Dr. Nuala O'Connor, GP Elmwood Medical Practice
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Tackling Antibiotic Resistance - The GP's role
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Dr. Nuala O'Connor, GP Elmwood Medical Practice
- 1. Tackling Antibiotic Resistance - The GP’s Role Why should all of you be worried ? What can you do ? DR Nuala O Connor ICGP Lead HCAI AMR Health Care Associated Infections and Antimicrobial Drug Resistance National Primary Care Conference Kilkenny November 2014
- 2. “WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health” APRIL 2014 “Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill,” BBC WORLD NEWS
- 3. E.coli resistant to 3rd generation Cephalosporins 2002 2012 Overall consumption of antibiotics is less/ use more narrow spectrum than broad spectrum
- 4. Antimicrobial resistance trends: Bloodstream infections in Ireland: 2002-2012 Data source: HPSC/EARS-Net 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Proportion resistance Year Meticillin-Resistant Staph. aureus Vancomycin-Resistant Enterococcus faecium Penicillin-Resistant Strep. pneumoniae Erythromycin-Resistant S. pneumoniae Cephalosporin- Resistant E. coli Quinolone-Resistant E. coli Multiple-Resistant E. coli 4
- 5. 25,ooo deaths from multi-drug resistant organisms each year in Europe HCAI from resistant bacteria- Difficult to treat, prolonged illness, hospital stays, risk of death “SUPERBUGS “
- 6. Why has this problem of Antibiotic resistance emerged? Multifactorial Increasing complexity of healthcare Ageing population Concerns about ‘missing sepsis’ Overuse of broad spectrum agents Failure to de-escalate from broad spectrum to narrow spectrum Not sending specimens to lab Not acting on lab reports Overly lengthy treatment courses Lack of awareness about the issue of resistance among HCW Lack of patients awareness about the issue of resistance Patient compliance issues Time pressure Patient pressure High antimicrobial use in veterinary sector Lack of regulation of antimicrobial dispensing in some countries Poor sanitation in developing world
- 7. How can general practioners help? What’s different about countries with low rates AMR • Overall consumption of antibiotics is less. • Greece and Cyprus use 3 times more antibiotics per head of population than Netherlands • Use more narrow spectrum Antibiotics than broad spectrum. Primary Care Antibiotic Consumption Rates
- 8. Ireland DDD’s Year Rate 2003 20.34 2004 20.19 2005 20.50 2006 21.09 2007 22.03 2008 21.00 2009 20.23 2010 19.75 2011 22.55 2012 22.80 2013 23.66 Primary Care Antibiotic Consumption Rates 80 % of antibiotics Community
- 9. Antimicrobial Use % Prevalence HALT Ireland V Europe If you are resident in an Irish nursing home, you are more than twice as likley to be on an antibiotic than in any other European Country 39% prophylaxis Majority prescribed within LTCF by GPs and directly-employed doctors
- 10. Demystify Antibiotic Stewardship Ensuring you prescribe the right antibiotic for the patient in front of you at the right time with the right dose duration and route for the condition you are treating causing the least amount of harm to that patient and future patients
- 11. Every time we consider prescribing GP’s need to ask themselves ……. Is this antibiotic really necessary ?
- 12. If you decide to prescribe ask the following questions ? What do I tend to prescribe for a particular condition? Is it the right drug for this condition ? Is it the right dose for the patient sitting in front of me ? How long do I tend to prescribe it for? What investigations, if any, do I use to support my decisions? Do I know about the Irish primary care prescribing guidelines and am I using them?
- 13. Narrow versus broad-spectrum Penicillin V for strep throat Co amoxiclav for strep throat GP’s need to think more scientifically – what are you treating ?
- 14. Am I keeping my patients Safe from Antibiotic Side-effects Nausea vomiting , diarrhoea ,rashes Toxicity from prolonged use – nitrofurantoin for UTI prophylaxis and pneumotoxicity Toxicity from idiosyncratic reactions –liver failure with co amoxiclav Toxicity when dose not reduced or incorrect antibiotic used for patients with chronic kidney disease Interaction with other medicines – statins and macrolides C. diff overgrowth leading to serious infection after few doses of antibiotic Serious Allergic reactions
- 15. Every time we consider prescribing GP’s need to ask themselves ……. Have I consulted the antibiotic guidelines recently? www.antibioticprescribing.ie
- 16. 16
- 17. 1. Community Resistance Data Tool 2.Antibiotic prescriber feedback mechanism for all Patients Gp owns the Data -used for Quality Improvement Collaboration between iPCRN, ICGP, Primary Care Directorate, Patient Quality and Safety , HCAI AMR Clinical Care Programme Improve patient care Audit requirements for medical council
- 18. Public Antibiotic Awareness Campaign Explain why we need to need to preserve this Taking antibiotics for colds and flu? There’s no point. A cold or flu is caused by a virus and antibiotics do not work on viruses. talk to your GP or pharmacist or visit www.hse.ie precious resource Antibiotics can kill bacteria. They have no effect on viruses such as head cold, flu, chickenpox. They will not reduce a fever They will not relieve pain. Rest, fluids and TLC important part of recovery from all infections. Do they know how to take them correctly?
- 19. www.underthweather.ie What to look for What can you do ? When to seek help ?
- 20. Things you can do now to help reduce Antimicrobial Drug resistance Do not prescribe antibiotics unless there is a definite clinical indication to do so Prescribe first line recommended antimicrobials – 5 antibiotics Co-amoxiclav is not a first-line drug for the common conditions encountered in General Practice Prescribe phenoxymethylpenecillin for tonsillitis unless the patient is truly allergic to penicillin. Restrict macrolides to patient with true penicillin allergy or definite clinical indication e.g mycoplasma Review any patients in LTCF on prophylactic treatment for UTI Develop simple antibiotic prescribing policy for your practice and for nursing home residents based on www.antibioticprescribing.ie Possible idea for audit requirement's 2014/2015 cycle
- 21. Mutltifactorial Global Strageties National Strageties Healthcare workers Professional Respsonsibility Public recognise they role they must play Stop the spread of infections Promote immunisation Encourage appropriate use of antibiotics in humans and agriculture Support development of new WHAT CAN WE DO ? antimicrobial agents
- 22. Some signs of improvement 2014 Community Antibiotic Consumption first half 2014 Use of co amoxiclav
- 23. Keeping Antibiotics Safe And Effective For Future Generations … Dept of Health HSE Pharmacists Surgeons Dept of Agriculture gp Patients Vets Physicians ..it’s everyone's responsibility
Editor's Notes
- In april this year the who published its first global report on antibiotic resistance . I will read a quote form one of the Headlines around the world that day ….there is a real sense of urgency among world experts that time is running put. The antibiotic's we have now are probably the best we will ever have . We cannot expect a steday supply of novel antibitocs and we must all act now to preserve this precious resource for future generations .
- These are 2 maps showing e. coli resistance to 3rd generation cephalsporins in blood stream isolates collected by EARRs which is european wide reporting system . There are a fe things I want o draw your attention too . Green is good meaning low levels of résistance red is bad meaning high levels of resistance and orange and yellow in between. Look at the rise in résistance in the 10 year time frame. I could show you another 20 maps different bug different antibiotc but the same pattern apart form MRSA which is the only good news story . Id also like to draw your attention to the northern southern europen divide with ne countries less reistance than soutern euoprean . There are 2 main reason for this ……..
- Why should we worry abut theses multi drug resistant organisms or the suberbugs as I like to call them . Well it is estimated they are responsible for 25,000 deaths each year in europe . While I in no way mean to belittle the enormous tragedy west aftica is facing with EBOLA when you compare the few deaths in europe form ebola to the silent growing epidemic of superbugs it is something we cannot ignore. The world is a very different place . Irish people are travelling all the tiem . The demographics of ireland are changing , we have peole resident here form all over the world and they travel home for weddings, funerals and holidays and the bugs are hitching a ride.
- If you are resident in an Irish nursing home you are more than twice as likley to be on an antibiotic than in any other european country
- Emphasize that most antibiotics are prescribed and consumed in the community not hospitals, not vetinary so community prescribers have a very signifgant role to play in the fight against AMR
- There is no indication to prescribe anything other than penicillin v for strep throat even with invasive group B strep Co amoxilcav most commonly prescribed antibiotic in our nursing homes and in general practice Uti studies yet not first line drug We prescribe far more macrolides that our European counterpart but no evidence we are more allergic
- Apart from unnecessary antibiotic use contributing to the growing problem of antimicrobial drug resistance they can also cause harm to patients and we need to think carefully before we prescribe them . Many antibiotics cause nausea vomiting or diarrhea especially infants and younger children . All have toxicity potential interact with other medicines sometime with very serious consequence's e.g prolongation of Qt interval macrolides and statins leading to increased risk od sudden cardiac death and of course we all know that serious anaphylaxis can occur
- Prescribing guidelines for primary care are updated as appropriate and widely distributed to all community settings. Feedback on individual prescribing data to GPs is established to encourage targeted prescribing of narrow spectrum antimicrobials. An audit tool for prescribing which meets professional competence requirements is considered. Timely national/local antimicrobial resistance data is fed back to GP’s There is adequate access to microbiological laboratory services with quick turnaround time, electronic feedback of results and microbiology consultant advice .
- Most common infections don’t need antibiotics – they get better by themselves. Taking antibiotics when you don’t need them puts your health and the health of your family at risk. If your doctor decides that you do need an antibiotic, make sure you take it exactly as prescribed and complete the course. “By the time I am sick enough to contact or visit a doctor because of a cold I usually expect to get a prescription for antibiotics” 48% of the public disagreed with this statement so as GP’s we are probably in a stronger position to to reassure our patients when an antibiotic is not needed than we realise .