1:239-46

36. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – preventative value of antibiotics in RTI It would take 12 working life times of a GP to see one case of Rheumatic Fever Treating sore throats with antibiotics has no effect on risk of developing Rheumatic Fever Rheumatic Fever Howie et al. Antibiotics, sore throat and rheumatic fever. BJGP 1985; 35 : 223-224

37. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – preventative value of antibiotics in RTI Glomerulonephritis is a rare condition (2.1 per 100,000 children) and is not prevented by treating sore throats with antibiotics Glomerulonephritis Taylor et al. Antibiotics, sore throat and acute nephritis. BJGP 1983; 33 : 783-786

38. Quality Education for a Healthier Scotland Multidisciplinary Myth busters – giving an antibiotic does no harm? The benefits of antibiotics have to be carefully balanced against their harm Most antibiotics can cause gastrointestinal effects such as nausea, vomiting and diarrhoea in some patients In addition, a number can cause serious rashes and skin reactions The harm of antibiotics British National Formulary 2013;64 Reviews of antibiotics in people with respiratory tract infections have found that, for every 16 people treated with antibiotics, rather than placebo, 1 person will suffer an adverse event The harm of antibiotics Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Review. 2004

39. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion Does this information help you understand more clearly the place in therapy of antibiotics in respiratory tract infections? Are their instances where you have treated patients with an antibiotic in these clinical situations? Do you feel more confident in not prescribing an antibiotic in these clinical situations as a result of the evidence?

40. Quality Education for a Healthier Scotland Multidisciplinary Managing complications- alternative strategies: delayed prescriptions

41. Quality Education for a Healthier Scotland Multidisciplinary Delayed prescriptions Spurling et al. Cochrane Database of Systematic Reviews 2007, Issue 3.Cochrane 2007 Delayed antibiotics for respiratory infections. Delayed prescriptions substantially reduce antibiotic use but might slightly worsen some symptoms compared with immediate prescriptions Delayed prescriptions might also reduce re-consultation rates For mild upper respiratory tract infections delayed prescriptions are not associated with important negative consequences

42. Quality Education for a Healthier Scotland Multidisciplinary Delayed prescriptions Spurling et al. Cochrane Database of Systematic Reviews, Issue 4.Cochrane 2013 Delayed antibiotics for respiratory infections. Update of 2007 Most clinical outcomes show no difference between strategies Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%) but not compared to none (87% versus 83%) In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics

43. Quality Education for a Healthier Scotland Multidisciplinary Delayed prescriptions National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) When using delayed antibiotic prescriptions, patients should be offered: Reassurance that antibiotics are not needed immediately since likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs Advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription. A delayed prescription with instructions - either given to patient or left at an agreed location to be collected at a later date.

44. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion Any experience of delayed prescriptions? How important is patient information in a delayed prescription strategy? Is a delayed prescription strategy worthwhile trialling in this practice?

45. Quality Education for a Healthier Scotland Multidisciplinary Event closure

46. Quality Education for a Healthier Scotland Multidisciplinary Facilitator lead discussion Next steps What strategy are we going to take to move forward? Changes to consultation style and/or delayed prescriptions? Can we reach a practice consensus? How we can measure progress? Evaluations (health board specific & CPD)