Multidisciplinary
ScRAP
Scottish Reduction in Antibiotic Prescribing Programme
Prescriber Learning Event
“Reducing the unnecessary prescribing of antibiotics”
“Can we ScRAP the unnecessary antibiotic prescription?”
October 2013 edition
Quality Education for a Healthier Scotland
Multidisciplinary
What are the barriers to
decreasing antibiotic use?
Quality Education for a Healthier Scotland
Introduction & contents
• Aim of ScRAP
• Facilitator led DVD presentation & discussion session
• What will be covered:
Multidisciplinary
• What are the barriers to decreasing antibiotic use?
• Resisting resistance – Presenting the evidence
– Local prescribing data
• Patient expectations – Examining a typical patient consultation
• Managing complications – Targeted use of antibiotics
– Myth busters
– Alternative strategies – delayed
prescriptions
• Event closure
Quality Education for a Healthier Scotland
Multidisciplinary
http://www.youtube.com/watch?v=m5N3dcPmxW0
Quality Education for a Healthier Scotland
Multidisciplinary
Resisting resistance –
presenting the evidence
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Antibiotic usage at a European population level
Multidisciplinary
ESAC data 2003
Surveillance of antimicrobial consumption in
Europe, 2003
United
Kingdom
ESAC data 2010
Surveillance of antimicrobial consumption in
Europe, 2010
United
Kingdom
United Kingdom
Sweden
Sweden
Quality Education for a Healthier Scotland
Antibiotic resistance at a European population level
Goossens et al. Lancet 2005; 365: 579-587
Outpatient antibiotic use in Europe and association with resistance: a cross-national
database study
Quality Education for a Healthier Scotland
Multidisciplinary
Antibiotic resistance at practice population level
Butler et al. Br J Gen Pract 2007; 57, 785
Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract
infections with reduction in antibiotic prescribing by general practices.
Reduction (%) in resistance to ampicillin & trimethoprim over a 7-year period, by quartile of reductions in total antibiotic
prescribing
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Overall
Year 1 %
58.7
50.6
49.2
50.0
51.3
Year 7 %
53.5
51.0
51.6
49.7
51.2
Reduction % (95% CI)
5.2(2.9 to 7.4)
-0.4 (-2.3 to 1.5)
-2.4 (-4.1 to -0.7)
0.3 (-1.4 to 2.0)
0.0 (-0.9 to 1.0)
Year 1 %
29.1
26.6
26.5
25.5
25.5
Year 7 %
25.7
24.9
25.0
24.7
25.0
Reduction % (95% CI)
3.4 (1.3 to 5.4)
1.7 (0.1 to 3.3)
1.5 (0.0 to 2.9)
0.8 (-0.7 to 2.3)
0.4 (-0.8 to 1.7)
Ampicillin
Trimethoprim
Quality Education for a Healthier Scotland
Multidisciplinary
Antibiotic resistance at patient level
Costelloe et al. BMJ 2010:340 c2090
Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual
patients: systematic review and meta-analysis
Multidisciplinary
• Individuals prescribed an antibiotic in primary care for a respiratory or
urinary infection develop bacterial resistance to that antibiotic
• The effect is greatest in the month immediately after treatment but
may persist for up to 12 months
• This effect not only increases the population carriage of organisms
resistant to first line antibiotics, but also creates the conditions for
increased use of second line antibiotics in the community
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
• What information did you already know?
• What information was new?
• What has the information added to your understanding of
antimicrobial resistance?
• How do you think this might affect how you interact with
patients in the future?
Quality Education for a Healthier Scotland
Multidisciplinary
Resisting resistance –
local prescribing data
Quality Education for a Healthier Scotland
Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group.
Report on Antimicrobial Use and Resistance in Humans in 2011
Quality Education for a Healthier Scotland
Multidisciplinary
Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group.
Report on Antimicrobial Use and Resistance in Humans in 2011
Quality Education for a Healthier Scotland
Multidisciplinary
Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group.
Report on Antimicrobial Use and Resistance in Humans in 2011
Quality Education for a Healthier Scotland
Multidisciplinary
Facilitator lead discussion
Multidisciplinary
• Antibiotic use at local level
• How does your antibiotic usage compare with other local
practices in your health board?
• Was your antibiotic use higher or lower than you expected?
• How has your antibiotic usage changed over time?
• Was the change in your antibiotic usage more or less than
you expected?
• Key points from local guidelines
Quality Education for a Healthier Scotland
Multidisciplinary
Patient expectations –
examining a typical patient consultation
Quality Education for a Healthier Scotland
Expectations – but whose are they really?
Multidisciplinary
Quality Education for a Healthier Scotland
Expectations – but whose are they really?
V Duijn et al. Br J Gen Pract. 2007 July 1; 57(540): 561–568.
Illness behaviour and antibiotic prescription in patients with respiratory tract
symptoms
Multidisciplinary
• Health care professionals over-estimate patient
demand for antibiotics
• In patients with bronchitis, antibiotic prescribing had
no effect on patient satisfaction scores
• Whereas careful physical examination did
Quality Education for a Healthier Scotland
Multidisciplinary
Patient consultation video
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
• ICE approach
(Matthys et al. Patients' ideas, concerns, and expectations (ICE) in
general practice: impact on prescribing Br J Gen Pract. 2009
January 1; 59(558): 29–36)
•
•
•
•
•
•
Examination and its role in patient satisfaction
Treating concerns not desires
Explanation – not a battle of wills
Explanation – natural history of infection
Safety net option
Any changes to consultation technique?
Quality Education for a Healthier Scotland
Multidisciplinary
Managing complications –
targeted use of antibiotics
Quality Education for a Healthier Scotland
Targeted use of antibiotics
Van Duijn et al. Br J Gen Pract. 2007 Jul;57(540):561-8.
Illness behaviour and antibiotic prescription in patients with respiratory
tract symptoms
Multidisciplinary
• The antibiotic revolution should be more focused...
• “Our mission is not to prescribe as few antibiotics as
possible, but to identify that small group of patients who
really need antibiotic treatment and to explain, reassure
and educate the large group of patients who don’t.”
Quality Education for a Healthier Scotland
Targeted use of antibiotics
National Institute for Health and Clinical Excellence.
Respiratory tract infections – Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and children in primary care. 2008.
(Clinical Guideline 69)
Multidisciplinary
The following subgroups of patients in whom an immediate antibiotic
strategy should be considered depending on clinical assessment of severity;
• Bilateral acute otitis media in children younger than two years
• Acute otitis media in children with otorrhoea
• Acute sore throat / acute pharyngitis / acute tonsillitis where three or more
Centor Criteria* are present
• A delayed prescription or no prescription strategy may also be
considered
*Centor criteria
•
•
•
•
Tonsillar exudate
Tender anterior cervical lymphadenopathy
History of fever
Absence of cough
Quality Education for a Healthier Scotland
Targeted use of antibiotics
National Institute for Health and Clinical Excellence.
Respiratory tract infections – Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and children in primary care. 2008.
(Clinical Guideline 69)
Multidisciplinary
An immediate antibiotic prescription and/or further appropriate
investigation and management should only be offered to patients (both
adults and children) in the following situations:
• Systemically very unwell
• Symptoms and signs suggestive of serious illness and/or complications
(particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis,
intraorbital and intracranial complications)
• High risk of serious complications because of pre-existing comorbidity
eg significant heart, lung, renal, liver or neuromuscular disease,
immunosuppression, cystic fibrosis, and young children who were born
prematurely
Quality Education for a Healthier Scotland
Targeted use of antibiotics
National Institute for Health and Clinical Excellence.
Respiratory tract infections – Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and children in primary care. 2008.
(Clinical Guideline 69)
Multidisciplinary
• If patient is older than 65 years with acute cough and two or more of
the following criteria, or older than 80 years with acute cough and one
or more of the following criteria:
 Hospitalisation in previous year
 Type 1 or type 2 diabetes
 History of congestive heart failure
 Current use of oral glucocorticoids
For these patients, the no antibiotic prescribing strategy and the delayed
antibiotic prescribing strategy should not be considered
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
• Does this information help you understand more clearly the
place in therapy of antibiotics in respiratory tract infections?
• Are there instances where you have treated patients out
with these criteria?
• Do you feel more confident in not prescribing an antibiotic
out with the criteria?
Quality Education for a Healthier Scotland
Multidisciplinary
Managing complications
– myth busters
Quality Education for a Healthier Scotland
Myth busters – value of antibiotics in RTI
Multidisciplinary
Acute sore throat
Spinks et al. Antibiotics for sore throat.
Cochrane database for systematic review issue 4 2006
•
Without antibiotics 40% will resolve after 3 days and 90% after 7
days
•
The NNT (Number Needed to Treat) was 6 to half pain at day 3
Quality Education for a Healthier Scotland
Myth busters – value of antibiotics in RTI
Multidisciplinary
Acute Rhinosinusitis
Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database
for systematic reviews issue 2 2008
•
80% resolve in 14 days with no antibiotics
•
Antibiotics have a small benefit after 7 days of illness
•
There was no additional benefit of antibiotics in older patients, more
severe pain or longer duration of symptoms
(NNT = 15)
Quality Education for a Healthier Scotland
Myth busters – value of antibiotics in RTI
Multidisciplinary
Acute Rhinosinusitis
Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database
for systematic reviews issue 2 2008
•
66% of children are better within 24 hours and antibiotics have no
effect on symptoms
•
90% of children are better in 2 to 7 days and antibiotics have only a
small effect on reducing pain by 16 hours (NNT =15)
Quality Education for a Healthier Scotland
Myth busters – value of antibiotics in RTI
Multidisciplinary
Acute Cough / Bronchitis
Fahey et al. Antibiotics for acute bronchitis. Cochrane database for systematic
reviews issue 4 2004
• Antibiotics reduced symptoms by only one day in an
illness lasting up to 3 weeks
Quality Education for a Healthier Scotland
Myth busters – value of antibiotics in RTI
Multidisciplinary
Acute Otitis Media
Sanders et al. Antibiotics for acute otitis media in children. Cochrane database for
systematic reviews issue 1 2004
• 66% of children are better within 24 hours and antibiotics have no
effect on symptoms
•
90% of children are better in 2 to 7 days and antibiotics have only a
small effect on reducing pain by 16 hours (NNT =15)
Quality Education for a Healthier Scotland
Myth busters – preventative value of
antibiotics in RTI
Sore throat and quinsy
Peterson et al. Protective Effects of antibiotics.BMJ 2007;335:982-984
Centor et al. The diagnosis of Strep throat in adults in the emergency room.
Med Decision Making 1981;1:239-46
• Overall NNT > 4000 to prevent one case of quinsy
Centor score of 3 or 4 = 1:60 chance of quinsy
•
Centor criteria:
•
•
•
•
Tonsillar exudate
Tender anterior cervical lymphadenopathy
History of fever
Absence of cough
Quality Education for a Healthier Scotland
Multidisciplinary
Myth busters – preventative value of
antibiotics in RTI
Rheumatic Fever
Howie et al. Antibiotics, sore throat and rheumatic fever. BJGP 1985; 35 : 223-224
•
It would take 12 working life times of a GP to see one case of
Rheumatic Fever
•
Treating sore throats with antibiotics has no effect on risk of
developing Rheumatic Fever
Quality Education for a Healthier Scotland
Multidisciplinary
Myth busters – preventative value of
antibiotics in RTI
Multidisciplinary
Glomerulonephritis
Taylor et al. Antibiotics, sore throat and acute nephritis. BJGP 1983; 33 : 783-786
• Glomerulonephritis is a rare condition (2.1 per 100,000 children) and
is not prevented by treating sore throats with antibiotics
Quality Education for a Healthier Scotland
Myth busters – giving an antibiotic does no harm?
Multidisciplinary
The harm of antibiotics
British National Formulary 2013;64
•
•
•
The benefits of antibiotics have to be carefully balanced against their harm
Most antibiotics can cause gastrointestinal effects such as nausea,
vomiting and diarrhoea in some patients
In addition, a number can cause serious rashes and skin reactions
The harm of antibiotics
Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane
Review. 2004
•
Reviews of antibiotics in people with respiratory tract infections have found
that, for every 16 people treated with antibiotics, rather than placebo, 1 person
will suffer an adverse event
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
• Does this information help you understand more clearly the
place in therapy of antibiotics in respiratory tract infections?
• Are their instances where you have treated patients with an
antibiotic in these clinical situations?
• Do you feel more confident in not prescribing an antibiotic
in these clinical situations as a result of the evidence?
Quality Education for a Healthier Scotland
Multidisciplinary
Managing complicationsalternative strategies: delayed
prescriptions
Quality Education for a Healthier Scotland
Delayed prescriptions
Spurling et al. Cochrane Database of Systematic Reviews 2007, Issue
3.Cochrane 2007
Delayed antibiotics for respiratory infections.
Multidisciplinary
•
Delayed prescriptions substantially reduce antibiotic use but might
slightly worsen some symptoms compared with immediate
prescriptions
•
Delayed prescriptions might also reduce re-consultation rates
•
For mild upper respiratory tract infections delayed prescriptions are
not associated with important negative consequences
Quality Education for a Healthier Scotland
Delayed prescriptions
Spurling et al. Cochrane Database of Systematic Reviews, Issue
4.Cochrane 2013
Delayed antibiotics for respiratory infections. Update of 2007
•
Most clinical outcomes show no difference between strategies
•
Delay slightly reduces patient satisfaction compared to
immediate antibiotics (87% versus 92%) but not compared to
none (87% versus 83%)
•
In patients with respiratory infections where clinicians feel it is
safe not to prescribe antibiotics immediately, no antibiotics with
advice to return if symptoms do not resolve is likely to result in
the least antibiotic use, while maintaining similar patient
satisfaction and clinical outcomes to delayed antibiotics
Quality Education for a Healthier Scotland
Multidisciplinary
Delayed prescriptions
National Institute for Health and Clinical Excellence.
Respiratory tract infections – Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and children in primary care. 2008.
(Clinical Guideline 69)
Multidisciplinary
When using delayed antibiotic prescriptions, patients should be offered:
• Reassurance that antibiotics are not needed immediately since likely to
make little difference to symptoms and may have side effects, for
example, diarrhoea, vomiting and rash
• Advice about using the delayed prescription if symptoms are not
starting to settle in accordance with the expected course of the illness or if
a significant worsening of symptoms occurs
• Advice about re-consulting if there is a significant worsening of
symptoms despite using the delayed prescription.
• A delayed prescription with instructions - either given to patient or left
at an agreed location to be collected at a later date.
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
• Any experience of
delayed prescriptions?
• How important is patient
information in a delayed
prescription strategy?
• Is a delayed prescription
strategy worthwhile
trialling in this practice?
Quality Education for a Healthier Scotland
Multidisciplinary
Event closure
Quality Education for a Healthier Scotland
Facilitator lead discussion
Multidisciplinary
Next steps
What strategy are we going to take to move forward?
Changes to consultation style and/or delayed prescriptions?
• Can we reach a practice consensus?
• How we can measure progress?
• Evaluations (health board specific & CPD)
Quality Education for a Healthier Scotland