Antibiotic Prescribing in
Primary care
Alastair Monk
Medicines Optimisation Team
NHS North of England Commissioning Support
Patient Safety Conference
Wednesday 1st April 2016
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What are the issues (patient
safety) ?
 Antimicrobial Resistance
 Clostridium difficile infection (and other
“Super bugs”)
 Drug side effects
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Antibiotic prescribing in the
North East and Cumbria
The Guardian 11 Jun 2013
UK map shows areas where GPs
are most, or least, likely to
prescribe antibiotics to patients.
ESPAUR report
Highlighting the North East as
high prescribers of antibiotics.
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The Area Teams compared
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Antimicrobial Resistance
 The emergence, selection and spread of
resistant bacteria is a major patient safety
and public health issue.
 Infections with antibiotic-resistant bacteria can result
in:
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increased patient morbidity
Increased mortality
increased hospital length of stay
Increased cost of care.
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UK 5 year AMR strategy
Key elements for primary care
 Antibiotic guideline, and audit
 Public/professional awareness campaign
 Educational resources
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The interventions? – a collection of multifaceted
interventions for individual prescribers,
practices and CCGs
Regional prescribing
guidelines
Education and
training
Awareness
campaign
Guideline document
eLearning
Posters and postcards
Smartphone app
Face to face workshops
‘Non-prescriptions’
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Clostridium difficile infection
 It’s not just C diff
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Enterococcus faecium
Staph.aureus (MRSA/VRSA)
C.difficile
Acinetobacter baumanii
Pseudomonas aeruginosa
Enterobacteriaceae
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C diff (contd)
 People at risk:
 Those who have been treated with broad spectrum
antibiotics
 People with serious underlying illnesses
 The elderly are at greatest risk – over 80% of
Clostridium difficile infections reported are in people
aged over 65 years (they are 10x more at risk)
 Prev. C.diff infection
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C diff (contd)
 Infection can lead to:
 Mild to severe diarrhoea – watery and odorous
 Pseudomembranous colitis
 Toxic megacolon
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How the Area Teams Compare
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ESBL’s
 Extended spectrum β-lactamase producers
 Mainly in E.coli and Klebsiella sp
 Resistant to ALL penicillins, cephalosporins and
many other antibiotics
 The only oral options available may be:
 Nitrofurantoin
 Pivmecillinam
 Fosfomycin
 Seen increasingly mainly in urine specimens of
the elderly population
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Possible Adverse Effects of
Antibiotics
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Allergy
Side effect of antibiotic
Interaction with other medication
Effect on normal bacterial flora resulting in:
 antibiotic associated diarrhoea
 oral and vaginal candidiasis
 colonisation or infection by resistant bacteria (MRSA, ESBL
producing Gram negatives, etc)

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Penicillin allergy
 In suspected penicillin allergy, a careful history of
the nature of the reaction should be taken:
 Vague/minor (e.g. gastrointestinal disturbance)
→ if appropriate, treatment with a penicillin is justified
 non-urticarial rash with penicillin
(without angio-oedema or anaphylaxis)
→ cephalosporins, could still be used with caution if appropriate
 urticarial rash/angio-oedema/anaphylaxis
→ all beta-lactams are contraindicated
Could lead to the use of “other” less appropriate antibiotics
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Resources
 TARGET antibiotics toolkit: http://www.rcgp.org.uk/targetantibiotics/
OR http://www.rcgp.org.uk/clinical-and-research/target-antibioticstoolkit.aspx
 ‘Stemming the Tide of Antibiotic Resistance’ educational programme
(STAR): http://www.stemmingthetide.org/
 http://bsac.org.uk/
 http://antibiotic-action.com/
 NICE Guidance:
 CG 69 Antibiotic Prescribing for Respiratory Infections
 NECS MO Website http://medicines.necsu.nhs.uk/
 www.antibiotic-action.com
 Department of Health website
 European Antibiotic Awareness Day
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 Thank you
 Any questions?
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