National Changes in Antibiotic
Policy
R. Andrew Seaton
Consultant Physician
Lead doctor Antimicrobial Management Team, NHS GG&C
SAPG Infection Management Workstream
• Developing and applying prudent
prescribing principles in hospital and
community
– Hospital infection management guidelines
– Surgical prophylaxis guidelines
– Primary care guidelines
• Prescribing indicators to underpin control
of HAI
• Unintended consequences of change
Clostridium difficile and prescribing in
Scotland
Ceftriaxone IV DDD/1000 bed days
Jan 2002 to July 2007
DDD=4g
7000
6000
25
5000
20
y = 0.0084x - 311.46
4000
3000
15
2000
10
1000
0
5
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
Feb-08
1997
Oct-06
1996
May-05
1995
Jan-04
1994
Sep-02
1993
1992
0
Apr-01
Jul-09
Adapted from Health Protection Scotland data
CDI Risk and Antibiotic
Treatment
NB. Any Antibiotic. Duration of therapy
CDI Risk and Antibiotic
Treatment
UPDATE: Quinolone
use is strongly
associated with Hypervirulent, quinoloneresistant 027 strain of
C difficile
NB. Any Antibiotic. Duration of therapy
Reduced MRSA risk
Increased MRSA risk
Clostridium difficile
NHS Greater Glasgow and
Clyde
• June 2008
• 55 CDI / 6 months
• 18 either primary
cause or
contributing to death
• Infection control
issues
• Antibiotic
prescribing
AMT response: June 2008
• Promote
• Urgent review of
prescribing, guidance
– Think before you
(case mix)
prescribe
• Stricter restrictions
– Narrow
spectrum
“4 Cs”
agents/ simplify
Cephalosporins
– Limit duration
Co-amoxiclav
– Combination
with gentamicin
Clindamicin
for serious
Ciprofloxacin
infection
(Quinolones)
– CDI Rx
guidelines
www.glasgowformulary.com
Recommended, Restricted
and Alert Antibiotics
Status
Oral
IV
Recommended
Amoxicillin
Clarithromycin
Co-trimoxazole
Doxycycline
Flucloxacillin
Metronidazole
Nitrofurantoin
Trimethoprim
Vancomycin
Amoxicillin
Clarithromycin
Co-trimoxazole
Flucloxacillin
Gentamicin
Vancomycin
Restricted
Clindamycin
Co-amoxiclav
Ciiproflaxacin
Clindamycin
Ceftriaxone
Co-amoxiclav
“Alert”
Linezolid
Ceftazidime
Ciprofloxacin
Daptomycin
Ertapenem
Linezolid
Meropenem
Piperacillin-Tazobactam
Teicoplanin
Tigecycline
National Response
• Independent review (Vale of Leven
Hospital)
– “Prudent antimicrobial prescribing
implemented and monitored both in the
Acute and Community sectors”
• Scottish Government: CEL 30, July
2008
– AMT for Primary care and secondary
care in all HBs
SAPG
AMTs
AMT
Education &
Communication
Guidance
And
Protocols
Antimicrobial
Resistance
and CDAD
Surveillance of
Usage
Antimicrobial
Practice
Alert
Restricted
Agents
Audit of Practice
SAPG, Nov 08
GGC hospitals DDD/1000 bed days 4C antibiotics (total)
450
400
Restrictive guidance
350
300
250
Co-amoxiclav
Quinolones
200
Cephalosporins
Clindamycin
Total
150
100
50
20
07
02
20
07
03
20
07
04
20
08
01
20
08
02
20
08
03
20
08
04
20
09
01
20
09
02
20
09
03
20
09
04
20
10
01
20
10
02
20
10
03
20
10
04
0
IV+ Oral Amoxicillin ddd/1000 bed days All GG&C hospitals, excluding Mental Health and Yorkhill
450
1 DDD amoxicillin IV = 1g
1 DDD amoxicillin oral = 1g
400
350
300
New policy
introduction
Restrictive
guidance
250
ddd/1000 bed days
200
150
100
50
0
200702
200703
200704
200801
200802
200803
200804
200901
200902
200903
200904
Clostridium difficile cases per month GG&C
160
140
y = -0.0131x + 627.63
R2 = 0.0303
Restrictive guidance
120
100
pre
post new policy
80
Linear (pre)
Linear (post new policy)
y = -0.0989x + 3988
R2 = 0.6392
60
40
20
0
Oct-06
Apr-07
Nov-07
Jun-08
Dec-08
Jul-09
Jan-10
Aug-10
HPS data C. difficile cases >65 years / 1000 total / acute OCBD
1.6
1.4
1.2
1
Scotland (average rate)
0.8
GG&C
0.6
0.4
0.2
0
Q4 2007
Q1 2008
Q2 2008
Q3 2008
Q4 2008
Q1 2009
Q2 2009
HEAT target to reduce CDI rate in ≥ 65
yrs by ≥ 30% by March 2011: Prescribing
indicators: Hospital
Improvement Action Plan for NHS
Greater Glasgow and Clyde Southern
General Hospital Inspection Date:
Monday 8 and Tuesday 9 March 2010
“It is recommended that NHS Greater
Glasgow and Clyde implements auditing of
20 patient records each month in all
receiving wards”
Unintended consequences
Gentamicin DDD/1000 bed days all GG&C hospitals excluding Yorkhill and Mental Health
• Toxicity
60
50
– Renal
– Oto-vestibular
40
New Policy Introduction
30
• Treatment failure
– ICU admission
– Death
1 DDD gentamicin = 240mg
DDD/1000 bed days
20
10 spend excluding Gartnavel + western
Meropenem
140000
0
200702
200703
200704
200801
200802
200803
200804
200901
200902
120000
• Prescribing
adaptation
• Resistance
100000
80000
royal
clyde
south
total
60000
40000
20000
0
2007 Q1 2007 Q2 2007 Q3 2007 Q4 2008 Q1 2008 Q2 2008 Q3 2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009 Q4
200903
200904
SAPG Vancomycin and Gentamicin
prescribing Guidelines, Sept 09
• National consensus to
adopt single national
Vancomycin guideline
• Agreed that boards would
adopt either Hartford
(7mg/kg) or NHS GGC
(5mg/kg) regimens
– Caution beyond 72 hours
• On line calculators for
dosage
GENTAMICIN AND VANCOMYCIN DOSE CALCULATOR
Enter data shown in blue
Creatinine Clearance (ml/min)
Age (years)
45
Weight (kg)
65
Sex (m/f)
m
Creatinine (umol/L)
120
Height (cm)
Recommended doses and dosage intervals are shown in red
GENTAMICIN
VANCOMYCIN PULSED INFUSION
Dose (mg)
240
Interval (h)
24
Infuse over 30 - 60 min
Loading Dose
Maintenance Dose (mg)
500
Interval (h)
12
Maximum infusion rate 500 mg/hour
OR Height (feet)
5
Ideal body weight (kg)
52.7
(inches)
1
Dosing weight (kg)
57.6
Loading Dose
Creatinine CL (ml/min)
51.3
Infusion over 12 hours (mg)
Height (cm)
155
For gentamicin monitoring guidelines
see gentamicin sheet
Creatinine clearance (ml/min) based on IBW, vancomycin loading dose based on total body weight, gentamicin
dose based on dosing weight
Developed by Alison Thomson, Pharmacy Dept, Western Infirmary, Glasgow , 0141 211 2022, Jan 2009
Checked by Ysobel Gourlay, Pharmacy Dept. Gartnavel General Hospital, Glasgow 0141 211 3322
1000 mg followed by
1000 mg 12 hours later
VANCOMYCIN CONTINUOUS INFUSION
1000 mg over 2 h
500
For vancomycin monitoring guidelines
see vancomycin sheets
Impact of Gentamicin on Renal Replacement Therapy
Dialysis
Pre
Post
196
182
Gentamicin 41% 35%
1st gentamicin until RRT (days)
100
0
-100
2007-08
2008-09
year
A. Helps et al, 2009
Impact of Gentamicin on VIII nerve toxicity
• Discussions with Scottish ENT society
– Concern over potential for toxicity
– No routine surveillance in place
• Retrospective review in NHS GGC
– >1,200 patients Rx with gentamicin
– No evidence of increase in ENT presentations
to date
• Prospective review / enhanced
surveillance underway
Challenges ahead
• Unintended consequences
– Including resistance, morbidity and mortality
– Changing prescribing pathways
• Vigilance with adherence to guidelines
– Education
– Information
– Pharma
• Prescribing targets
• Organisation, sustainability and
collaboration