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

“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

“WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health” APRIL 2014

E.coli resistant to 3rd generation

Cephalosporins

2002 2012

Overall consumption of antibiotics is less/ use more narrow spectrum than broad spectrum

Antimicrobial resistance trends:Bloodstream infections in Ireland: 2002-2012

Data source: HPSC/EARS-Net

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pro

po

rtio

n r

esi

stan

ce

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

25,ooo deaths from multi-drug resistant organisms each year in Europe

“SUPERBUGS “

HCAI from resistant bacteria-Difficult to treat, prolonged illness, hospital stays, risk of death

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

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

Ireland DDD’sYear Rate2003 20.342004 20.192005 20.502006 21.092007 22.032008 21.002009 20.232010 19.752011 22.552012 22.802013 23.66

Primary Care Antibiotic Consumption Rates

80 % of antibiotics Community

Antimicrobial Use % Prevalence HALTIreland 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

Majority prescribed within LTCF by GPs and directly-employed doctors

39% prophylaxis

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

Every time we consider prescribing GP’s need to ask themselves …….

Is this antibiotic really necessary ?

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?

Narrow versus broad-spectrum

GP’s need to think more scientifically – what are you treating ?

Penicillin V for strep throat Co amoxiclav for strep throat

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

Am I keeping my patients Safe from Antibiotic Side-effects

Every time we consider prescribing GP’s need to ask themselves …….

Have I consulted the antibiotic guidelines recently? www.antibioticprescribing.ie

16

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

talk to your GP or pharmacist or visit www.hse.ie

Taking antibioticsfor colds and flu?

There’s no point.

A cold or flu is caused by avirus and antibiotics do notwork on viruses.

Public Antibiotic Awareness CampaignExplain why we need to need to preserve this

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?

What to look for

What can you do ?

When to seek help ?

www.underthweather.ie

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 phenoxymethylpenecillinfor 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

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 antimicrobial agents WHAT CAN WE DO ?

Some signs of improvement 2014

Community Antibiotic Consumption first half 2014 Use of co amoxiclav

Keeping Antibiotics Safe And Effective For Future Generations …

Dept of Health

HSE

Pharmacists

Surgeons

Dept of Agriculture

gp

Vets

Patients

Physicians

..it’s everyone's

responsibility