F1 Microbiology Session
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Transcript of F1 Microbiology Session
F1 Microbiology SessionF1 Microbiology Session
Matt RogersMatt Rogers
Consultant MicrobiologistConsultant Microbiologist
August 2009August 2009
Session PlanSession Plan
Brief InductionBrief Induction Prescribing an antibioticPrescribing an antibiotic Antibiotic PolicyAntibiotic Policy Infection Control HighlightsInfection Control Highlights
Microbiology Services 1Microbiology Services 1 Pathology Dept 4Pathology Dept 4thth Floor West Wing Floor West Wing
BacteriologyBacteriology VirologyVirology ParasitologyParasitology MycologyMycology EnvironmentalEnvironmental
See pathology handbook for service detailsSee pathology handbook for service details Lab opening hours 8am-7pm for examination of Lab opening hours 8am-7pm for examination of
routine specimens (9am-11.30am Saturday)routine specimens (9am-11.30am Saturday) Specimens should be at transport collection Specimens should be at transport collection
points no later than 4.30pm Rugby and 5.30pm points no later than 4.30pm Rugby and 5.30pm Walsgrave to be processed that day, 10am on Walsgrave to be processed that day, 10am on SaturdaySaturday
Microbiology Services 2Microbiology Services 2 Urgent specimens should be notified to the lab Urgent specimens should be notified to the lab
in normal hours and labelled EMERGENCY in normal hours and labelled EMERGENCY SPECIMEN, forward ASAP to Path reception SPECIMEN, forward ASAP to Path reception UHCW or Specimen Reception RugbyUHCW or Specimen Reception Rugby
EMERCENCY SERVICE out of hoursEMERCENCY SERVICE out of hours Technical advice/specimen processingTechnical advice/specimen processing Please contact switchboard and ask to speak to Please contact switchboard and ask to speak to
Microbiology Biomedical Scientist on callMicrobiology Biomedical Scientist on call ResultsResults
CRRS should be used to review results in the first CRRS should be used to review results in the first instanceinstance
Bacteriology Bacteriology x25428x25428 VirologyVirology x25468x25468
Clinical serviceClinical service Clinical adviceClinical advice
Normal hoursNormal hours UHCW 25446/x25487UHCW 25446/x25487 GE 5325GE 5325 SWH 4227SWH 4227 Ask to speak to a MedicAsk to speak to a Medic Out of HoursOut of Hours Contact duty Medical Microbiologist via switch (24hrs Contact duty Medical Microbiologist via switch (24hrs
365 days/year)365 days/year) Ward roundsWard rounds
UHCW/SWH/GEHUHCW/SWH/GEH Conduct daily ward rounds Mon-Fri on GCC/ITUConduct daily ward rounds Mon-Fri on GCC/ITU UHCW includes Cardiothoracic Critical Care, also follow UHCW includes Cardiothoracic Critical Care, also follow
up review requests on other wardsup review requests on other wards
GentamicinGentamicin Levels done round the clock by Levels done round the clock by
BiochemistryBiochemistry Dose of Gent in this Trust is 5mg/kg od Dose of Gent in this Trust is 5mg/kg od
iv (Lean Body Mass)iv (Lean Body Mass) 24hrly if CC >61ml/min24hrly if CC >61ml/min 36hrly if CC 41-60 ml/min36hrly if CC 41-60 ml/min 48hrly if CC 21-40 ml/min48hrly if CC 21-40 ml/min Check a random level at 48hr if CC <21 Check a random level at 48hr if CC <21
ml/minml/min Check level before 2Check level before 2ndnd or 3 or 3rdrd dose should be dose should be
less than 1mg/lless than 1mg/l
VancomycinVancomycin
Levels done round the clock by Levels done round the clock by BiochemistryBiochemistry
Standard adult dose 1g bd ivStandard adult dose 1g bd iv If CC normal 1g bdIf CC normal 1g bd If CC 50ml/min give 1g 24hrlyIf CC 50ml/min give 1g 24hrly If CC 25ml/min give 1g 48hrlyIf CC 25ml/min give 1g 48hrly Check pre dose level before 4Check pre dose level before 4thth or 5 or 5thth
dosedose Pre dose levels should be 12-15mg/lPre dose levels should be 12-15mg/l
Diseases notifiable (to Local Authority Proper Diseases notifiable (to Local Authority Proper Officers) under theOfficers) under the
Public Health (Infectious Diseases) Public Health (Infectious Diseases) Regulations 1988Regulations 1988
Health Protection Agency Unit Contact number Health Protection Agency Unit Contact number 01926 493491 x30701926 493491 x307
Outside normal hours please contact switch and ask Outside normal hours please contact switch and ask them to put you through to the Public Health Doctor on them to put you through to the Public Health Doctor on callcall
Do not hesitate to contact either the Public Health Do not hesitate to contact either the Public Health Doctor on call, or On call Medical Microbiologist if Doctor on call, or On call Medical Microbiologist if further advice is required further advice is required
Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery FoodAcute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Foodpoisoning Leptospirosis Malaria Measles Meningitis (poisoning Leptospirosis Malaria Measles Meningitis (meningococcal pneumococcal meningococcal pneumococcal
haemophilushaemophilusInfluenzae viral other specifiedunspecified)Influenzae viral other specifiedunspecified) Meningococcal septicaemia (without Meningococcal septicaemia (without
meningitis) meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever
RubellaRubellaScarlet fever Smallpox Tetanus Scarlet fever Smallpox Tetanus TuberculosisTuberculosis Typhoid fever Typhus fever Viral Typhoid fever Typhus fever Viralhaemorrhagic fever Viral hepatitis haemorrhagic fever Viral hepatitis Hepatitis A Hepatitis B Hepatitis C other Hepatitis A Hepatitis B Hepatitis C other WhoopingWhoopingcough Yellow fever Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Deptcough Yellow fever Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Dept
TBTB
Increased burden of TBIncreased burden of TB Several Cases of TB in Trust have been Several Cases of TB in Trust have been
undiagnosed for a period of time leading undiagnosed for a period of time leading to large look back exercisesto large look back exercises
Suspicion of/or confirmed TB MUST be Suspicion of/or confirmed TB MUST be notified to Health Protection Agency Unitnotified to Health Protection Agency Unit
Please contact Infection Control Please contact Infection Control immediately and isolate the patientimmediately and isolate the patient
Complete form found on Intranet under Complete form found on Intranet under Clinical Support>TB data collectionClinical Support>TB data collection
Antibiotic PolicyAntibiotic Policy
Is the antibiotic policy Is the antibiotic policy relevant 1relevant 1
Yes!Yes! Core policy in The Health Act 2006: Code of Core policy in The Health Act 2006: Code of
practice for the prevention and control of practice for the prevention and control of healthcare associated infectionshealthcare associated infections
Minimise the use of broad spectrum antibioticsMinimise the use of broad spectrum antibiotics Longer the hospital stay, greater chance of Longer the hospital stay, greater chance of
acquisition of HAIacquisition of HAI Ensure only those needing antibiotics receive Ensure only those needing antibiotics receive
them and that they get the appropriate durationthem and that they get the appropriate duration Minimise the use of iv antibioticsMinimise the use of iv antibiotics Iv/oral switch a central strategyIv/oral switch a central strategy Certain antibiotics are associated with particular Certain antibiotics are associated with particular
HAIsHAIs
Is the antibiotic policy Is the antibiotic policy relevant 2relevant 2
C.difficileC.difficile Cefuroxime clearly Cefuroxime clearly
associated with associated with C.difficileC.difficile Trusts that have abolished Trusts that have abolished
its use have seen dramatic its use have seen dramatic reduction in rates (Stoke reduction in rates (Stoke Mandeville)Mandeville)
Other antibiotics such as Other antibiotics such as ciprofloxacin have been ciprofloxacin have been associated with Outbreaksassociated with Outbreaks
MRSA/ESBLsMRSA/ESBLs Ciprofloxacin usage is Ciprofloxacin usage is
related to selection of related to selection of resistant organismsresistant organisms
Evidence of antibiotic Evidence of antibiotic prescribing problems prescribing problems
within the trustwithin the trust Antibiotic audit evidenceAntibiotic audit evidence C.difficile rates need to be reducedC.difficile rates need to be reduced Pharmacy monitoring continues to Pharmacy monitoring continues to
show use of antibiotics outside of the show use of antibiotics outside of the Hospitals Antibiotic PolicyHospitals Antibiotic Policy
MAU AuditMAU AuditZoe Campbell F2 SHOZoe Campbell F2 SHO
Only those with Severe Only those with Severe pneumonia according pneumonia according to CURB criteria should to CURB criteria should receive IV antibioticsreceive IV antibiotics
18 out of 25 patients 18 out of 25 patients received IV antibioticsreceived IV antibiotics
18 patients were 18 patients were classified mild/mod (? classified mild/mod (? Oral antibiotics)Oral antibiotics)
7 patients were 7 patients were classified severe (? IV classified severe (? IV antibiotics)antibiotics)
I.V.
Oral
Mild/mod
Sev
MAU Audit: IV/Oral MAU Audit: IV/Oral SwitchSwitch
Only 2 out of 25 Only 2 out of 25 (8%) patients had (8%) patients had an IV to oral an IV to oral switch or a switch or a review/stop date review/stop date specified on initial specified on initial clerkingclerking
No date specified
Date specified
Current HAI impactCurrent HAI impact MRSAMRSA
Impact on patients quality of life of an acquired Impact on patients quality of life of an acquired infection can be hugeinfection can be huge
Associated with significant morbidity/mortalityAssociated with significant morbidity/mortality Trust performance managed on MRSA bacteraemia Trust performance managed on MRSA bacteraemia
figuresfigures Clostridium difficileClostridium difficile
Impact on patients quality of life of an acquired Impact on patients quality of life of an acquired infection can be hugeinfection can be huge
Associated with significant morbidity/mortalityAssociated with significant morbidity/mortality 40 cases/month at £4500 each can cost Trust up to 40 cases/month at £4500 each can cost Trust up to
£180,000/month£180,000/month Trust now performance managed on C.difficile figuresTrust now performance managed on C.difficile figures PCTexpect a 20% reduction in rate in C.difficile PCTexpect a 20% reduction in rate in C.difficile
New policyNew policy This evidence made it clear that we This evidence made it clear that we
needed a new fit for purpose policyneeded a new fit for purpose policy
Key PrinciplesKey Principles Evidence based policyEvidence based policy Improve guidance on diagnosis of Improve guidance on diagnosis of
infection, specimen collection etc.infection, specimen collection etc. Improve guidance on when to use Improve guidance on when to use
of oral or iv antibioticsof oral or iv antibiotics Improve guidance on iv to oral Improve guidance on iv to oral
switchswitch Provide guidance on duration of Provide guidance on duration of
treatmenttreatment
Key antibiotic changesKey antibiotic changes Stop use of cefuroxime throughout the TrustStop use of cefuroxime throughout the Trust
Use lower risk augmentin (but monitor Use lower risk augmentin (but monitor C.difficileC.difficile rates)rates)
Reduce use of ciprofloxacin (consider penicillin Reduce use of ciprofloxacin (consider penicillin allergy)allergy)
Antibiotic policy available under Clinical Antibiotic policy available under Clinical Guidelines on the intranetGuidelines on the intranet
Antibiotic guideline credit cards distributedAntibiotic guideline credit cards distributed
Cefuroxime Spend by UHCW NHS Trust
£0
£500
£1,000
£1,500
£2,000
£2,500
£3,000Ap
r-07
May-
07
Jun-
07
Jul-0
7
Aug-
07
Sep-
07
Oct-0
7
Nov-
07
Dec-
07
Jan-
08
Feb-
08
Mar-0
8
Apr-0
8
May-
08
Jun-
08
Jul-0
8
Aug-
08
Sep-
08
Oct-0
8
Nov-
08
Dec-
08
Jan-
09
Feb-
09
Mar-0
9
Apr-0
9
May-
09
Jun-
09
Jul-0
9
Aug-
09
Sep-
09
Oct-0
9
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar-1
0
Expe
nditu
re
Diagnostics and Service Division
Medicine and Emergency Division
Rugby St Cross
Specialised Networks Division
Surgery Division
TRUST TOTAL
Total Oral Ciprofloxacin spend by UHCW NHS Trust(Includes inpatient, TTO & outpatient issues)
£0
£100
£200
£300
£400
£500
£600
£700Ap
r-07
May-
07
Jun-
07
Jul-0
7
Aug-
07
Sep-
07
Oct-0
7
Nov-
07
Dec-
07
Jan-
08
Feb-
08
Mar-0
8
Apr-0
8
May-
08
Jun-
08
Jul-0
8
Aug-
08
Sep-
08
Oct-0
8
Nov-
08
Dec-
08
Jan-
09
Feb-
09
Mar-0
9
Apr-0
9
May-
09
Jun-
09
Jul-0
9
Aug-
09
Sep-
09
Oct-0
9
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar-1
0
Expe
nditu
re
Diagnostics and Service Division
Medicine and Emergency Division
Rugby St Cross
Specialised Networks Division
Surgery Division
TRUST TOTAL
Oral Ciprofloxacin Costs for inpatient use at UHCW NHS Trust
£0
£25
£50
£75
£100
£125
£150
£175
£200
£225
£250Ap
r-07
May
-07
Jun-
07
Jul-0
7
Aug-
07
Sep-
07
Oct
-07
Nov-
07
Dec-
07
Jan-
08
Feb-
08
Mar
-08
Apr-0
8
May
-08
Jun-
08
Jul-0
8
Aug-
08
Sep-
08
Oct
-08
Nov-
08
Dec-
08
Jan-
09
Feb-
09
Mar
-09
Apr-0
9
May
-09
Jun-
09
Jul-0
9
Aug-
09
Sep-
09
Oct
-09
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar
-10
Expe
nditu
re
Ciprofloxacin Suspension 250mg/5ml
Ciprofloxacin Tablets 250mg
Total IV Ciprofloxacin Spend by UHCW NHS Trust
£0
£100
£200
£300
£400
£500
£600
£700Ap
r-08
May-
08
Jun-
08
Jul-0
8
Aug-
08
Sep-
08
Oct-0
8
Nov-
08
Dec-
08
Jan-
09
Feb-
09
Mar-0
9
Apr-0
9
May-
09
Jun-
09
Jul-0
9
Aug-
09
Sep-
09
Oct-0
9
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar-1
0
Expe
nditu
re
Diagnostics and Service Division
Medicine and Emergency Division
Rugby St Cross
Specialised Networks Division
Surgery Division
TRUST TOTAL
Antibiotic prescribingAntibiotic prescribingWhat’s important?What’s important?
WhenWhen Is there an infection?Is there an infection?
HowHow To diagnose. What specimens?To diagnose. What specimens?
WhyWhy What is the indication/Likely pathogens?What is the indication/Likely pathogens?
WhatWhat What antibiotic/route/durationWhat antibiotic/route/duration
When?When?
Diagnosing infection is a CLINICAL skillDiagnosing infection is a CLINICAL skill ““Hello it’s the SHO here I’ve got this pt, Hello it’s the SHO here I’ve got this pt,
could you tell me if they have an could you tell me if they have an infection”infection”
Basic signs and symptoms of infectionBasic signs and symptoms of infection Please remember apart from sterile Please remember apart from sterile
sites (urine/csf/blood etc) most areas sites (urine/csf/blood etc) most areas you culture WILL grow bacteriayou culture WILL grow bacteria
When not to ‘classics’When not to ‘classics’
CSU-urine cloudyCSU-urine cloudy Chest-we think they’ve got CCF but Chest-we think they’ve got CCF but
thought we’d give some coverthought we’d give some cover Wound with serous exudateWound with serous exudate Sloughy UlcersSloughy Ulcers Isolated spikes of tempIsolated spikes of temp To treat a high WCCTo treat a high WCC
How?How?
How to diagnose Infection???How to diagnose Infection??? What specimens do you need to What specimens do you need to
take?take? What investigations do you need to What investigations do you need to
ask for?ask for?
Why?Why?
Know your basic MicrobiologyKnow your basic Microbiology The indication (UTI/LRTI etc)The indication (UTI/LRTI etc) The setting (Pt+environment)The setting (Pt+environment)
Hospital v Community (feasibility)Hospital v Community (feasibility) Why are we giving AntibioticsWhy are we giving Antibiotics
Empirical/Prophylactic/TargetedEmpirical/Prophylactic/Targeted The likely pathogens (CRRS)The likely pathogens (CRRS)
What?What?
Where, When and Why have been Where, When and Why have been addressedaddressed
Now What is the Most appropriate choice Now What is the Most appropriate choice of therapyof therapy Pharmacokinetics/Interactions/Allergy/Side Pharmacokinetics/Interactions/Allergy/Side
effectseffects What routeWhat route What durationWhat duration
5-7 days for MOST infections5-7 days for MOST infections What outcome expectedWhat outcome expected
Also How much?Also How much?
Unfortunate but Healthcare Unfortunate but Healthcare economics are always a economics are always a considerationconsideration
Particularly with some newer drugsParticularly with some newer drugs AntifungalsAntifungals AntibacterialsAntibacterials AntiviralsAntivirals
What must an antibiotic What must an antibiotic prescription include?prescription include?
Must be documented with review Must be documented with review dates in the patients notesdates in the patients notes
Length of course or a Review dateLength of course or a Review date (all i/v antibiotics must be reviewed at 48 hours (all i/v antibiotics must be reviewed at 48 hours
and changed to oral where clinically appropriate)and changed to oral where clinically appropriate) IndicationIndication All antibiotics must be reviewed All antibiotics must be reviewed
dailydaily
A few casesA few cases
Case 1Case 1
Case OneCase One A 65 year old lady admitted 10 days A 65 year old lady admitted 10 days
ago with a Community Acquired ago with a Community Acquired Pneumonia has had 10 days of IV Pneumonia has had 10 days of IV Amoxicillin 1g tds.Amoxicillin 1g tds.
Now presents with cellulitis around Now presents with cellulitis around venflon site.venflon site.
Case 2Case 2
Case TwoCase Two A 72 year old lady presenting to A 72 year old lady presenting to
MAU with confusionMAU with confusion Says she has previous history of Says she has previous history of
UTIsUTIs
Case 3Case 3
Case ThreeCase Three A 17 year old male University A 17 year old male University
student presenting to GP then the student presenting to GP then the Emergency Department with Emergency Department with Meningitis (non-blanching rash / Meningitis (non-blanching rash / headache /photophobia)headache /photophobia)
Case 4Case 4
Case FourCase Four A 32 year old female IVDU A 32 year old female IVDU
presenting with Groin abscess and presenting with Groin abscess and new heart murmurnew heart murmur
Case 5Case 5
Case FiveCase Five A year old man treated on W12 for a A year old man treated on W12 for a
mild pneumonia with Co-amoxiclav mild pneumonia with Co-amoxiclav and erythromycinand erythromycin
Develops diarrhoea ?C.difficileDevelops diarrhoea ?C.difficile
Handwashing auditHandwashing audit
Conducted by F1/F2s last yearConducted by F1/F2s last year Covert observation of handwashing Covert observation of handwashing
practices on ward roundspractices on ward rounds Noting Hand decontamination Noting Hand decontamination
procedures between each patient procedures between each patient visitvisit
The resultsThe results Contact and correct HDCContact and correct HDC
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
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Me
an
Clinical Team
Results: SpecialityResults: Speciality
Contact and Contact and correct HDCcorrect HDC
Patient Patient contact and contact and any HDCany HDC
Medicine Medicine (432)(432) 39.2%39.2% 82.9%82.9%
Surgery (156)Surgery (156) 9.6%9.6% 64.9%64.9%
Others (82)Others (82) 52.4%52.4% 89.7%89.7%
Results: GradeResults: Grade
Contact and Contact and correct HDCcorrect HDC
Patient Patient contact and contact and any HDCany HDC
Consultants Consultants (429)(429) 36.1%36.1% 80.9%80.9%
Junior Staff Junior Staff (241)(241) 31.2%31.2% 72.0%72.0%