1 5 December, 2017 TARGET Antibiotics 1. The top part of this notes section is for presenters to use during the workshop, and can be used verbatim or paraphrased. Extra notes below contain extra background information about the evidence base for the information on the slides and details about the references quoted, or how to obtain particular information or resources. Underlined notes are instructions. If you want to use the voice over at any time please make sure your laptop or PC has functional speakers and they are not on mute. While you are waiting for staff to arrive it is really useful to get them to think about their current antibiotic prescribing practice by getting them to complete the self-assessment checklist available at Giving them the TARGET patient leaflet to look at (available at ) Print out and ask the group to consider and chat about some of the case studies in the slides at the end of the presentation. Lets begin! Slide one presenter notes: I hope you all agree with the UK Chief Medical Officer, Dame Sally Davies, that “There are few public health issues of potentially greater importance for society than antibiotic resistance” but lets take a moment to reflect. Next slide. “There are few public health issues of potentially greater importance for society than antibiotic resistance” 2013 CMO Prof Dame Sally Davies TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

2 Context 5 December, 2017 If we don’t tackle drug resistant infections now, they could kill an extra 10 million people across the world each year by 2050. In the UK, 80% percent of antibiotic prescribing occurs in the community. National developments to optimise and incentivise antibiotic prescribing (antimicrobial prescribing indicators, Quality Premium, NICE Guideline NG15, Patient Safety Alert). So, there is much information out there about the threat and consequences of antimicrobial resistance. We know that around 80% of antibiotic prescribing takes place in primary care and many of these are for respiratory tract infections. There have been a number of initiatives and developments at a national level to get people thinking more responsibly about antibiotic prescribing. NICE issued guidance on Antimicrobial Stewardship (NG 15); the NHS and Public Health England jointly issued a Patient Safety Alert around AMS; there are prescribing quality measures and incentives and the DH would like us to get back to the level of prescribing that we had in 2010. The TARGET Guide to Resources provides more detail on these measures, and the TARGET toolkit helps you to optimise your use of antibiotics. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

3 TARGET: Self Assessment Checklist to complete while waiting for whole team5 December, 2017 Presenter notes: We suggest you send this to practice staff before the event or give it out as soon as you arrive – while you are waiting for all staff to gather. Go through self-assessment check list with the staff, this acts as a very good ice breaker and can be referred back to during the session. The Primary Care Self Assessment tool is a tool for you to decide and measure how far you are along the road to optimising antibiotic prescribing in your practice. It highlights the different strategies you can use and how you can find resources to support these strategies. This tool is a guide to providing strategies that may help to optimise antibiotic prescribing in primary care. There is also a separate part for commissioners which it would be useful for trainers to access and complete to see how well their local area is doing. Presenter notes – we suggest at this point you get them to have a quick look to see how many of the 13 strategies they are using to optimise antibiotic prescribing in their practice. Make sure you are familiar with the local antibiotic guidance and how they can access it, how you can help with audits, and Read codes. Encourage the practice to identify a lead for prescribing, and if possible book another visit to go over their progress with local indicators of antibiotic prescribing and their use of the resources. Encourage the practice again to use leaflets and posters and if possible put some antibiotic posters up while you are there. Are the laboratory protocols for reporting antibiotic susceptibility in line with local antibiotic guidance. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

4 Aims of this workshop Brief background5 December, 2017 Brief background Discuss some clinical cases where we could improve our antibiotic prescribing Suggest strategies and share materials Show the evidence for using the materials Provide evidence showing the link between antibiotic prescribing and resistance in your patients Show how reducing antibiotic prescribing can reduce antibiotic resistance, and also patient consultations Presenter notes: The aims of this workshop are to discuss with you, using clinical scenarios, the need for optimising antibiotic prescribing, by showing you the: evidence that there is a link between antibiotic prescribing and resistance in GP patients how reducing antibiotic prescribing can not only reduce antibiotic resistance, but also patients’ future expectations for an antibiotic and a consultation. We will also discuss and share materials and strategies (and the evidence behind them) that can help us together with our hospital and veterinary colleagues improve our antibiotic prescribing TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

5 Simpson et al. J. Antimicrob. Chemother. 2007;59:292-6. ESPAUR 20155 December, 2017 What do you think about antibiotic resistance? Is it important in your practice? UK research indicates GPs recognise the wider importance of resistance Not a problem in their practice Believe hospitals/other prescribers e.g. vets also main contributors to resistance BUT 80% of antibiotics are prescribed in general practice Presenter notes: Lets take a moment to reflect. What do you think about antibiotic resistance? Is it important in your practice? (Pause for feedback) Does your own antibiotic prescribing influence antibiotic resistance in your patients or community? (pause for feedback) Click to bring in second part of slide text Interviews with GPs indicate that: GPs recognise the wider importance of resistance But they don’t really think that it is a problem in their own practice And they believe that hospitals and other prescribers such as vets are as important or more important contributors to resistance. Click to bring in third part of slide text However this data shows that 80% of antibiotics are prescribed in the community and therefore GP staff hold much of the responsibility for rising use and antibiotic resistance. However this doesn’t mean that the other groups antibiotic prescribing is not important. In deed it is and that is why there is the Start Smart Then Focus strategy in hospitals, and a strategy to improve antibiotic prescribing in animals. Extra notes for reference Simpson et al Simpson et al. conducted qualitative research with the aim of achieving a deeper understanding of GPs’ perceptions of antimicrobial resistance. Methods: Forty GPs were interviewed, 26 from high fluoroquinolone prescribing practices and 14 from average fluoroquinolone prescribing practices. Results: Most GPs were concerned about the broad issue of antimicrobial resistance and agreed that it was a growing problem. However, many said they infrequently encountered its consequences in their everyday practice and some questioned the evidence linking their prescribing decisions to resistance and poorer outcomes for their patients. They felt conflicted by their apparent inability to influence the problem in the face of many other competing demands. A number said they would welcome more information from their microbiological colleagues about resistance patterns locally, and felt that undergraduate and graduate education about antimicrobial prescribing and resistance should be enhanced. However, a few mentioned that a heightened awareness of antimicrobial resistance locally may cause them to prescribe more second line agents as empirical therapy. Conclusions: Antimicrobial resistance is only one of a range of important influences on GPs decisions whether or not to prescribe an antibiotic and is not the most immediate. These influences all need to be taken into account when promoting a more cautious use of antibiotics in primary care. More information from microbiologist colleagues about local resistance would be clinically useful, but on its own, may paradoxically influence some GPs to prescribe newer, broader spectrum agents more often. Hospitals outpatients Hospital inpatients Dentists Other General practice DDD / 1000 inhabitants/day Simpson et al. J. Antimicrob. Chemother. 2007;59: ESPAUR 2015 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

6 Prescribing: EU Community Antibiotic Consumption5 December, 2017 DDD per 1000 inhabitants per day (2013) Presenter notes: This slide shows where we are in the European league table of antibiotic use. We prescribe much less than Greece, which has a major resistance problem, but twice as much as the Netherlands which has a similar population to us. I suggest therefore that there is an opportunity to reduce our community antibiotic prescribing. The differences are partially due to cultural norms in the UK compared to other Northern EU countries who prescribe less for respiratory tract infections. Extra presenter notes: The EU expresses community antibiotic consumption in Defined Daily Doses per inhabitants and per day, which is slightly different to the ADQs used in the UK. Each bar refers to a specific country while the colours indicate the recorded consumption of the different antibiotic classes in that country. Total community antibiotic consumption ranged from 11.1 DDD per inhabitants and per day in Latvia to 39.4 DDD per 1,000 inhabitants and per day in Greece. As in previous years, antibiotics of the penicillin class were the most frequently used antibiotics in all countries . The UK still prescribes more than any of our northern European colleagues. DDDs (or if we used ADQs) is influenced by antibiotic dose, so as clinicians use of amoxicillin increases from 250 to 500mg routinely, the ADQs and DDDs increase, even if the number of items remains the same. © ECDC TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

7 Prescribing: What is happening to GP prescribing in England?5 December, 2017 Trends in prescribing of other antibacterial items excluding penicillins Presenter notes So let us now look at prescribing of antibiotics other than amoxicillin. Congratulations! Nationally prescribing of cephalosporins and ciprofloxacin (which should very rarely be used first line) has fallen over the last 5 years. These antibiotics are associated with MRSA, Clostridium difficile and selecting out resistance in UTI pathogens so it is excellent that these are decreasing – although the amount does vary by practice. Click to bring in next slide However there is increasing use of co-amoxiclav, which should very rarely be used as a first line agent. This seems to be replacing the use of ciprofloxacin and cephalosporins, but is associated with C.difficile. So we really do need to consider our use of this antibiotic and whether it is always needed when we prescribe it. In contrast there has also been increase in the use of nitrofurantoin and trimethoprim, which are recommended first line for UTI. Other antibiotics within the national guidance: macrolides and tetracyclines are also increasing so this is excellent. Especially as tetracyclines cause much less of a risk for developing C.difficile. ESPAUR 2015 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

8 Prescribing: What is happening to Primary Care prescribing in England?5 December, 2017 New cartoons 800 700 600 500 400 300 200 100 Items per 1000 patients FLU Andybiotic 12% increase 10% increase in Penicillins Presenter notes: So how are we doing in England? The antibiotic campaign in England following the publication of the 1998 Standing Medical Advisory Committee report, “The path of least resistance”3 led to a fall in community antibiotic prescriptions, but between 2007 and 2013 total antibacterial items prescribed have risen by about 12% with a 10% rise in penicillins (which includes amoxicillin, co-amoxiclav and flucloxacillin). The 10% rise is mainly amoxicillin for RTIs which equates to 350/1000 patients or 35%. Extra presenter notes: The chart above was taken from Apr 12 – Mar 13 Apr 99 – Mar 00 Apr 98 – Mar 99 Apr 01 – Mar 02 Apr 00 – Mar 01 Apr 03 – Mar 04 Apr 02– Mar 03 Apr 04 – Mar 05 Apr 11 – Mar 12 Apr 10 – Mar 11 Apr 09– Mar 10 Apr 08 – Mar 09 Apr 07– Mar 08 Apr 06 – Mar 07 Apr 05 – Mar 06 Penicillins Tetracyclines Macrolides Cephalasporins Sulphonamides & Trimethoprim Quinolines Metronidazeole & Tinidazole All other bacterial drugs © NHSBSA 2012 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

9 A meta analysis of English Primary CareEvidence: Risk of resistance persists for at least 12 months after your prescribing 5 December, 2017 Increased risk of resistant organism Antibiotic in past 2 months Antibiotic in past 12 months UTI 5 studies: n = 14,348 2.5 times 1.33 times RTI 7 studies: n = 2,605 2.4 times Presenter notes: The risk of resistance was even greater in the first two months after an antibiotic as shown here for UTIs and Respiratory Tract infections, but was still higher 12 months after antibiotic use for both UTIs and RTIs. Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection have an increased risk of subsequently carrying resistant organisms – so that the next time they have an infection it may be with one of these antibiotic resistant organism. So in conclusion, any antibiotic increases our future risk of carrying resistant bacteria. Details of paper: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; 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. Therefore in conclusion, individuals prescribed an antibiotic in primary care for a respiratory or urinary infection have an increased risk of carrying resistant organisms – so that the next time they have an infection it is with a antibiotic resistant organism. 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. A meta analysis of English Primary Care Costello et al. BMJ. (2010) 340:c2096. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

10 UK 5-year AMR Strategy 2013-18: Seven key areas for action5 December 2017 UK 5-year AMR Strategy : Seven key areas for action DH – High Level Steering Group (cross government) PHE Human health Defra Animal health DH Improving the evidence base through research Developing new drugs, vaccines and other diagnostics and treatments Strengthening UK and international collaboration Optimising prescribing practice Improving professional education, training and public engagement Better access to & use of surveillance data Improving infection prevention and control AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-Oredope EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope Impact of EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope & Ms Katerina (Aikaterini) Chaintarli TARGET antibiotics presentation Lancashire ppt

11 5 December, 2017 Quality Premium (QP) 2016/17 Maximum QP payment for a CCG expressed as £5 per head of population (AMR component worth 10% of the QP for CCGs) Primary care component: The required performance in 2016/17 must either be: a 4% (or greater) reduction on 2013/14 performance OR equal to (or below) the England 2013/14 mean performance of items per STAR-PU The number of co-amoxiclav, cephalosporins and quinolones as a proportion of the total number of selected antibiotics prescribed in primary care to either: - to be equal to or lower than 10%, or - to reduce by 20% from each CCG’s 2014/15 value The Quality Premium (QP) was introduced in 2015/16 to reward clinical commissioning groups (CCGs) for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities. The QP scheme was re-launched for 2016/17 and continues to have an AMR component. The AMR measure consists of two parts (each worth 50% of the Quality Premium payment available for this indictor): Part a) reduction in the number of antibiotics prescribed in primary care Part b) reduction in the proportion of broad spectrum antibiotics prescribed in primary care. Part a) reduction in the number of antibiotics prescribed in primary care. The required performance in 2016/17 must either be:  a 4% (or greater) reduction on 2013/14 performance OR  equal to (or below) the England 2013/14 mean performance of items per STAR-PU Part b) number of co-amoxiclav, cephalosporins and quinolones as a proportion of the total number of selected antibiotics prescribed in primary care to either: - to be equal to or lower than 10%, or - to reduce by 20% from each CCG’s 2014/15 value The elements can be met separately and paid separately – so if the CCG only attains a reduction in items the CCG will get paid that proportion. The money has to be spent on Quality improvement, and CCGs are not eligible if they are not going to meet their spending targets. Further information is available here: https://www.england.nhs.uk/resources/resources-for-ccgs/ccg-out-tool/ccg-ois/qual-prem/ TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

12 Prescribing: Your Data July 2015 – June 20165 December, 2017 Prescribing: Your Data July 2015 – June 2016 Total antibacterial Items/STAR-PU Vs Co-amoxiclav, Cephalosporin and Quinolone % Items Total antibiotic items/ STAR PU % of total: cephalosporins, co-amoxiclav and quinolones Darker dots = CCGs Presenter notes:– Antibiotic prescribing data is available from the NHS England Antibiotic Quality Premium monitoring dashboard here: This is free to access on the NHS England web site and will be updated at the start of each month. You should be able to access prescribing data for your CCG and insert it onto this slide. This scatter plot shows the variation in total number of antibiotic items on the vertical Y axis, and the % of the total that the co-amoxiclav, cephalosporin and quinolone items make up, on the horizontal X axis. As you can see there is a wide variation in use in total items across England, but also here locally in this CCG (seen in the darker dots). There is an even greater variation in the use of co-amoxiclav, cephalosporins and quinolones. This dot represents where you fall in the distribution compared to others in this CCG and nationally. You are … [describe location on the chart] The variation suggests that there is an opportunity for you to decrease your prescribing. e-PACT data in England TARGET antibiotics presentation Lancashire ppt

13 Prescribing: Local Data5 December, 2017 Prescribing: Local Data Total items prescribed per 1000 population per practice (2012/13) Presenter notes. This is another way of representing the data which you can also obtain from the e-PACT website. We have chosen to put the 3C antibiotics cephalosporins, ciprofloxacin and co-amoxiclav in the red tones to draw attention to them, and the antibiotics on the guidance in green or blue. As you can see there is a two fold variation in the number of items prescribed and the make up of the antibiotic use varies by practice. Some practices use more amoxicillin than others, and some use a lot of penicillin V presumably for sore throats. Discuss local data that can be obtained by following the steps below. Obtaining PCT antibiotic prescribing data: https://www.prescqipp.info/user/login TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

14 Possible Answers 5 December, 2017 How can we fit together the evidence and change behaviour during consultation with our patients to improve antibiotic prescribing? Practice GP Presenter notes: So how can we fit all of this evidence together and change behaviour within the practice consultation with our patients to improve prescribing? Evidence Patient TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

15 The TARGET Antibiotics Toolkit5 December, 2017 This toolkit is here to help clinicians and commissioners to use antibiotics responsibility and meet CQC requirements Presenter notes: So what is the TARGET Antibiotics Toolkit? TARGET stands for Treat Antibiotics Responsibly, Guidance, Education, Tools. The TARGET Antibiotics Toolkit is free on the RCGP website (and easy to find if you Google TARGET antibiotics). This is the landing page of the TARGET antibiotics website. The tools available on the website will help you to prescribe antibiotics responsibly and assist in the ensuring some of the Care Quality Commission regulations are met. The website has links to pages containing: Training resources for group or personnel continuing professional development around infections and antibiotic use. Patient information leaflets. A self-assessment check list like the one you just completed. Resources for clinicians to use in their waiting rooms. The PHE antibiotic and diagnostic guides. Other external links to other useful resources around antibiotic use. There is also a hard copy Guide to Resources. We will now go through some clinical scenarios, some evidence behind what can influence prescribing, and how the TARGET resources can be used to support changes in prescribing. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

16 Acute cough www.rcgp.org.uk/TARGETantibiotics 5 December, 2017Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. Allow the participants to discuss the case for 2 minutes and specifically ask several different people what they would do and /or prescribe. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

17 Acute cough 45 year old smoker with cough 1/52, green sputum.5 December, 2017 45 year old smoker with cough 1/52, green sputum. Temp 37.8°C. Has had several previous episodes of bronchitis and insists antibiotics ‘always help’. PEFR normal. Scattered course creps and wheeze, vesicular breath sounds, no focal crepitations. Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. Allow the participants to discuss the case for 2 minutes and specifically ask several different people what they would do and /or prescribe. It may be useful to also change the scenario slightly- how would this change if the patient was 81 years old and had been in hospital 6 months previously. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

18 TARGET acute cough: PHE Antibiotic Management Guidance5 December, 2017 ILLNESS COMMENTS DRUG ADULT DOSE Click on for child dose TREATMENT DURATION Acute cough bronchitis CKS6 NICE 69 Antibiotic little benefit if no co-morbidity1-4A+ Consider 7d delayed antibiotic with advice1,5A Symptom resolution can take 3 weeks. Consider immediate antibiotics if > 80yr and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR > 65yrs with 2 of above. Consider CRP test1a,4A if antibiotic being considered. If CRP<20mg/L no antibiotics, mg/L delayed, CRP >100mg immediate antibiotics amoxicillin or doxycycline 500mg TDS 200mg stat then100mg OD 5 days Presenter notes: We suggest you take your local guidance with you The TARGET website also has the national antibiotic guidance, which is used by most CCGs to develop their local guidance. This is a snapshot of the aims and principles of treatment section of the Management of Infection Guidance for acute cough. As you can see each section has links to other guidance, comments on when antibiotics should be used, recommended first and second line antibiotics dose and duration. For acute cough, we suggest that antibiotics have little benefit if no co-morbidity. We recommend amoxicillin first line; co-amoxiclav is not recommended second line, rather PHE recommends doxycycline second line. This PHE guidance on the TARGET website, also has an extensive rationale section which is really useful for trainers and trainees, or just when you want a bit more information for yourself or the patient. Presenter please tell the participants where to find your local guidance and how locums can get extra copies if needed. Rationale behind recommendations 1. NICE Clinical Guideline 69. Respiratory Tract Infections - antibiotic prescribing for self-limiting respiratory tract infections in adults and children in primary care. July RATIONALE: Describes strategies for limiting antibiotic prescribing in self-limiting infections and advises in which circumstances antibiotics should be considered. A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/chronic bronchitis. In the 2 RCTs included in the review, the delay was 7-14 days from symptom onset and antibiotic therapy. Patients should be advised that resolution of symptoms can take up to 3 weeks and that antibiotic therapy will make little difference to their symptoms and may result in side effects. Patients should also be advised to seek a clinical review if condition worsens or becomes prolonged. The evidence behind these statements is primarily from the studies referred to below. There has been no systematic review of the evidence of length of antibiotic treatment for acute cough or bronchitis when antibiotics are prescribed. However the NICE pneumonia guidance group found evidence for the efficacy of 5 days’ antibiotic to treat pneumonia; therefore it is reasonable to consider that 5 days would also be effective in bronchitis. 2. Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library, 2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd Accessed RATIONALE: Systematic review of nine studies (4 in primary care). Studies in primary care showed antibiotics reduced symptoms of cough and feeling ill by less than one day in an illness lasting several weeks in total. 3. Chronic cough due to acute bronchitis. Chest. 2006;129:95S-103S. RATIONALE: Clinical guidelines on managing cough associated with acute bronchitis. Large body of evidence including meta-analyses and systematic reviews does not support routine antibiotic use. 4. Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group. 2008;07: RATIONALE: Discusses the evidence to support self care and limiting antibiotic prescriptions. Systematic review of 13 RCTs found that antibiotics only modestly improved outcomes compared with placebo. 5. Francis N et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:2885. RATIONALE: Utilising an information booklet during primary care consultations for children with RTIs significantly decreased antibiotic use (absolute risk reduction 21.3% (95%CI, p<0.001). Reconsultation occurred in 12.9% of children in intervention group and 16.2% in control group (absolute risk reduction 3.3%, no statistical difference). There was no detriment noted to patient satisfaction in the intervention group. 6. Treatment of acute bronchitis available in Clinical Knowledge Summaries website: Accessed Acute exacerbation of COPD 1. Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Int Med 1987;106: RATIONALE: Describes the cardinal signs of an infective exacerbation of COPD and the evidence for commencing antibiotics. Randomised double blinded cross-over trial showed a significant benefit from using antibiotics. Success rate with antibiotic therapy 68% vs 55% with placebo. 2. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Management of exacerbations. Updated December Discusses the aetiology, pathophysiology and evidence based therapeutic management of COPD. Antibiotic therapy is stratified according to severity of disease. S. pneumoniae, H. influenzae, M. catarrhalis remain the predominant pathogens in mild disease. 3. Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care. NICE Clinical Guideline 12 February Accessed RATIONALE: A meta-analysis of nine trials found a small but statistically significant effect favouring antibiotics over placebo in patients with exacerbations of COPD. Effect size 0.22 (95% CI, 0.1 to 0.34). Four studies assessed whether there was a relationship between severity of exacerbation and the effectiveness of antibiotic use. Three of these studies suggest that the worse the COPD severity of exacerbation (lung function impairment (FEV1, PEFR), purulence of sputum) then the greater the degree of benefit from antibiotics. 4. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PMM. Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Thorax 2008;63: RATIONALE: In this meta-analysis they concluded that a short course of antibiotic treatment was as effective as the traditional longer treatment in patients with mild to moderate exacerbations of chronic bronchitis and COPD. The meta-analysis included 21 double-blind randomised clinical trials with 10,698 adults with exacerbation of COPD or chronic bronchitis, no antimicrobial therapy at the time of diagnosis and random assignment to antibiotic treatment for less than or equal to 5 days versus more than 5 days. At early follow-up (<25 days), the summary odds ratio (OR) for clinical cure with short treatment versus conventional treatment was 0.99 (95% CI 0.90 to 1.08). At late follow-up the summary OR was 1.0 (95% CI 0.91 to No trials of amoxicillin or doxycycline were included in the meta-analysis; however there is no microbiological reason that a 5 day course of these agents would be inferior to a 5 day course of clarithromycin in acute exacerbations of COPD. Available via PHE or RCGP websites with full rationale & references TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

19 Acute cough: feedback Antibiotic little benefit as no co-morbidity,5 December, 2017 45 year old smoker with cough 1/52, green sputum. Temp 37.8°C. Has had several previous episodes of bronchitis and insists antibiotics ‘always help’. PEFR normal. Scattered course creps and wheeze, vesicular breath sounds, no focal crepitations. Antibiotic little benefit as no co-morbidity, Consider no, or 7d back up antibiotic with safety netting, Share a leaflet with the patient – e.g. the TARGET leaflet, Advise patient symptom resolution can take 3 weeks. Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. In this case a no, or back-up antibiotic prescription (7 day) strategy with safety netting advice using a patient leaflet (see TARGET) could be used as the symptoms do not suggest immediate antibiotic use is required. But the clinician needs to assess how ”ill” he considers the patient is. NICE Clinical Guideline 69. Respiratory Tract Infections - antibiotic prescribing for self-limiting respiratory tract infections in adults and children in primary care. July The NICE guidance suggests a no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/chronic bronchitis. In the 2 RCTs included in the review, the delay was 7-14 days from symptom onset and antibiotic therapy. Patients should be advised that resolution of symptoms can take up to 3 weeks and that antibiotic therapy will make little difference to their symptoms and may result in side effects. Patients should also be advised to seek a clinical review if condition worsens or becomes prolonged. In a European study of 3,000 primary care patients with acute cough across 13 countries, clinical outcome was similar whether antibiotics were given or not (Butler et al BMJ:339 b 2242). In an RCT of amoxicillin 1g tds vs placebo in 2061 patients 18yrs with acute LRTI when pneumonia was not suspected. New or worsening symptoms were significantly less common in amoxicillin (15.9%) than in the placebo group 19.3% (NNT30). Nausea, rash or diarrhoea were significantly more common in the amoxicillin group (number needed to harm 21. There was no increased benefit those over 60 yrs (Little et al, Lancet Infect Dis 2013:123-9). In this same patient series those with a history of significant co-morbidities experienced a significantly greater reduction in symptom severity between days 2 & 4. Those with a short prior illness <7days, or non smokers antibiotics provided a modest benefit. (Br J Gen Pract 2014). TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

20 Hawker et al J AC 2014; Ashworth et al BJGP 2005.5 December, 2017 Prescribing: Consultations, and amoxicillin prescribing for acute cough and cold is increasing 537 UK GP practices Presenter notes: So why despite our discussions that we don’t usually prescribe for uncomplicated cases is prescribing increasing as shown in this graph? Think about your own prescribing – how often do you use amoxicillin for coughs? This data from general practices in England and Wales from the RCGP GP Research network shows that consultations for coughs and colds has increased since 2000, and the antibiotic prescribing has increased with it. The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in But there was marked variation in the percentage of patients in each practice that were prescribed antibiotics, in 2011 the 10th to 90th percentile range was 32%–65%. This variation was NOT influenced by age or social group. This study also looked at other infections: the proportion of GP consultations in which patients were prescribed antibiotics for sore throat was 62% in 2011 – but again with a wide range 10th to 90th percentile range of 45%–78%. There was a similar very wide range for the % of patients prescribed antibiotics who had a consultation for otitis media 63%–97% and all upper respiratory tract infections from 33%–74%. This suggests that all of us could probably reduce our antibiotic prescribing – but those at the higher end of the range could do so more than others. Think about your own prescribing – do you think you are at the upper end? If yes you may wish to consider CRP more actively CLICK TO BRING IN: In another longitudinal study Ashworth et al showed that practices that reduced their antibiotic prescribing also reduced their consultations for RTI, suggesting that patients can be retrained not to expect antibiotics and as a result consult less. So reducing your workload – or at least allowing you to concentrate on other things! Extra presenter notes from reference: Hawker et al. J Antimicrob Chemother. 2014: doi: /jac/dku291. Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995–2011: analysis of a large database of primary care consultations. This study measured trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice. Patients and methods: A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995–2011. Results: The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in There was marked variation by primary care practice in 2011 [10th–90th percentile range (TNPR) 32%–65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%–78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16–74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in All these changes in annual prescribing were highly statistically significant (P,0.001). Conclusions: The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs. Ashworth et al BJGP Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995–2000. analysed data from the General Practice Research Database, including all registered patients from 108 practices between 1995 and For each practice, numbers of consultations for acute respiratory tract infections and the proportion of consultations resulting in an antibiotic prescription were obtained. An age- and sex-standardised consultation ratio (SCR) and standardised prescription ratio (SPR) were calculated for each practice. We evaluated whether SPR and SCR values were associated. The results showed that for the mid-year data (1997), the crude consultation rate for all acute respiratory infections ranged from 125–1110 per 1000 registered patients at different practices; the proportion of consultations with antibiotics prescribed ranged from 45–98%. After standardising for varying age and sex structure of practice populations, practices with lower SPR values had lower SCR values (r = 0.41; P<0.001). This association was observed in each study year. Moreover, practices that demonstrated reductions in SPR between 1995 and 2000 also showed reductions in SCR (r = 0.27; P = 0.005). Consultation rates related to prescribing In a longitudinal study, practices who reduced prescribing experienced a reduced consultation rate Thus patients can be retrained not to expect antibiotics reducing your consultations Hawker et al J AC 2014; Ashworth et al BJGP 2005. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

21 The Patient Perspective: Why do patients do when they have an RTI?5 December, 2017 1,767 ≥15y in England 58% had RTI in last 6 months What did they do? 60% took OTC(50%) or alternative medicine(21%) for symptoms 37% took extra rest 20% Contacted or visited GP surgery 6% asked pharmacy for advice 1.4% used NHS direct 0.4% took left-over antibiotics 0% visited NHS walk in centre Presenter notes: Do patients expect antibiotics for RTIs? In a 2011 face to face survey in randomly selected homes, 58% of 1767 participants reported having an RTI in the past 6 months. Of these, the majority self-cared at home, taking symptomatic treatment, and / or extra rest. Only 20% contacted or visited their GP surgery, and only 6% asked their pharmacy for advice. However this is still a substantial burden on GP services, with 12% of the population seeking help for an RTI in a six month period. Next slide Extra presenter notes, reference abstract: Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. McNulty et al. Abstract Background Respiratory tract infection (RTI) is the commonest indication for community antibiotic prescriptions. Prescribing is rising and is influenced by patients’ consulting behaviour and beliefs. Aim To build up a profile of the ‘RTI clinical iceberg’ by exploring how the general public manage RTI, visit GPs and why. Design and setting Two-phase qualitative and quantitative study in England. Method Qualitative interviews with 17 participants with acute RTI visiting pharmacies in England, and face-to-face questionnaire survey of 1767 adults ≥15 years in households in England during January 2011. Results Qualitative interviews: interviewees with RTI visited GPs if they considered their symptoms were prolonged, or severe enough to cause pain, or interfered with daily activities or sleep. Questionnaire: 58% reported having had an RTI in the previous 6 months, and 19.7% (95% CI = 16.8 to 22.9%) of these contacted or visited their GP surgery for this, most commonly because ‘the symptoms were severe’; or ‘after several days the symptoms hadn’t improved’; 10.3% of those experiencing an RTI (or 53.1% of those contacting their GP about it) expected an antibiotic prescription. Responders were more likely to believe antibiotics would be effective for a cough with green rather than clear phlegm. Perceptions of side effects of antibiotics did not influence expectations for antibiotics. Almost all who reported asking for an antibiotic were prescribed one, but 25% did not finish them. Conclusion One-fifth of those with an RTI contact their GP and most who ask for antibiotics are prescribed them. A better public understanding about the lack of benefit of antibiotics for most RTIs and addressing concerns about illness duration and severity, could reduce GP consultations and antibiotic prescriptions for RTI. McNulty, Nichols, French, Joshi & Butler. British Journal of General Practice, 2013 e429) TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

22 The Patient Perspective: They visited their GP if they were worried5 December, 2017 The Patient Perspective: They visited their GP if they were worried 51% Symptoms severe 47% Symptoms not improved after several days 14% family or friends suggestion 11% Other health problem 9% I usually visit GP with these symptoms 5% Worried will infect others who may get very ill What did they expect? 53·1% Expected antibiotics 22% Other treatment for symptoms 24% Advice about self-care 12% Rule out more serious illness 7% Information about illness duration 6% A sick/fit note for work 3% For referral to hospital/specialist For Tamiflu Presenter notes: so why did patients visit their GP? Patients visited their GP because they were worried – either because the symptoms were severe (and this usually meant they kept them awake at night or off work, or gave them pain), or they had another health problem, or symptoms had not improved after several days, often after a weekend. A significant number reported that they usually visit the GP with these RTI symptoms, suggesting that these patients could be retrained not to expect a consultation. Bring in What did they expect and box What did they expect from their GP practice? Half the patients expected an antibiotic, indicating that there is a significant pressure on GPs to prescribe antibiotics. However many also expected advice about self-care, treatment for their symptoms, information about illness duration and reassurance that the illness wasn’t severe. As a result of this we have produced a patient leaflet addressing these issues which is available on the TARGET website, via EMIS, SystmOne and patient.co.uk. So to increase use in your practice you may want to consider developing a computer prompt to bring this up when you enter an RTI or antibiotic READ code. Extra notes for presenter: the patient leaflet can be accessed via: Presenter Add this phrase if not using next slide about patient trust in GPs – We know from the same survey of 1625 respondents that 88% of the general public trust their Gp’s advice and 69% trust their nurse’s advice as to whether they need antibiotics or not, so it is worth sharing information with patients in the consultation. McNulty, Nichols, French, Joshi & Butler. British Journal of General Practice, 2013 e429) TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

23 McNulty, Butler, et al Ipsos Mori 2014The Patient Perspective: A 2014 survey showed patients trust GPs’ and nurses’ advice 5 December, 2017 Presenter notes: We know patients trust you to give them advice. 88% of participants in a 2014 survey of 1625 randomly selected members of the English public reported that they trusted their GP’s advice as to whether they needed antibiotics or not; 69% trusted their nurse and 66% trusted their pharmacist. So there is a great opportunity for clinicians and pharmacists to share information with patients about the need or not for antibiotics. Extra presenter notes: The 2014 survey also showed that two-thirds of patients with an infection who visited a health professional (67%) received some information about the illness or antibiotics, but only a third received any printed information. – so there is an opportunity to do a lot more. This survey is also supported by another recent large Eurobarometer survey showing that 90% of the UK public would use their GP as a trustworthy source of antibiotic information. It’s worth sharing information about the need or not for antibiotics in consultations, and self care McNulty, Butler, et al Ipsos Mori 2014 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

24 Cals et al, BMJ 2009;338:1374, NICE clinical guideline 1915 December 2017 Evidence for CRP and communication in acute cough in general practice Care for LRTI Antibiotics prescribed Usual care 68% Communication skills and leaflet 33% CRP to aid diagnosis 39% Both CRP & communication 23% I M P A C3 T NICE: Patients with LRTI symptoms if diagnosis of pneumonia has not been made and it is not clear whether antibiotics are needed C-reactive protein mg/litre Management Less than 20 Do NOT routinely offer antibiotics Consider delayed antibiotic prescription Greater than 100 Offer immediate antibiotics The IMPACT study in the Netherlands showed that use of communication skills with GPs in which they shared information with patients halved antibiotic use. This supports the use of shared information. CRP alone was also very effective and the combination of both decreased antibiotic use the most. Click to bring in information about NICE: Thus NICE guidance now suggests that: For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C-reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. Use the results of the C-reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows: Do not routinely offer antibiotic therapy if the C-reactive protein concentration is less than 20mg/litre. Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C-reactive protein concentration is between 20mg/litre and 100mg/litre. Offer antibiotic therapy if the C-reactive protein concentration is greater than 100mg/litre. NICE clinical guideline 191. Diagnosis and management of community- and hospital-acquired pneumonia in adults. Issued: December https://www.nice.org.uk/guidance/cg191 Accessed Reference for the IMPACT study: Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. Jochen W L Cals, Christopher C Butler, Rogier M Hopstaken, Kerenza Hood, Geert-Jan Dinant. BMJ 2009;338:b1374 doi: /bmj.b1374. Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection. Design: Pragmatic, 2×2 factorial, cluster randomised controlled trial. Setting: 20 general practices in the Netherlands. Participants: 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection. Main outcome measures: The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement. Interventions: General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care. Results: General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was nonsignificant). Patients’ recovery and satisfaction were similar in all study groups. Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfactionwith care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care. Trial registration Current Controlled Trials ISRCTN Cals et al, BMJ 2009;338:1374, NICE clinical guideline 191 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

25 TARGET solution: Shared Patient Information5 December, 2017 All sections can be personalised and added to by the GP “Usually lasts” section educates patients about when to consult Safety netting Extra presenter notes: It would be useful to print off a copies of this leaflet and take enough with you for each GP. They can be found at The leaflet is also available on SystmOne and EMIS. The use of shared information about illness length, self-care and /or delayed/back-up antibiotic prescribing can help to reduce prescribing for less complex infections and can be supported by using the treating your infection leaflet. The leaflet has been developed through extensive feedback with patients and clinicians over the last 3 years. It is designed to be shared with the patient and completed with them during the consultation. Its aim is to increase the patients confidence to self-care, and to facilitate the use of back-up antibiotic, but it also allows the patients to go away with something, so ending the consultation on a positive note. Bring in personalised text box All sections can be personalised and added to by the GP. And it is important to share it with the patient and add extra infections , self-care instructions in the third column and alarm symptoms in the fourth column that may be required. Bring in ‘usually lasts’ text box The ‘usually lasts’ section allows patients to understand not only for this consultation but also others when they should consult. This section has consistently been seen as very useful by patients of all ages. Bring in safety netting box Whatever the infection, in this era of antibiotic resistance and with increasing numbers of elderly or vulnerable patients, it is extremely important to give some clear safety netting instructions. These are some that can be used and saved by patients. Bring in back-up prescription box The back-up prescription can reduce antibiotic prescribing by about 30 to 40%, and is extremely useful for particularly demanding patients or just before a weekend to reduce visits to out of hours services. Bring in information box Although most patients know they shouldn’t take antibiotics for coughs and colds, far fewer know that sinusitis, ear infections and sore throats and many other infections get better on their own without antibiotics. Likewise they know little about antibiotic resistance, so we should take every opportunity to educate them. In % of antibiotics were taken without a prescription, this is a particular problem in patients under 24 years. So take the opportunity to stress not to share antibiotics. There is a READ code for delayed/ back-up antibiotics or leaflet given and if you Read code the infections featured in the leaflet with EMIS and some other computer systems this leaflet will appear on your computer via the patient.co.uk system. Extra notes for presenter: Most prescribers have access to many leaflets, both paper ones and ones that can be printed off their computer system or the web. However, not all information resources are based on the best available evidence or have been developed through rigorous processes. The Antibiotic Information Leaflet has been developed through over 24 months of literature searching, consultation, focus groups with patients and staff, drafting and revision. Overview of the leaflet To use this leaflet properly, it is important that clinicians use it as a tool to interact with patients, rather than just handing it to them as a ‘parting gift’. In order to communicate this effectively you must make sure that you are very familiar with its content. Please make sure that, in addition to completing this training, you take some time to thoroughly familiarise yourself with the leaflet. Back-up prescription Information about antibiotics & resistance Read codes: Delayed:8CAk, Leaflet: 8CE TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

26 Acute cough: Reflect on actions your practice can take to improve prescribing5 December, 2017 Evidence Most patients with acute cough do not require antibiotics reducing antibiotic prescribing can reduce consultations Patients trust you to give reassurance and advice What actions can we agree for this year? Ideas from other GP staff and medicine managers Use antibiotic guidance so consistent approach in practice use NO, or back-up antibiotic and safety net Use the TARGET leaflet Consider CRP to guide in difficult cases Consider and audit of antibiotic use in acute cough Complete the free RCGP RTI clinical course Presenter notes: Thus Most patients with acute cough do not require antibiotics Reducing antibiotic prescribing can reduce consultations Patients trust you to give reassurance and advice What actions can we agree for this year? Try to get to get participants to suggest some of the things that others have used in their practice – including the things on this list. Use antibiotic guidance so consistent approach in practice – use the local or direct to the PHE one with rationale on the RCGP website, and make sure used by all in the practice Use NO, or back-up antibiotic and safety net – discuss how this could be done in their practice Use the TARGET leaflet: discuss how they use leaflets and if they know about the TARGET leaflet Consider CRP to guide in difficult cases or for clinicians with particularly high antibiotic use Consider and audit of antibiotic use in acute cough using the resource on the RCGP website Complete the free RCGP RTI clinical course TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

27 Urinary tract infection?5 December, 2017 35 year old Strong smelling urine, Dysuria over 2 days Frequency Recent laparoscopy and removal endometriosis Had trimethoprim in the past month for suspected UTI post operation What do you need to ask to determine treatment choice? Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. PHE and SIGN guidance both indicate that if Severe or ≥ 3 symptoms of UTI (Dysuria, Frequency, Suprapubic tenderness, Urgency, Polyuria, Haematuria)with no vaginal discharge or irritation that 90% of these case will have a positive urine culture and therefore empirical antibiotics should be given. If mild or 2 symptoms obtain a urine culture and dipstick if cloudy. If not cloudy consider another diagnosis. Additional advice from SIGN National guidance In SIGN. Management of suspected bacterial urinary tract infection in adults: a national clinical guideline. Scottish Intercollegiate Guidelines Network Accessed RATIONALE: Diagnosis in women: expert consensus is that it is reasonable to start empirical antibiotics in women with symptoms of UTI without urine dipstick or urine culture. Diagnosis in men: a urine sample is recommended because UTI in men is generally regarded as complicated (it results from an anatomic or functional abnormality) and there are no studies on the predictive values of dipstick testing in men. Duration of treatment for men: there is no evidence to guide duration of treatment; expert consensus is that 7 days of antibiotics should be used because men are likely to have a complicating factor. Second line treatment: resistance is increasing to all antibiotics used to treat UTI, if possible antibiotic choice should be based on microbiology results. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

28 Urinary tract infection: PHE guidance 20155 December, 2017 Treat women if severe/or ≥ 3 symptoms & no vag. discharge Women mild/or ≤ 2 symptoms AND Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% PPV; nitrite, leucocytes, blood all negative 76% NPV: Consider back-up / delayed antibiotic Use nitrofurantoin first line (if GFR over 45ml/min; GFR 30-45:only use if resistance & no alternative) as resistance & community multi-resistant ESBL increasing Trimethoprim (if low risk of resistance) and Pivmecillinam are alternative first line agents. Always safety net. In treatment failure: always perform culture Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. PHE and SIGN guidance both indicate that if Severe or ≥ 3 symptoms of UTI (Dysuria, Frequency, Suprapubic tenderness, Urgency, Polyuria, Haematuria)with no vaginal discharge or irritation that 90% of these case will have a positive urine culture and therefore empirical antibiotics should be given. If mild or 2 symptoms obtain a urine culture and dipstick if cloudy. If not cloudy consider another diagnosis and a delayed ?back up antibiotic. Presenter Bring in antibiotic guidance : Use nitrofurantoin first line (if GFR over 45ml/min; GFR 30-45:only use if resistance & no alternative) as resistance & community multi-resistant ESBL increasing Trimethoprim (if low risk of resistance) and Pivmecillinam are alternative first line agents. Always safety net. In treatment failure: always perform culture Additional advice from SIGN National guidance In SIGN. Management of suspected bacterial urinary tract infection in adults: a national clinical guideline. Scottish Intercollegiate Guidelines Network Accessed RATIONALE: Diagnosis in women: expert consensus is that it is reasonable to start empirical antibiotics in women with symptoms of UTI without urine dipstick or urine culture. Diagnosis in men: a urine sample is recommended because UTI in men is generally regarded as complicated (it results from an anatomic or functional abnormality) and there are no studies on the predictive values of dipstick testing in men. Duration of treatment for men: there is no evidence to guide duration of treatment; expert consensus is that 7 days of antibiotics should be used because men are likely to have a complicating factor. Second line treatment: resistance is increasing to all antibiotics used to treat UTI, if possible antibiotic choice should be based on microbiology results. PHE guidance also at TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

29 TARGET: Antibiotic and diagnostic Guides5 December, 2017 Antibiotic Management Guidance Fungal skin and nail infections Infectious diarrhoea H. pylori PVL S. aureus MRSA UTI Vaginal discharge Venous Leg Ulcers Presenter notes optional slide: Evidence based diagnostic guides can be found for each of the above topics These are some of the diagnostic guides available from Public Health England, which could help you to optimise your antibiotic use. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

30 Urinary tract infection? Alternative scenario in elderly patient5 December, 2017 80 year old resident in nursing home Strong smelling urine, but clear looking Increasing confusion over 2 days Positive dipstick – nitrites and leucocytes No history of fever, temp 37.4°C. Has had antibiotics in the past for suspected UTI Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. National guidance indicates that older men and women should not receive antibiotic treatment for asymptomatic bacteriuria. Mortality and the frequency of symptomatic episodes are not reduced, but for every three people given antibiotics, one will experience adverse effects (such as rash or GI symptoms) [Nicolle et al 1987]. In a cohort study, 318 elderly residents in care homes were followed for 9 years with urine cultures every six months [Abrutyn et al 1994]. Asymptomatic bacteriuria occurred in 25% of women >65years and 10% of men >65years. Although patients with bacteriuria had a higher mortality it was not an independent risk factor for mortality in elderly women without catheters. That is bacteriuria was an incidental finding and residents died with their bacteriuria rather than because of it. The treatment of UTI in older people should follow the same principles as in younger patients and should be based on whether the infection is uncomplicated or whether there is evidence of pyelonephritis or bacteraemia. In uncomplicated UTI (ie believed to be without renal tract or bladder pathology) a three day course of nitrofurantoin (if eGFR>44ml/min), pivmecillinam or trimethoprim may be used in women as systematic reviews have shown that there was no significant difference in persistent UTI, clinical failure or re-infection rates but side-effects were higher in those given 7 days treatment [Lutters et al 2002]. In men again antibiotics should only be prescribed if they are symptomatic. There is no evidence to guide duration of treatment; but expert consensus is that seven days of antibiotics should be used because men are more likely to have a complicating factor, and a urine sample is recommended [Grabe et al 2009]. Empirical diagnosis of UTI in delirium: Available evidence indicates that clinicians should only start empirical antibiotics and send urine for culture if a patient has two or more signs of infection, especially dysuria, fever > 38 o or new incontinence [Benton et al 2006-Loeb et al Conf, Loeb et al 2005]. A positive urine culture or dipstick test will not differentiate between UTI or asymptomatic bacteriuria, and there is no robust evidence for the use of leucocyte esterase or nitrite by urine dipstick testing in the elderly [SIGN 2006]. Patients with asymptomatic bacteriuria may also have white blood cells in the urine, as the immune system does not differentiate between asymptomatic carriage and infection. In older patients, diagnosis should be based on a full clinical assessment, including vital signs. In patients who can explain their symptoms, dysuria (as in younger women) is the most diagnostic symptom. For residents who do not have an indwelling catheter, minimum criteria for initiating antibiotics included acute dysuria alone or fever (>37.9ºC or 1.5ºC increase above baseline temperature) and at least one of the following: new or worsening urgency/incontinence, frequency, signs of irritation of the urinary tract such as suprapubic pain or flank or loin tenderness, or gross haematuria [Loeb et al Conf]. In addition UTI should be considered if there are signs of septicaemia and generalized illness: nausea, vomiting, rigors, new or increasing malaise and confusion, tachycardia, tachypnoea, poor peripheral circulation, reduced urine output, low blood pressure [SIGN 2006]. There is some concern that there may be some mismanagement of cases of UTI infection in the community. By 2011 E. coli accounted for almost one third (32.2%) of all bacteraemia reports in England, with a 35% increase between 2007 and Half of E.coli bacteraeimias were from a urogenital source, half had a healthcare interaction in the prior four weeks and 10% have a urinary catheter. This suggests that a proportion of community onset bacteriuria is being missed by clinicians in the community or inappropriate antibiotics are being given. Patients or their carers should be advised to collect and commence antibiotics prescribed promptly, and what symptoms or signs should prompt them to contact their GP again. For patients with recent hospitalisation or antibiotics or operation, consideration should be given to the prescription of pivmecillinam, co-amoxiclav or ciprofloxacin over trimethoprim, but if these are prescribed always safety net and send a urine specimen for culture and susceptibility, so that treatment can be modified on receipt of the culture result. What should you ask about? TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

31 Urinary tract infection?5 December, 2017 80 year old resident in nursing home, Strong smelling urine, but clear looking. Increasing confusion over 2 days. Positive dipstick – nitrites and leucocytes. No history of fever, temp 37.4°C. Has had antibiotics in the past for suspected UTI Criteria for initiating antibiotics include: Acute dysuria alone OR Fever (>37.9ºC or 1.5ºC increase above baseline) AND > 1 new or worsening urgency/incontinence, frequency, signs of irritation of the urinary tract such as suprapubic pain or flank or loin tenderness, or gross haematuria. Also look for signs of sepsis Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. National guidance indicates that older men and women should not receive antibiotic treatment for asymptomatic bacteriuria. Mortality and the frequency of symptomatic episodes are not reduced, but for every three people given antibiotics, one will experience adverse effects (such as rash or GI symptoms) [Nicolle et al 1987]. In a cohort study, 318 elderly residents in care homes were followed for 9 years with urine cultures every six months [Abrutyn et al 1994]. Asymptomatic bacteriuria occurred in 25% of women >65years and 10% of men >65years. Although patients with bacteriuria had a higher mortality it was not an independent risk factor for mortality in elderly women without catheters. That is bacteriuria was an incidental finding and residents died with their bacteriuria rather than because of it. The treatment of UTI in older people should follow the same principles as in younger patients and should be based on whether the infection is uncomplicated or whether there is evidence of pyelonephritis or bacteraemia. Signs of sepsis incude: nausea, vomiting, rigors, tachycardia, new or increasing malaise and confusion, low BP, tachypnoea, poor peripheral circulation, reduced urine output. In uncomplicated UTI (ie believed to be without renal tract or bladder pathology) a three day course of nitrofurantoin (if eGFR>44ml/min), pivmecillinam or trimethoprim may be used in women as systematic reviews have shown that there was no significant difference in persistent UTI, clinical failure or re-infection rates but side-effects were higher in those given 7 days treatment [Lutters et al 2002]. In men again antibiotics should only be prescribed if they are symptomatic. There is no evidence to guide duration of treatment; but expert consensus is that seven days of antibiotics should be used because men are more likely to have a complicating factor, and a urine sample is recommended [Grabe et al 2009]. Empirical diagnosis of UTI in delirium: Available evidence indicates that clinicians should only start empirical antibiotics and send urine for culture if a patient has two or more signs of infection, especially dysuria, fever > 38 o or new incontinence [Benton et al 2006-Loeb et al Conf, Loeb et al 2005]. A positive urine culture or dipstick test will not differentiate between UTI or asymptomatic bacteriuria, and there is no robust evidence for the use of leucocyte esterase or nitrite by urine dipstick testing in the elderly [SIGN 2006]. Patients with asymptomatic bacteriuria may also have white blood cells in the urine, as the immune system does not differentiate between asymptomatic carriage and infection. In older patients, diagnosis should be based on a full clinical assessment, including vital signs. In patients who can explain their symptoms, dysuria (as in younger women) is the most diagnostic symptom. For residents who do not have an indwelling catheter, minimum criteria for initiating antibiotics included acute dysuria alone or fever (>37.9ºC or 1.5ºC increase above baseline temperature) and at least one of the following: new or worsening urgency/incontinence, frequency, signs of irritation of the urinary tract such as suprapubic pain or flank or loin tenderness, or gross haematuria [Loeb et al Conf]. In addition UTI should be considered if there are signs of septicaemia and generalized illness: nausea, vomiting, rigors, new or increasing malaise and confusion, tachycardia, tachypnoea, poor peripheral circulation, reduced urine output, low blood pressure [SIGN 2006]. There is some concern that there may be some mismanagement of cases of UTI infection in the community. By 2011 E. coli accounted for almost one third (32.2%) of all bacteraemia reports in England, with a 35% increase between 2007 and Half of E.coli bacteraeimias were from a urogenital source, half had a healthcare interaction in the prior four weeks and 10% have a urinary catheter. This suggests that a proportion of community onset bacteriuria is being missed by clinicians in the community or inappropriate antibiotics are being given. Patients or their carers should be advised to collect and commence antibiotics prescribed promptly, and what symptoms or signs should prompt them to contact their GP again. For patients with recent hospitalisation or antibiotics or operation, consideration should be given to the prescription of pivmecillinam, co-amoxiclav or ciprofloxacin over trimethoprim, but if these are prescribed always safety net and send a urine specimen for culture and susceptibility, so that treatment can be modified on receipt of the culture result. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

32 Urinary tract infection PHE guidance Risk factors for resistance5 December, 2017 Risk factors for increased resistance include: care home resident, unresolving or recurrent UTI, hospitalisation >7d in the last 6 months, previous known UTI resistant to trimethoprim, cephalosporins or quinolones, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, If increased resistance risk: Send culture for susceptibility testing & give safety net advice. Nitrofurantoin is a good first-line choice If GFR<45 ml/min or elderly Consider pivmecillinam 400mg TDS for 3 days or fosfomycin (3g stat in women plus 2nd 3g dose in men 3 days later18) TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

33 Why do we need to worry about our antibiotic use in UTI?5 December, 2017 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

34 Evidence: Antibiotic resistance affects your patients with UTI5 December, 2017 Clinical outcomes of UTIs in English general practice treated with empirical trimethoprim Prospective study of 497 women (18–70 years) with ≥ 2 UTI symptoms Patients with p-value Resistant UTI Susceptible UTI Median time to symptom resolution (207) 7 days 4 days 0.0002 Re-consultation in first week or less (317) 17/44, 39% 17/273, 6% <0.0001 Further antibiotic in first week (317) 16/44, 36% 11/273, 4% Still had bacteriuria at 1 month (132) 8/19 42% 23/113, 20% 0.04 Presenter notes: So first what is the evidence that antibiotic resistance is important in your day to day practice? Maybe you could consider when you last had a patient with UTI reconsult after treatment. Pause see if there are nods or not This study looked at clinical outcome in acute uncomplicated UTI in women treated with empirical trimethoprim. Click for next part of the slide Patients with a UTI resistant to the antibiotic in the left column in red took twice as long to become asymptomatic compared to those with a susceptible organism shown in green. Furthermore 40% of those with a resistant organism reconsulted in the first week, compared to only 6% with a susceptible organism. In fact half of those patients who reconsulted in the first week had a resistant organism grown from their urine, and the majority of these had further antibiotics in that first week. And at one month 42% of those patients with a resistant organism still had the same resistant bacteria in the urine, and this would have been much greater but 11 of these 19 patients had received a second antibiotic. Extra notes for presenter, Study reference details: McNulty et al. studied whether patients with an uncomplicated community-acquired urinary tract infection (UTI) and an isolate resistant to trimethoprim had worse clinical outcomes following empirical treatment with trimethoprim 200 mg twice daily for 3 days than did those with a susceptible isolate. This was a prospective cohort study of clinical outcome where 497 women (18–70 years) presenting to general practitioner surgeries in Norwich and Gloucester with at least two symptoms of acute (<7 days) uncomplicated UTI were enrolled. Significant bacteriuria was defined as 104 cfu/mL from a mid-stream urine (MSU). The results showed that of enrolled patients, 75% (334/448) had significant bacteriuria and trimethoprim resistance was present in 13.9% (44/317) of isolates. Patients with resistant isolates had a longer median time to symptom resolution (6 versus 3 days, P = ), greater reconsultation to the practice (39% versus 6% in first week, P < ), more subsequent antibiotics (36% versus 4% in first week, P < ) and higher rates of significant bacteriuria at 1 month (42% versus 20% with susceptible isolate, P = 0.04). Half of patients reconsulting in the first week had a resistant organism. McNulty et al. J. Antimicrob. Chemother. (2006) 58 (5):  TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

35 Evidence: Antibiotic resistance is increasing5 December, 2017 Trimethoprim resistance by age group (Welsh data) Notes for presenter So although we can show that antibiotic resistance is important in individual patients with UTI and other infections (such as skin infections with MRSA) what is the evidence is it a significant problem in your own patients? This data from Welsh primary care patients (who I think would be considered similar to the rest of the UK!), shows that antibiotic resistance in organisms from urine specimens is slowly increasing, and is significantly higher in those over 80 years. This data does not represent the data for all patients presenting to you with acute uncomplicated UTI, as we know most GPs tend to only send urines to the laboratory from patients with recurrent UTI or persistent symptoms, but it certainly gives us some indication of the greater resistance in the elderly and how it is slowly increasing over time. It is likely to be about half the rate showed on this biased lab data in acute uncomplicated UTI in patients under 70 years, as the previous study I showed you the rate was 13% when the lab rate was 27%. What are the implications of this data? It suggests that nitrofurantoin may be a better choice first line in acute uncomplicated UTI as resistance is lower. However nitrofurantoin should not be used if upper UTI is suspected or the eGFR is less than 45 ml/min. Another choice may be pivmecillinam if your laboratory undertakes susceptibility testing on this antibiotic. Furthermore, all patients should be told to come back to the GP if their symptoms haven't improved by 3 days or have got worse despite antibiotics. Extra note for the presenter: If you have this data for your own area this will be much stronger information than presenting this information from Wales. If you send this slide to your local microbiology department they should be able to produce similar data for you. Routine laboratory data generated by the Welsh Antimicrobial Resistance Programme, Public Health Wales TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

36 Evidence: antibiotic use in UTI increases resistance5 December, 2017 Costelloe: Examined previous antibiotic use and subsequent resistance 5 studies of UTI with 14,348 patients in general practice This Forest plots shows individual study and pooled odds ratio of increased risk Antibiotic in last 6 months Increased risk (Odds Ratio) Antibiotic use decreases RESISTANCE increases RESISTANCE Steinke Any antibiotic 1.36 Donnan Trimethoprim 1.67 3.95 Hillier Amoxicillin 1.83 1.65 2.57 Metlay Sulpha / trim 4.10 Pooled results 14,348 pts 2.18 0.6 1 5 Presenters notes: So we have shown that resistance is important and is increasing – but does our antibiotic use cause increased risk of antibiotic resistant infections in our patients? This study goes some way to show that. These researchers examined 5 studies of UTI with 14,348 patients in primary care Presenter click to bring in table It found that antibiotic use in the past 6 months increased the risk of resistance two times. This forest plot shows risk of having a resistant organism if patients have had an antibiotic in the last 6 months. As you can see risk was increased in all the studies as the odds ratios are to the right of the line. Presenter click to bring in text Longer duration and multiple courses of antibiotics were associated with greater resistance. Details of paper: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; 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. Therefore in conclusion, individuals prescribed an antibiotic in primary care for a respiratory or urinary infection have increased risk of developing 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. Longer duration and multiple courses associated with greater resistance Costelloe C et al. BMJ 2010;340:bmj.c2096 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

37 Antibiotic resistance data from E.coli in blood cultures 2004 – 20135 December, 2017 Prescribing: As ciprofloxacin & cephalosporin use has decreased so has resistance Antibiotic resistance data from E.coli in blood cultures 2004 – 2013 Ciprofloxacin % blood culture isolates resistant Cephalosporin Presenter notes: With the decrease in ciprofloxacin and cephalosporin use over the last 9 years we have also seen a parallel decrease in resistance to ciprofloxacin and cefotaxime in blood cultures. 90% of E.coli bacteraemias are community acquired and therefore antibiotic use in the community has a great influence on these resistance rates. So congratulations – your decreased use of these agents is worthwhile and shows you can and do make a difference! Extra presenter notes: This is data from Public Health England. At least 50% of bacteraemias are related to the urinary tract and 10% to urinary catheters. The majority have had contact with a health professional in the previous 4 weeks – either in hospital or community setting. New data will be produced annually. Livermore et al Lancet Infectious Diseases 2013 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

38 Evidence: Antibiotics increase the risk of Clostridium difficile5 December, 2017 60% of all C.difficile diarrhoea is now community acquired – why? Significant association between any antibiotics in the past 4 weeks & C.difficile Community study Leeds & Truro % positive who had each antibiotic Presenters notes: Furthermore there is evidence that your antibiotic prescribing increases the risk of Clostridium difficile in your patients. In 2013 English surveillance data showed that half of all cases of C.difficile were community acquired and had no recent hospital visits. So what is causing this? There is evidence now that exposure to most antibiotics including amoxicillin increases your risk of C.difficile. Bring in first graph This case control study of 2000 patients with diarrhoea showed that 2% were positive for C.difficile toxin. Those who’d had two courses of antibiotics were at the greatest risk of C.difficile compared to controls. But patients who’d had a beta lactam, ampicillin or cephalosporin were also significantly more likely to have Clostridium difficile. Bring in second graph This second study is a very large meta-anlysis of both community and hospitalised patients to see which antibiotics put you most at risk of C.difficile. All antibiotics except tetracycline (that may be protective) put patients at increased risk of C.difficile – but some more than others – and the risk increases as you go down the bar chart. Here when the authors say penicillins they mean co-amoxiclav, ampicillin and amoxicillin as well as penicillin itself. In conclusion any antibiotic will increase your patients risk of C.difficile – so we need to consider this when prescribing. Extra notes for presenter on reference Wilcox et al. estimated the incidences of community-associated CDI in 2000 in two distinct settings in England, one urban (29.5 cases per 100,000 population) and the other rural (20.2 cases per 100,000 population), by examining faecal samples (n 2,000) submitted by general practitioners from individuals with diarrhoea in the community (214). In both settings, 2.1% of samples were cytotoxin positive. Notably, hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P 0.02). However, almost half of the cases had not received antibiotic therapy in the previous month, and approximately one-third had neither exposure to antibiotics nor recent hospitalization. Interestingly, contact with infants aged 2 years was significantly associated with CDI (14% versus 2%; P 0.02). Reference Deshpande et al JAC 2013 Eight studies (n¼30184 patients) met their inclusion criteria. Antibiotic exposure was associated with an increased risk of CA-CDI (OR 6.91, 95% CI 4.17–11.44, I2¼95%). The risk was greatest with clindamycin (OR 20.43, 95% CI 8.50–49.09) followed by fluoroquinolones (OR 5.65, 95% CI 4.38–7.28), cephalosporins (OR 4.47, 95% CI 1.60–12.50), penicillins (OR 3.25, 95% CI 1.89–5.57), macrolides (OR 2.55, 95% CI 1.91–3.39) and sulphonamides/trimethoprim (OR 1.84, 95% CI 1.48–2.29). Tetracyclines were not associated with an increased CDI risk (OR 0.91, 95% CI 0.57–1.45). Conclusions: Antibiotic exposure was an important risk factor for CA-CDI, but the risk was different amongst different antibiotic classes. The risk was greatest with clindamycin followed by fluoroquinolones and cephalosporins, whereas tetracyclines were not associated with an increased risk. Odds ratio for risk of C.difficiie Wilcox, Mooney et al. JAC 2008;62:388-96; Deshpande et al JAC 2013 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

39 NHS Organisation Targets for C. difficile infections:Consider: reduced 3Cs will also help reduce Clostridium difficile in the community 5 December, 2017 Reduce use of Ciprofloxacin Cephalosporins Co-amoxiclav Increase use of Nitrofurantoin Trimethoprim Pivmecillinam for UTI Trimethoprim still good for lower UTI in younger patients, or if known results Presenter notes: Reducing Clostridium in the community is a priority for many CCGs so you may wish to specifically address this in the priorities for each practice Reducing Clostridium in the community is a priority for many CCGs – you can help do this by specifically thinking about your prescribing of ciprofloxacin, cephalosporins and co-amoxiclav for UTI and only using co-amoxiclav when definitely needed. First line co-amoxiclav is only recommended for: Pyelonephritis in pregnancy Facial cellulitis or prophylaxis post dog or human bites Diverticulitis In UTI use macrodantin (which can be taken twice daily) first line unless e-GFR is below 45ml/min. Still consider trimethoprim in patients under 60 years with no risk factors for resistance. Consider pivmecillinam in the older patients if your lab undertakes susceptibility testing for it. Co-amoxiclav ONLY recommended for: Pyelonephritis in pregnancy Facial cellulitis or prophylaxis post dog or human bites Diverticulitis NHS Organisation Targets for C. difficile infections: TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

40 Evidence: Antibiotic use and Clostridium difficile vary by area5 December, 2017 A recent Public Health England report shows that total (hospital and general practice combined) antibacterial consumption is correlated with Clostridium difficile infection rate, across Area Teams. This initial PHE data suggests that about variation in total antibiotic use explains approximately 20% of the variation in Clostridium difficile across Area Teams, obviously more work needs to be done in this area to explain the reasons for the rest of the variation. So as antibacterial use increases, so does Clostridium difficile . This is another very good reason to only prescribe responsibly and reduce total antibiotic use, not just your broad spectrum antibiotics. PHE surveillance data, Susan Hopkins 2014. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

42 Consider: Audits can help inform your prescribing behaviour5 December, 2017 The TARGET website has audit templates for : UTI Sore Throat Acute cough Acute otitis media Otitis externa Acute rhinosinusitis Presenter notes: Have you done any personal or practice wide antibiotic audits in the last year? The self-assessment check list suggests a biannual practice wide antibiotic audit You keep a personal action plan following audits. Read coding facilitates audits The TARGET website has audit templates with appropriate guidance and Read codes to use for: Otitis media, Sore Throat, acute cough, UTI Audits. These will also help you comply with your CPD and revalidation. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

43 How could your practice decrease 3Cs antibiotic prescriptions for UTI?5 December, 2017 Agree antibiotic choice in line with local guidance Agree diagnostic tests in line with local laboratory Consider back-up prescription in those with mild symptoms Always do safety netting especially in the elderly Use computer reminders for leaflets & back-up prescriptions Do a UTI audit Do RCGP Management of UTI free online course Add information about using EPS for back-up prescriptions Is there an appropriate leaflet to use for UTI? Presenter notes: TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

44 Clinical scenario: sore throat5 December, 2017 Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. This patient has 3 of the 4 Centor criteria – and is therefore more likely to have a group A beta haemolytic streptococcus. She could warrant an immediate or back-up/delayed antibiotic – however the benefit with immediate antibiotics may still be quite small and needs to be discussed with the patient. Centor Criteria: History of fever; absence of cough; tender anterior cervical lymphadenopathy and tonsillar exudates. A low Centor score (0-2) has a high negative predictive value (80%) and indicates low chance of Group A Beta Haemolytic Streptococci (GABHS). A Centor score of 3-or-4 suggests the chance of GABHS is 40%. If a patient is unwell with a Centor score of 3-or-4 then the chance of developing Quinsy is 1:60. Centor RM, Whitherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decision Making 1981;1: TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

45 Clinical scenario: sore throat5 December, 2017 17 year old girl. 4/7 days sore throat, fever, tiredness, cough. Difficulty swallowing. Temp 37.5°C. Slough on swollen tonsils, palatal petechiae. Cervical and axillary lymphadenopathy. ‘Antibiotics helped’ for tonsils last year. Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. Go to one of the next two slides using Centor or FEVERpain scores TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

46 Sore throat – feedback Centor criteria5 December, 2017 17 year old girl. 4/7 days sore throat, fever, tiredness, cough. Difficulty swallowing. Temp 37.5°C. Slough on swollen tonsils, palatal petechiae. Cervical and axillary lymphadenopathy. ‘Antibiotics helped’ for tonsils last year. Centor Criteria: History of fever; absence of cough; tender anterior cervical lymphadenopathy and tonsillar exudates. A low Centor score (0-2) has a high negative predictive value (80%) and indicates low chance of Group A Beta Haemolytic Streptococci A Centor score of 3-or-4 suggests the chance of GABHS is 40%. If a patient is unwell with a Centor score of 3-or-4 then the chance of developing Quinsy is 1:60. This patient Centor 3 criteria –warranting immediate or back-up /delayed antibiotic – however the benefit with immediate antibiotics may still be quite small and needs to be discussed with the patient. Presenter notes: Decide whether to use the Centor or Fever PAIN scoring system and hide the other slide. These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. This patient has 3 of the 4 Centor criteria – and is therefore more likely to have a group A beta haemolytic streptococcus. She could warrant an immediate or back-up/delayed antibiotic – however the benefit with immediate antibiotics may still be quite small and needs to be discussed with the patient. It may be worth discussing some slightly different scenarios, and what factors makes a clinician more likely to prescribe – and if this is a correct approach. Centor Criteria: History of fever; absence of cough; tender anterior cervical lymphadenopathy and tonsillar exudates. A low Centor score (0-2) has a high negative predictive value (80%) and indicates low chance of Group A Beta Haemolytic Streptococci (GABHS). A Centor score of 3-or-4 suggests the chance of GABHS is 40%. If a patient is unwell with a Centor score of 3-or-4 then the chance of developing Quinsy is 1:60. Centor RM, Whitherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decision Making 1981;1: TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

47 Sore throat – feedback Using FeverPAIN score5 December, 2017 17 year old girl. 4/7 days sore throat, fever, tiredness, cough. Difficulty swallowing. Temp 37.5°C. Slough on swollen tonsils, palatal petechiae. Cervical and axillary lymphadenopathy. ‘Antibiotics helped’ for tonsils last year. FeverPAIN is a five-item score based on: Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza; She scores 2. A low FeverPAIN score 0-1: only 13-18% have streptococcus, close to background carriage. NO antibiotic strategy appropriate with discussion A FeverPAIN score 2-3: 34-40% have streptococcus, A back-up/ delayed antibiotic is appropriate with discussion A Fever PAIN score of >4: 62-65% have streptococcus, consider immediate antibiotic if symptoms are severe, or a short delayed prescribing strategy may be appropriate (48 hours) Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. This patient has 2 of the 5 FeverPAIN criteria – and therefore has a 34-40% likelihood of a beta haemolytic streptococcus. She could warrant a back-up/delayed antibiotic and this needs to be discussed with the patient. It may be worth discussing some slightly different scenarios, and what factors makes a clinician more likely to prescribe – and if this is a correct approach. FeverPAIN is a five-item score based on Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza (FeverPAIN) had moderate predictive value You can link to a scoring system at https://ctu1.phc.ox.ac.uk/feverpain/index.php Reference Little P, Moore M, Hobbs FDR, et al. BMJ Open 2013, 2013;3:e doi: /bmjopen ABSTRACT Objective: To assess the association between features of acute sore throat and the growth of streptococci from culturing a throat swab. Design: Diagnostic cohort. Setting: UK general practices. Participants: Patients aged 5 or over presenting with an acute sore throat. Patients were recruited for a second cohort (cohort 2, n=517) consecutively after the first (cohort 1, n=606) from similar practices. Main outcome: Predictors of the presence of Lancefield A/C/G streptococci. Results: The clinical score developed from cohort 1 had poor discrimination in cohort 2 (bootstrapped estimate of area under the receiver operator characteristic (ROC) curve (0.65), due to the poor validity of the individual items in the second data set. Variables significant in multivariate analysis in both cohorts were rapid attendance ( prior duration 3 days or less; multivariate adjusted OR 1.92 cohort, 1.67 cohort 2); fever in the last 24 h (1.69, 2.40); and doctor assessment of severity (severely inflamed pharynx/ tonsils (2.28, 2.29)). The absence of coryza or cough and purulent tonsils were significant in univariate analysis in both cohorts and in multivariate analysis in one cohort. A five-item score based on Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza (FeverPAIN) had moderate predictive value (bootstrapped area under the ROC curve 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection (38% in cohort 1, 36% in cohort 2 scored ≤1, associated with a streptococcal percentage of 13% and 18%, respectively). A Centor score of ≤1 identified 23% and 26% of participants with streptococcal percentages of 10% and 28%, respectively This score was further tested in an RCT: Little P, Hobbs FDR, Moore M. et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management) BMJ. Available from: Rationale: A multicentre randomised controlled trial in UK general practices designed to determine the effect of clinical scores that predict streptococcal infection or rapid streptococcal antigen detection tests compared with delayed antibiotic prescribing in patients aged >3 with acute sore throat. This study compared three strategies for limiting or targeting antibiotic using a validated FeverPAIN score in 631 patients with sore throat: they compared delayed antibiotic prescribing, the use of a clinical score designed to identify streptococcal infection, and the targeted use of rapid antigen tests according to the clinical score. Findings suggest that across a range of practitioners and practices, use of either the simple FeverPAIN clinical score or the clinical FeverPAIN score with a rapid antigen test is likely to moderately improve symptom control and reduce antibiotic use; the addition of the Rapid antigen test to the FeverPAIN score gave no clear advantages compared with use of the FeverPAIN score alone. Use of antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no significant differences in complications or reconsultations. The authors therefore suggest the use of the following scoring system and clinical management: With a low FeverPAIN score of 0-1: only 13-18% have streptococcus, close to background carriage and therefore a no antibiotic strategy is appropriate with discussion. With a FeverPAIN score of 2-3: 34-40% have streptococcus, therefore a back-up/delayed antibiotic is appropriate with discussion. With a FeverPAIN score of >4: 62-65% have streptococcus, therefore consider immediate antibiotic if symptoms are severe or a short 48 hour delayed antibiotic prescribing strategy may also be appropriate after agreement with the patient and safety netting advice. If a patient is unwell with a Centor score of 3-or-4 then the chance of developing Quinsy is 1:60. Little P, Moore M, Hobbs FDR, et al. BMJ Open 2013, 2013;3:e doi: /bmjopen TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

48 TARGET acute sore throat: PHE Antibiotic Management Guidance5 December, 2017 ILLNESS COMMENTS DRUG ADULT DOSE TREATMENT DURATION Acute sore throat CKS FeverPAIN Avoid antibiotics as 90% resolve in 7 days1A+ without, and pain only reduced by 16 hours.2A+ Use FeverPAIN Score: Fever in last 24h, Purulence, Attend rapidly under 3d, severely Inflamed tonsils, No cough or coryza).3B+,4B+ Score 0-1: 13-18% streptococci, use NO antibiotic strategy; 2-3: 34-40% streptococci, use 3 day back-up antibiotic; >4: 62-65% streptococci, use immediate antibiotic if severe, or 48hr short back-up prescription.5A- Always share self-care advice & safety net. Antibiotics to prevent Quinsy NNT >4000.4B- Antibiotics to prevent Otitis media NNT 200.2A+ 10d penicillin lower relapse vs 7d in <18yrs.8 phenoxymethylpenicillin5B- Penicillin Allergy: Clarithromycin 500mg QDS 1G BD6A+ (QDS if severe7D) mg BD 10 days 5 days Presenter notes: We suggest you take your local guidance with you The TARGET website also has the national antibiotic guidance, which is used by most CCGs to develop their local guidance. This is a snapshot of the aims and principles of treatment section of the Management of Infection Guidance for acute sore throat. As you can see each section has links to other guidance, comments on when antibiotics should be used, recommended first and second line antibiotics dose and duration. This PHE guidance on the TARGET website, also has an extensive rationale section which is really useful for trainers and trainees, or just when you want a bit more information for yourself or the patient. We recommend oral penicillin V for tonsillitis. The evidence from a trial in patients under 18 years indicated that relapse was lower when the FULL 10 day course was taken. Presenter please tell the participants where to find your local guidance and how locums can get extra copies if needed. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

49 What is the evidence for back-up / delayed prescribing?5 December, 2017 English RCT comparing three treatment strategies for sore throat (n=582) Presenter notes: There has been much discussion about the use of giving delayed antibiotic prescriptions in acute uncomplicated infections, to reduce antibiotic use and reduce patient expectations (although patients understand the term back-up more easily – so we have now changed to this term. A Cochrane review has recently shown the benefits of this approach, without increasing complications in patients. This study in acute sore throat is an exemplar. patients in 11 English GP practices were randomised into immediate antibiotics, delayed antibiotics and no antibiotics groups. There was no difference in recovery rates and high levels of satisfaction with all strategies. Compared to immediate antibiotics those given no antibiotics or delayed antibiotics had a reduction in belief in antibiotics for sore throat and were less likely to visit the GP again for similar symptoms. A more recent study of acute sore throat (the DESCARTE study) in fact showed that complications in those who received immediate were similar to those receiving a back-up prescription even though 30% did not collect the prescription, and were higher in the no antibiotic group. The back-up prescription is very useful to give to patients who have a high expectation for antibiotics, and can be given using the patient leaflet I will show you. Detailed results of Little et al: Median duration of antibiotic use differed significantly in the three groups (10 v 0 v 0 days, P < 0.001); 69% of patients in group 3 did not use their prescription. The proportion of patients better by day 3 did not differ significantly (37% v 35% v 30%, P = 0.28), nor did the duration of illness (median 4 v 5 v 5 days, P = 0.39), days off work or school (median 2 v 2 v 1, P = 0.13), or proportion of patients satisfied (96% v 90% v 93%, P = 0.09), although group 1 had fewer days of fever (median 1 v 2 v 2 days, P = 0.04). More patients in group 1 thought the antibiotics were effective (87% v 55% v 60%, P < 0.001) and intended coming to the doctor in future attacks (79% v 54% v 57%, P < 0.001). "Legitimation" of illness-to explain to work or school (60%) or family or friends (37%)-was an important reason for consultation. Patients who were more satisfied got better more quickly, and satisfaction related strongly to how well the doctor dealt with patient's concerns. In other studies delayed prescribing has led to the greatest reduction in future consultation in sore throat (Little 2007) and LRTI (Moore 2009). A Cochrane review of 10 studies has shown that delayed prescribing reduces antibiotic prescriptions without reducing satisfaction Antibiotic use (%) Satisfaction (%) Immediate 93 92 Delayed 32 87 No 14 83 Little, Williamson, Warner et al. BMJ . (1997) 314: TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

50 The Patient Perspective: Back-up/delayed Prescribing: What patients do5 December, 2017 IPSOS Mori Surveys: 2014 Random samples 1625 > 15 yrs, England 4% Offered back-up / delayed prescribing in past year 60% collected and took the antibiotic Presenter notes: This survey of the public showed that 4% of the public in 2014 reported being given a delayed antibiotic prescription, so the strategy is being used by GPs. Of those participants given a delayed prescription from their surgery, 58% (83/142) did so in comparison with 68%(115/169) of participants collecting their delayed prescription from their local pharmacy. Of those collecting their delayed antibiotics. 97% do take the course. Back-up antibiotics can reduce antibiotics by % McNulty,Hawking, Lecky, Butler. FIS 2014 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

52 TARGET: Patient Information Leaflets5 December, 2017 Treating Your Infection leaflet All sections can be personalised and added to by the GP “Usually lasts” section educates patients about when to consult Safety netting Extra presenter notes: It would be useful to print off a copies of this leaflet and take enough with you for each GP. It can be found at It is also available on SystmOne and EMIS clinical systems. The use of delayed/back-up antibiotic prescribing can be supported by using the TARGET leaflet The treating your infection leaflet has been developed through extensive feedback with patients and clinicians over the last 2 years. It is designed to be shared with the patient and completed with them during the consultation. Its aim is to increase the patients confidence to self-care, and to facilitate the use of back-up antibiotic, but it also allows the patients to go away with something, so ending the consultation on a positive note. Bring in personalised text box All sections can be personalised and added to by the GP. And it is important to share it with the patient and add extra infections , self-care instructions in the third column and alarm symptoms in the fourth column that may be required. Bring in ‘usually lasts’ text box The ‘usually lasts’ section allows patients to understand not only for this consultation but also others when they should consult. This section has consistently been seen as very useful by patients of all ages. Bring in safety netting box Whatever the infection, in this era of antibiotic resistance and with increasing numbers of elderly or vulnerable patients, it is extremely important to give some clear safety netting instructions. These are some that can be used and saved by patients. Bring in back-up prescription box The back-up prescription can reduce antibiotic prescribing by about 30 to 40%, and is extremely useful for particularly demanding patients or just before a weekend to reduce visits to out of hours services. Bring in information box Although most patients know they shouldn’t take antibiotics for coughs and colds, far fewer know that sinusitis, ear infections and sore throats and many other infections get better on their own without antibiotics. Likewise they know little about antibiotic resistance, so we should take every opportunity to educate them. In % of antibiotics were taken without a prescription, this is a particular problem in patients under 24 years. So take the opportunity to stress not to share antibiotics. There is a READ code for delayed/ back-up antibiotics or leaflet given and if you Read code the infections featured in the leaflet with EMIS and some other systems this leaflet will appear on your computer via the patient.co.uk system. Extra notes for presenter: Most prescribers have access to many leaflets, both paper ones and ones that can be printed off their computer system or the web. However, not all information resources are based on the best available evidence or have been developed through rigorous processes. The Antibiotic Information Leaflet has been developed through over 24 months of literature searching, consultation, focus groups with patients and staff, drafting and revision. Overview of the leaflet To use this leaflet properly, it is important that clinicians use it as a tool to interact with patients, rather than just handing it to them as a ‘parting gift’. In order to communicate this effectively you must make sure that you are very familiar with its content. Please make sure that, in addition to completing this training, you take some time to thoroughly familiarise yourself with the leaflet before you start using it. . Back-up prescription Information about antibiotics & resistance Read codes: Delayed:8CAk, Leaflet: 8CE TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

53 TARGET: Resources for clinical and waiting areas5 December, 2017 Posters for Display Videos for patient waiting areas Presenter notes: These posters and videos may make a difference to patient expectations about when to expect antibiotics, IF used in the waiting room where patients can see them and IF they have the time to digest the information. In % of the general public surveyed remembered seeing the first poster and 95% of these correctly answered that antibiotics don’t help most coughs and colds. Used alone without any other strategies posters will make little difference to patients expectations for antibiotics, but they can be used to reduce expectations and can be used as a prompt for dialogue – “you may have seen from the posters or videos in the waiting room that we in this practice encourage responsible antibiotic prescribing” The videos were developed with patients and each animal cartoon video appealed to different people. A recent small survey of their use showed that those patients who saw them remembered the messages – however often the video sound was muted, chairs were pointing in the wrong direction or the video screen was off. If you intend to use them please don’t make this mistake. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

54 McNulty, Butler, et al Ipsos Mori 2014How could your practice use sore throat scores & back-up antibiotic prescriptions? 5 December, 2017 Action plan: how to reduce antibiotics in acute sore throat? Use the Centor or Fever pain scoring system Use patient leaflets Use back-up/ delayed antibiotic prescribing Set up computer reminders for leaflets and back-up antibiotics – who can do this? Use delayed date on electronic prescription Use electronic prescribing “token” and get patient to pick up later from the surgery Agree who will put up posters in the surgery Presenter notes: Developing a definite action plan with responsibilities will help to reduce antibiotic use in acute sore throat. Here are some of the ideas – but how they will be taken forward needs to be discussed Use the Centor or Fever pain scoring system to see whom they could delay antibiotics safely in Use the TARGET or when should I worry childrens patient leaflets to encourage self-care Use back-up/ delayed antibiotic prescribing: How do they want to do this? - can they issue a Electronic Prescribing System token, which allows you to print off the prescription to be picked up later from the surgery; post date the prescription for at least 24 hours. Arrange for them to not pick it up from the pharmacy for at least 24 hours. Set up computer reminders for leaflets and back-up antibiotics – who can do this? Use electronic prescribing “token” and get patient to pick up later from the surgery McNulty, Butler, et al Ipsos Mori 2014 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

55 Optional clinical scenario: otitis media5 December, 2017 TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

56 Optional clinical scenario: otitis media5 December, 2017 5 year old boy screaming with pain in left ear. No history of fever, temp 37.4°C. Not vomiting. Paracetamol helps but pain returns before next dose due. Had AOM this time last year. Left ear drum bulging and red. Had antibiotics last time and mother very keen to have antibiotics again. These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. Presenter notes: OM resolves in 60% in 24 h without antibiotics, which only reduce pain at 2 days (NNT15) and does not prevent deafness Consider 2 or 3-day delayed or immediate antibiotics for pain relief if: <2 years AND bilateral AOM (NNT4) or bulging membrane & ≥ 4 marked symptoms All ages with otorrhoea NNT3 Therefore in this situation antibiotics are unlikely to be beneficial The evidence comes from: Rovers MM, Glasziou P, Appleman CL, Burke P, McCormick DP, Damoiseaux RA, Little P, Le Saux N, Hoes AW. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007;119(3): RATIONALE: The risk of prolonged illness was 2 times higher for children <2years with bilateral AOM than for children with unilateral AOM. For this sub-group parents should be advised that symptoms may persist for up to 7 days, and they should optimise analgesia use. The protective immunity against infections with encapsulated bacteria, such as the species that cause AOM, depends on the ability to produce specific antibodies against bacterial capsular polysaccharides, which is inadequate until 2 years of age. The anatomic features of the eustachian tubes and the nasopharynx also differ with age. Consequently, children under 2 years of age seem to be more susceptible to AOM. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

57 TARGET acute otitis media: Antibiotic Management Guidance5 December, 2017 ILLNESS COMMENTS DRUG CHILD DOSE TREATMENT DURATION Acute otitis media CKS OM NICE feverish children Optimise analgesia and target antibiotics 2,3B- AOM resolves in 60% in 24hrs without antibiotics, which only reduce pain at 2 days (NNT15) and does not prevent deafness Consider 2 or 3-day delayed 1A+ or immediate antibiotics for pain relief if: <2 years AND bilateral AOM (NNT4) or bulging membrane and ≥ 4 marked symptoms5-7+ All ages with otorrhoea NNT3 Antibiotics to prevent Mastoiditis NNT >4000 amoxicillin Penicillin Allergy: erythromycin Neonate 7-28 days 30mg/kg 1 month-1 yr: 125mg 1-5 years: 250mg 5-18 years: 500mg <2 years 125mg 2-8 years 250mg 8-18 years mg 5 days TDS 5 days QDS Presenter notes: We suggest you take your local guidance with you The TARGET website also has the national antibiotic guidance, which is used by most CCGs to develop their local guidance. This is a snapshot of the aims and principles of treatment section of the Management of Infection Guidance for acute otitis media. This PHE guidance on the TARGET website, also has an extensive rationale section which is really useful for trainers and trainees, or just when you want a bit more information for yourself or the patient. OM resolves in 60% in 24 h without antibiotics, which only reduce pain at 2 days (NNT15) and does not prevent deafness Consider 2 or 3-day delayed or immediate antibiotics for pain relief if: <2 years AND bilateral AOM (NNT4) or bulging membrane & ≥ 4 marked symptoms All ages with otorrhoea NNT3 Therefore in this situation antibiotics are unlikely to be beneficial. The evidence comes from: Rovers MM, Glasziou P, Appleman CL, Burke P, McCormick DP, Damoiseaux RA, Little P, Le Saux N, Hoes AW. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007;119(3): RATIONALE: The risk of prolonged illness was 2 times higher for children <2years with bilateral AOM than for children with unilateral AOM. For this sub-group parents should be advised that symptoms may persist for up to 7 days, and they should optimise analgesia use. The protective immunity against infections with encapsulated bacteria, such as the species that cause AOM, depends on the ability to produce specific antibodies against bacterial capsular polysaccharides, which is inadequate until 2 years of age. The anatomic features of the eustachian tubes and the nasopharynx also differ with age. Consequently, children under 2 years of age seem to be more susceptible to AOM. Presenter please tell the participants where to find your local guidance and how locums can get extra copies if needed. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

58 TARGET: Information for parents and patients5 December, 2017 Links to relevant websites DH Leaflet Presenter notes for optional slide: This slide show examples of other resources they can access from the Information for patients section of the website. Research has shown that patient satisfaction is more related to having a careful examination and having their concerns identified and addressed than to receiving a prescription for antibiotics. This provides us with a great opportunity, and many prescribers are already very good at providing patients1 with information and reassuring them. We know how busy prescribers are, and how important it is to use precious consultation time efficiently. In order to address the whole range of information needs that patients might have, within a busy consultation, clinicians need to have a range of ‘tools’ at their disposal. The use of leaflets There is evidence that the use of leaflets or booklets outlining the natural history of respiratory tract infections (and information about when to reconsult) can result in reduced antibiotic prescribing. Reductions in antibiotic prescribing have been shown to result in reductions in future demand for consultations. So it is worth investing a bit of time in these consultations in order to reap future benefits. Booklet to share with parents and carers Antibiotic prescription 20% v 40% Intention to reconsult 55% v 76% TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

59 TARGET: Could your practice commit to doing an audit this year?5 December, 2017 The TARGET website has audit templates for : UTI Sore Throat Acute cough Acute otitis media Otitis externa Acute rhinosinusitis Presenter notes: Have you done any personal or practice wide antibiotic audits in the last year? The self-assessment check list suggests a biannual practice wide antibiotic audit You keep a personal action plan following audits. Read coding facilitates audits The TARGET website has audit templates with appropriate guidance and Read codes to use for: Otitis media, sore throat, acute cough, UTI, otitis externa, acute rhinosinusitis. These will also help you comply with your CPD and revalidation. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

60 TARGET antibiotics presentation 18.09.14TARGET: Training Resources 5 December, 2017 Managing Urinary Tract InfectionS Managing Acute Respiratory Tract Infections Antibiotic Resistance in Primary Care Presenter notes: These are examples of the training resources available on the TARGET antibiotics website. Each of these training tools are free and you do not need to be registered with the RCGP to use them. They also count towards your CPD. Extra presenter notes: You may wish to complete these educational modules yourself so that you can reflect on the training opportunities and give advice on how useful they are. They can be accessed here: MARTI: MUTS: Antibiotic Resistance in Primary Care: UTI: Skin Infections: Diarrhoea: Skin Infections Managing Infectious Diarrhoea

62 How could your practice decrease antibiotic prescriptions for acute otitis media?5 December, 2017 Action plan ideas for next 12 months Agree criteria for prescribing, so parents do not return to a different clinician Use the children’s “when should I worry” leaflet Use back-up / delayed prescribing Set up computer reminders for leaflets and back-up antibiotics – who can do this? Use delayed date on electronic prescription Use electronic prescribing “token” and get patient to pick up later from the surgery Do an audit Complete MARTI clinical course on RCGP website Presenter notes: Developing an action plan with who will be responsible is important, as otherwise good intentions may not be converted into action Agree criteria for prescribing, so parents do not return to a different clinician Use the children’s “when should I worry” leaflet Use back-up / delayed prescribing Set up computer reminders for leaflets and back-up antibiotics – who can do this? Use delayed date on electronic prescription Use electronic prescribing “token” and get patient to pick up later from the surgery Do an audit Complete MARTI clinical course on RCGP website TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

63 Optional clinical scenario: skin infection5 December, 2017 75 year old man who fell 7 days ago Abrasion on left shin. Has had increasing redness of shin spreading up towards the knee over last 2 days Previous history of CVA and poor swallowing No history of fever, temp 38.2°C. Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. National guidance from Public Health England advises that: If patient afebrile and healthy other than cellulitis, use 7 days oral flucloxacillin alone 500mg QDS 1,2C If penicillin allergic: clarithromycin 1,2,3C 500mg BD or clindamycin 1,2C300–450mg QDS. Stop clindamycin if diarrhoea occurs. Continue for a further 7 days if needed If facial: co-amoxiclav 4C500/125mg TDS If river or sea water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment 1C TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

64 Skin infection? Feedback5 December, 2017 75 year old man who fell 7 days ago Abrasion on left shin. Has had increasing redness of shin spreading up towards the knee over last 2 days Previous history of CVA and poor swallowing No history of fever, temp 38.2°C. Class I: If patient afebrile & healthy other than cellulitis: use oral flucloxacillin alone 500mg QDS for 7 days, (rather than flucloxacillin plus penicillin or amoxicillin) as active against streptococci as well as staphylococci Class II: If febrile and ill, or comorbidity use IV treatment Penicillin allergic: clarithromycin 500mg BD If facial: co-amoxiclav to include Haemophilus influenzae If river or sea water exposure: discuss with microbiologist. Unresolving: clindamycin mg QDS Presenter notes: These cases are examples that can be printed out and discussed in pairs or groups, or with the group as a whole. National guidance from Public Health England based on CREST guidance in 2005 advises that: If patient afebrile and healthy other than cellulitis, use 7 days oral flucloxacillin alone 500mg QDS 1,2C If penicillin allergic: clarithromycin 1,2,3C 500mg BD clindamycin 1,2C300–450mg QDS is recommended as a further alternative in penicillin allergic patients, or others with more severe unresolving infection . (Stop clindamycin if diarrhoea occurs.) Continue antibiotics for a further 7 days if needed If facial: co-amoxiclav 4C500/125mg TDS If river or sea water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment 1C CREST Guidelines on the management of cellulitis in adults. Clinical Resource Efficiency Support Team Accessed Expert consensus is that people who have no signs of systemic toxicity and no uncontrolled co-morbidities can usually be managed on an outpatient basis with oral antibiotics. Flucloxacillin 500mg QDS (or clarithromycin 500mg BD for those with penicillin allergy) are suitable oral antibiotics because they cover staphylococci and streptococci, the most commonly implicated pathogens. Clindamycin 300mg QDS is also recommended as a further alternative for people with penicillin allergy. Who don’t resolve. Most cases of uncomplicated cellulitis can be treated successfully with 1-2 weeks of treatment. Clindamycin may be used in cases where the cellulitis is not resolving. Consider outpatient antimicrobial treatment (OPAT) with IV antibiotics if patient systemically unwell or co-morbidities (so called Class II). Jones, G.R. Principles and practice of antibiotic therapy for cellulitis. CPD Journal Acute Medicine. 2002;1(2): Oral agents will be as effective as intravenous agents for cellulitis if they can maintain the free antibiotic level above the MIC of the pathogen for more than 40% of the dose interval. Flucloxacillin 500 mg, clarithromycin 500 mg and clindamycin 300 mg are suitable oral doses. Morris AD. Cellulitis and erysipelas. Clinical Evidence London. BMJ Publishing Group. This systematic review found no RCTs of antibiotics compared with placebo of sufficient quality for inclusion. Although 11 RCTs were identified that compared antibiotic treatments, these studies were small and only powered to demonstrate equivalence, not superiority, between antibiotics. Two RCTs using intravenous flucloxacillin were found, but none using oral flucloxacillin. Oral azithromycin was compared with erythromycin, flucloxacillin, and cefalexin in three RCTs. Oral co-amoxiclav was compared with fleroxacin (available in Germany) in one sub-group analysis. Fischer RG and Benjamin DK Jr. Facial cellulitis in childhood: a changing spectrum. Southern Medical Journal. 2002;95: Buccal cellulitis is commonly due to Haemophilus influenzae infection, although rates are decreasing following the Hib immunization programme. The Health Protection Agency and the Association of Medical Microbiologists recommends co-amoxiclav for empirical treatment of facial cellulitis because it is broader spectrum than flucloxacillin and also covers H. influenzae. Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. Cochrane Database of Systematic Reviews Issue 6. Accessed This review included 25 studies with a total of 2488 participants. The primary outcome ’symptoms were rated by participant or medical practitioner or proportion symptom-free’ was commonly reported. No two trials examined the same drugs, therefore the review grouped similar types of drugs together. Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99, 95% CI 0.68 to 1.43). Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98). TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

65 Do you need to explore your management of skin infections?5 December, 2017 Consider an audit of flucloxacillin and co-amoxiclav use Complete skin infections clinical course on RCGP website TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

66 Reducing antibiotic prescribing in your practiceIn summary 5 December, 2017 Reducing antibiotic prescribing in your practice Makes a difference to resistance in your patients Helps to slow future antibiotic resistance Increase patient self-care Helps to reduce future consultations Presenter notes: Thus in summary, I hope you agree that the evidence suggests that by reducing the antibiotic prescribing in your practice – you can: Make a difference to the care of individual patients. Help to slow the development of future resistance in our community. AND as a bonus help to increase patient self-care and reduce future consultations for minor infections. TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

67 What can and will you do? Actions 5 December, 2017Presenter notes: So what can and will you as an individual and as a practice do to help? Please can we discuss a plan? Need to discuss a plan with each practice They are all evidence based Get them to do the planning – so moves on within the practice Get them to prioritise Get them to plan review with audit. Identify a person to take forward Find the individual with computer interest and get them to help with a computer reminder linking to the TARGET patient shared information. Action plan, timescale, review date 3 year plan – as a lot going on and can’t do it all now Need to show them the scale of change which can be attained TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

68 Action planning: Developing priorities for you & this CCG5 December, 2017 Aim to start rolling back to prescribing in 2010 Reducing total antibiotics by 1% per year HOW Use the leaflets to reduce patient expectations Develop computer prompt or use patient.co.uk to increase use of leaflet Use back-up/delayed prescribing (the leaflet will help) Refer to the posters to introduce antibiotics Make sure everyone has access to antibiotic guidance Do an antibiotic audits with action planning Give an individual responsibility of taking these forward Presenter notes: The DH would like to encourage you to get back to the prescribing levels of 2010. This will help as I said to reduce Clostridium locally (and is a priority for many CCGs), and help control antibiotic resistance rates. Ask them what they are going to do: then bring up the list of things other practices have done. And see which ones they will agree to Use the leaflets to reduce patient expectations Develop computer prompt or use patient.co.uk to increase use of leaflet Use back-up/delayed prescribing (the leaflet will help) Refer to the posters to introduce antibiotics Make sure everyone including locums and trainees and nurses have access to antibiotic guidance Do an antibiotic audit Give an individual responsibility of taking these forward TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt

69 Many thanks 5 December, 2017 Please complete the evaluation form, so we can send you your CPD certificate TARGET antibiotics presentation clinical scenario based USE THIS ONE.ppt