Dublin North SARI Newsletter
Issue 2, October 2009
Contents
Pneumococcal Infection
 Empiric therapy - ICGP guidelines –
Page 1
 Vaccination – Page 3
 Dublin North Laboratory Surveillance
Data on Antibiotic Resistance– Page 3
 Dublin North Antibiotic Consumption
– Page 5
HCAI and Infection Control Links– Page 6
Education Day for Healthcare Workers in the
Community, Wed 2nd Dec 2009 - Page 6
1. Update on
Streptococcus pneumoniae infection
Streptococcus pneumoniae (pneumococcus) is the most common bacterial cause of
community acquired pneumonia. There are over ninety serotypes of S. pneumoniae.
Transmission is usually from person to person through respiratory droplet spread but
may also be by direct oral contact or indirectly through articles contaminated with
respiratory discharges. S. pneumoniae can also cause secondary infection in patients
with a primary viral lower respiratory tract infection (e.g., Influenza virus)
The most common infections caused by S. pneumoniae include:
 Middle ear infections (particularly common in children)
 Community acquired pneumonia.
 Bacteraemia.
 Sinus infection.
 Meningitis.
Individuals most at risk of pneumococcal infections are usually very young or the
elderly. Pneumococcal disease can be prevented by vaccination.
What empiric therapy is recommended for antibiotic treatment lower
respiratory tract infection in the community?
Table 1 outlines the draft ICGP guidelines for empiric antibiotic therapy of lower
respiratory tract infection in the community. The full guidelines can be downloaded
from the Health Protection Surveillance Centre website at: http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIrelan
dSARI/Communityantibioticstewardship/
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Table 1: Empiric therapy of lower respiratory tract infections in the
community
Infection
Comment
Drug
Duration
Communityacquired
pneumonia
-treatment
in the
community
Start antibiotics immediately.
If no response in 48 hours
consider admission or if on
amoxicillin consider cover for
Mycoplasma infection (rare in
over 65s) (i.e.,
clarithromycin/tetracycline)
Amoxicillin 500 mg - 1g
TDS
Up to 10
days
Acute
exacerbation
of COPD
In severely ill give parenteral
benzylpenicillin before admission
and seek risk factors for
Legionella and S. aureus
infection.
30% viral, 30-50% bacterial, rest
undetermined
Use antibiotics if increased
dyspnoea and increased
purulence of sputum volume.
Acute
bronchitis
(in
otherwise
healthy
adults &
children)
or
Clarithromycin 500 mg BD
or
Doxycycline 200 mg
stat/100 mg OD
Amoxicillin 500 mg TDS
or
5 days
Doxycycline 200 mg
stat/100 mg OD
or
Clarithromycin 250-500
mg BD
In penicillin allergy use
clarithromycin if doxycycline
contraindicated
If clinical failure to first
line antibiotics:
co-amoxiclav 625 mg TDS
In primary care, antibiotics
have marginal benefits in
otherwise healthy adults
Patient information leaflets can
reduce antibiotic use.
Symptomatic relief
Cough expectorants(guaifenesin)
5 days
Mucolytic agent(carbocisteine – exputex)
Cough suppressants(dextromethorphan)
Codeine containing
products should be used
with care due to
dependence potential
Amoxicillin 500 mg TDS
or
Doxycycline 200 mg
stat/100 mg OD
Avoid tetracyclines in pregnancy.
High doses of penicillins will maximise efficacy and more likely to reduce resistance.
The quinolones ciprofloxacin and ofloxacin have poor activity against pneumococci. However,
they do have use in PROVEN pseudomonal infections.
Moxifloxacin and Levofloxacin has some anti-Gram-positive activity but should
not be needed as first line treatment.
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Pneumococcal vaccination – who should be vaccinated?
Fig 1 outlines patients that are particularly at risk and it is in these groups that
pneumococcal vaccine is recommended.
Two types of vaccines against pneumococcal disease are available in Ireland.
•
•
Pneumococcal polysaccharide vaccine is a 23-valent polysaccharide
vaccine (PPV23) which protects against 23 of the most common serotypes of
pneumococcus. The vaccine is approximately 65% effective in preventing
pneumonia and is currently recommended for use in all adults who are 65
years of age and older, as well as for anyone 2 years of age and older who is
at high risk for disease. For some individuals at highest risk of disease
(people whose antibody levels are likely to have declined more rapidly, e.g.,
those with no spleen, with splenic dysfunction or with nephrotic syndrome), a
second dose should be given five years later.
Pneumococcal conjugate vaccine is a seven valent conjugate vaccine
(PCV7) and protects against seven of the pneumococcal serotypes most
commonly associated with disease. PCV7 is licensed for use in children up to
five years of age who are considered at risk. PCV7 protects against
approximately 70% of the pneumococcal infections.
Since September 2008, PCV7 is part of the routine primary immunisation
programme. All children born on or after 1st July 2008 should receive the vaccine
(2 doses in year 1 and 1 dose at 12 months of age). Additionally, any child born
between 2nd September 2006 and 30th June 2008 should receive one dose of
PCV7 as part of the catch-up campaign (campaign ends on October 31st 2009).
Fig 1: Patient groups in whom pneumococcal vaccination is recommended









Persons 65 of age or older.
Asplenia or severe dysfunction of the spleen including surgical splenectomy.
Chronic renal disease or nephrotic syndrome.
Chronic heart lung or liver disease including cirrhosis.
Diabetes mellitus sickle cell disease.
Immunosuppression due to disease of treatment including HIV infection at all stages.
Patients with CSF leaks either congenital or complicating or skull fracture or neurosurgery.
Individuals with cochlear implants.
Children under 5 years of age with a history of invasive pneumococcal disease,
irrespective of vaccine history.
 All children born since 2nd September 2006.
Further information on pneumococcal vaccination (including patient factsheets) can
be found at http://www.hpsc.ie/hpsc/A-Z/VaccinePreventable/PneumococcalDisease/
Increasing pneumococcal drug resistance: Situation in Dublin North?
a. S. pneumoniae bloodstream infection
Nationally, there is an increasing concern that S. pneumoniae is becoming
increasingly resistance to some of the more commonly used antibiotics. The
European Antimicrobials Resistance Surveillance Scheme (EARSS) which records the
antimicrobial susceptibility data of organisms causing bloodstream infection has
shown increasing rates of penicillin resistance in S. pneumoniae isolates (Fig 2).
29% of isolates were penicillin non-susceptible in quarter one 2009 and 32% in
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quarter four 2008. The annual trend has increased from 10% in 2004 to 17% in
2007 and 23% in 2008. This is the highest annual proportion since surveillance
began. Therefore it is essential that patients at high risk of pneumococcal infection
should receive the pneumococcal vaccine as S. pneumoniae isolates are becoming
increasingly resistant to many of the first-line antibiotics.
Fig 2: Penicillin non-susceptible S. pneumoniae (PNSP) trends among
invasive isolates of S. pneumoniae, 1999-2009 (Source: HPSC)
500
12
19
20
23
28
41
42
42
44
42
42
450
40%
42
35%
400
25%
300
250
20%
200
%PNSP
Number of isolates
30%
350
15%
150
10%
100
5%
50
0
0%
Time period
Total S.pneumoniae
PNSP
%PNSP
All six hospitals in the Dublin North Hospitals group participate in the EARSS
Surveillance Scheme. In 2008, 19% of EARSS isolates in Dublin North were penicillin
non-susceptible and in quarter one 2009 this figure was 20%.
b. Antimicrobial susceptibility of sputum isolates in Dublin North
In order to obtain information on the antimicrobial susceptibility pattern of sputum
isolates, laboratories in the region where asked to provide data on S. pneumoniae
isolates from sputum specimens received in quarter 4 2008 (Fig 3). 20% isolates
were resistant to penicillin, which reflect the trend towards increasing penicillin
resistance in the EARSS bloodstream data.
Fig 3: Antimicrobial susceptibiltiy of S. pneumoniae isolated from sputum
in Dublin North Q4 2008
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c. Antimicrobial Consumption in the community in Dublin North and north
east region (excludes hospital data):
The prescription of antibiotics in the Dublin north/north east community was lower
than the national use of antimicrobials throughout 2007 and 2008 (Fig 4)..
Antimicrobial consumption displays seasonal variation in the Dublin North and North
East region as use appears to be highest in the autumn/winter months i.e.,
September through to January and lowest in the spring/summer months ie March
through to August. The most commonly prescribed antibiotics in Dublin North and
the North East region in quarter 4 2008 are presented in Fig 5. Co-amoxiclav
accounts for 24.8% of all antibiotic prescriptions in the community in the 4th quarter
of 2008. Amoxicillin accounted for 15.9% and clarithromycin, 13.4% of all antibiotic
prescriptions.
Fig 4: Antibiotic consumption 2007-2008: National data and data from
Dublin North/North East (Data source: HPSC)
DID (defined daily dose per 1000
inhabitants per
30.00
25.00
20.00
Dublin/Nth East
15.00
National
10.00
5.00
0.00
Jan Feb Mar April May June July Aug Sept Oct
2007
2007
Nov Dec Jan Feb Mar April May June July Aug Sept Oct
2007 2008
2008
Nov Dec
2008
% of total antibiotic consumption
Fig 5: Antibiotics prescribed in the community in Dublin North / North East
Q4 2008
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
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2. Healthcare Associated Infection and infection control
The Health Protection Surveillance website has a number of useful documents
(including patient information leaflets) on HCAI and other topics(www.hpsc.ie).
 Pandemic (H1N1) 2009: The latest information on Pandemic (H1N1) 2009
including information for general practitioners is available at www.hpsc.ie.
Infection control precautions for patients with A (H1N1) are available at:
http://www.hpsc.ie/hpsc/AZ/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHeal
thProfessionals/InfectionControl/
 National guidelines: National Guidelines are available for download which
include MRSA, Hand Hygiene, C. difficile, TB, Norovirus and legionaires
disease. The easiest way to access information is under A-Z topics.
 Hand hygiene audit tool: A hand hygiene audit tool is available at:
http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Handwashing/AuditTools/
 C. difficile audit tool: An audit tool to measure compliance with national C.
difficile guidelines is available at: http://www.hpsc.ie/hpsc/AZ/Gastroenteric/Clostridiumdifficile/Audittoolforhealthcarefacilities/
 SARI: Key SARI documents including information on membership and
previous newsletters from the Dublin North SARI Regional Committee are also
available at http://www.ndsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialRe
sistanceinIrelandSARI/OverviewandKeyDocuments/
 Care bundles: Information on care bundles are available at:
http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/CareBundles/
 Healthcare Associated Infections in European Long Term Care
Facilities (HALT Study – May 2010). Information on a European Study
on healthcare associated infection in long term care that will take place in
May 2010 is available at : http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHealthcareAssociatedInfection/
3. Date for your diary: Dublin North SARI Regional
Committee Education Day – Wednesday 2nd December
2009
Our second prevention of healthcare-associated infection educational day aimed at
healthcare staff working in the community will be held in the Catherine McAuley
Centre Lecture Room, Nelson Street (off Eccles Street and opposite the
Mater Hospital) on 2nd December 2009 at 1.30pm. Topics to be covered
include the HIQA Infection Control Standards, MRSA, C. difficile, TB, ESBL and
prevention of urinary catheter infection.
No registration fee, however places are limited.
To reserve a place please contact Ms. Suzanne Gannon at
Suzanne.gannon@hse.ie
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