Judicious Use and Misuse of Antibiotics cases from the frontline Primaryfamily health care focus

1
Judicious Use and Misuse of Antibiotics- -
cases from the frontline- Primary/family health
care focus

• Paula Renouf, MS, NP, FCNA
• NPNZ 20th October 2007
• Auckland

2
Outline

• Judicious use of antibiotics
• Misuse of antibiotics
• Cases

3
Judicious use

• Awareness of antibiotic resistance, cross
  resistance and multidrug resistance - current,
  local and national/international trends
• Knowledge of impact on NNT of vaccines eg
  HIBgtMeNZBgtPrevnar
• Use of pharmacokinetic and dynamic principles to
  make rational antibiotic choices
• Knowledge of current evidence based treatment
  guidelines for common infections etg ENT and
  Respiratory
• See BPAC NZ Quizes
• PHARMAC-
• Ability to manage patient expectation and
  demands- successful education/health promotion
  strategies/culturally appropriate and addressing
  health literacy level of client quality
  clinician/client interaction, non-prescription
  pads!
• See Judicious Use of Antibiotics- Aguide for
  Oregon Clinicians
• PHARMAC

4
What IS antibiotic misuse?
5
Consumer understandings/ misuse

• Pressurising doctors to prescribe antibiotics
• Not completing course of treatment
• Hoarding and self treating
• Acquiring and self prescribing ( rife in
  developing countries which have not adopted WHO
  essential medicines lists and where all
  medications are available OTC)
• Increased knowledge is not clearly related to
  prudent use!
• McNulty et al (2007) n7120 face to face
  interviews in Britain

6
Prescriber misuse

• Treating viruses with antibiotics (especially
  URTIs, bronchitis)
• BPAC NZ 2006-7
• Treating benign self-limiting bacterial
  infections with antibiotics
• EBN 2007
• Treating patient demand/expectation rather than a
  susceptible bacteria
• Not keeping up with evidence regarding length and
  dose of treatment/ changing recommendations eg re
  prophylaxis
• Conway et al JAMA 2007, Bradley-Stevenson et al
  BMJ Clinical Evidence 2007

7
Antibiotic misuse- contributing factors

• Habits and expectations hard to change/ cultural
  factors
• Lack of knowledge re risks
• More knowledge associated with self medication
  and non-completion! McNulty et al (2007)
• Educating public without engineering prescribing
  practice change not necessarily effective (and
  vice versa!) McNulty et al(2007)
• Lack of control over aggressive marketing in
  developing countries . WHO Essential Drug List,
  there are only 20 antibiotics but there are over
  200 antibiotic preparations sold in Malaysia and
  other developing countries
• Subsets of immigrants with a great insistance
  for Rx/ people importing own antibiotics

8
Paediatrics- isnt that just giving amoxil? (a
GP recently!)
9
Results of misuse/overuse

• Antibiotic resistant organisms
• Risk of harmful side effects
• Impact on client cost and expectation of
  treatment
• Cost to client
• Cost to health system
• Cost to nation
• see handout word doc Pharmac (p2)

10
Untoward side effects-Ampicillin rash with EBV
11
Rationale use of antibiotics in ENT URTI
infections

• But the snot is green
• But shes been coughing really bad for a whole
  week
• But the school wont let her back until she gets
  an antibiotic for pink eye
• But it could be bacterial what about rheumatic
  fever?

12
ENT Case 1

• 5 yr old URTI, left ear ache, T37.5, nasal
  congestion copious thick and green am, clears
  later in day , red left ear drum. 2 Previous ear
  infections, NKDA which antibiotics would you
  prescribe?
• Amoxicillin, Amox-Clavulanate, Erythromycin, Pen
  V, no antibiotic?
• BPAC Respiratory quiz

13
(No Transcript)
14
ENT Case 1 Answer

• 60 GPs and expert panel NO antibiotics
• 37 thought Amoxil
• Comment panel would encourage NOT to use
  antibiotic as unlikely significant benefit
• But negociable ( consider SES, smoking?)
• Back pocket Rx and good nose blowing, pamol,
  warm packs for sore ear , hygiene, nutrition

15
Bulging eardrum ( not just red) Fever unwell
looking Bilateral otitis Otorrhea benefit from
antibiotics
16
Facts about cough in kids True or false?

• Majority of coughs resolve within 1 week
• 5 of coughs last longer than 4 weeks
• Family members with persistant cough gt4 weeks
  suggests possible pertussis
• Honking coughgt4 weeks absent during sleep
  suggests habit cough
• Post viral cough is the most frequent cause of
  coughgt4 weeks

17
Case 1 Acute Infective Conjunctivitis

• A three year old has a 2 day history of purulent
  left conjunctivitis. Kept out of kindy, presents
  afebrile,rubbing eye, injected bulbar and
  palpebral conjunctivae, TMs normal, mild clear
  coryza, shotty L) preauricular node, active,
  playing. A cousin and sib have had same.
• Does he need antibiotics?

18
Conjunctivitis needing antibiotics Gonococcal
Pneumococcus Bulbar to iris_ uveitis
19
Conjunctivitis delayed/immediate or no
antibiotics?

• Studies show most infective conjunctivitis
  resolves spontaneously after 1 wk
• Antibiotics improve clinical bacterial remission
• Prescription chloramphenicol improves duration of
  moderate symptoms (by1.5days)
• No difference in symptom severity on Day1-3
  Antibiotic versus non
• Everitt et al BMJ 2006/ Renouf EBN 2007
• Hence perhaps delayed or back pocket Rx is
  best? Plus soothing/hygiene measures?

20
However, consider

• Who benefits from immediate versus delayed or no
  antibiotic prescription?
• 80 of Acute infective Conjunctivitis in children
  under 6yrs IS bacterial (opposite for adults
  viral)
• Consider also underlying ill health,
  otitis-conjunctivitis? Fever?
• spread of infection, school and work days missed,
  access to health setting, and OTC antibiotics
  need for patient ed or will use moregt resistance?
• Renouf EBN 2007

21
Pharyngitis- Case 1

• An 18 yr old Caucasian Auckland retail assistant
  presents with 4 d sore throat and fever. She
  feels unwell, doesnt want to take time off
  work.She has 38.2C, exudative pharyngitis,
  enlarged anterior cervical nodes. No allergies
• Would you get a throat swab?
• Which antibiotic would you prescribe
• Amoxil, erythromycin, amoxicillin-clavulante,
  Penecillin V or no antibiotic?
• BPAC RESP Quiz Case 3 p 5

22
Pharyngitis Case 2

• A 6 yr old Tongan child presents with Temp 37.8,
  pulse 80, clear coryza and cough- day and night.
  No lymph node tenderness or enlargement, he is
  complaining of a very sore throat ( day 2) -
  tonsils 3, red, no exudate. Lives in Auckland in
  NZDep10.
• What other information would be important?
• Does he need a throat swab?
• What antibiotic would you give?

23
New NZ Guide for Sore Throat Management Feb 2007

• refer to your handout
• See Algorithm 4 for sore throat management
• Routine antibiotics
• Antibiotics for recurrent infection
• Case 1 pharyngitis
• Answer Swab back pocket Rx
• (Consider Sexual health hx! Gonorrhea/chlamydia)
• Case 2
• Family Rheum Fever? if not, no swab, no Rx

24
(No Transcript)
25
Risk factors for RF Maori, Pacific, 3-45 yrs,
lower SES North Island,, Past hx acute
RF Criteria to swab/treat Tempgt38, no cough,
swollen tender Anterior cervical nodes, tonsilar
swelling / exudate 2007 Sore Throat Guideline NZ
26
Case 1 Lower Respiratory

• 30.8.07 a 8 yr old Indian boy, Ht, WT 50th5ile
  presents to you with dry night cough, no wheeze,
  last Ventolin use 2.07. His medical history of
  the last 8 months consists of
• 6 presentations to GP
• Given Redipred and Amoxicillin each time for
• cough, bilateral creps chest
• Bronchitis
• What do you think? What would you do?

27
Considerations

• Other signs/symptoms? No fever, cough
  non-productive, some exercise induced cough/ ?
  wheeze
• O/E No fever, ENT neg except clear coryza,lungs
  symA/E no wheeze, occasional creps, cough non
  productive,
• No such thing as bronchitis in young children?
• Patient/family educated to expect antibiotics
  for viral illnesses
• Discussion of viral versus Bacterial, trial of
  ventolin nocte/ before exercise, back pocket
  Rx?

28
Case 2 Lower Respiratory

• A previously well 30yr old office worker has
  cough, green productive sputum for 7 days, came
  in with CC of Shortness of breath playing weekly
  squash game . O/E scattered wheeze, temp 37.7C
  NKDA. Which antibiotic does he need?
• Amoxicillin, Amox-clavulanate, Erythromycin, Pen
  V, no antibiotic?
• BPAC Resp Quiz Q6, P6

29
Case 2 63 prescribers said no antibioticGP
expert panel equivocal

• Time one week of cough versus 3wks
• Difficulty excluding atypical pneumonia versus
  viral bronchitis (most likely)
• More hx needed smoker? Atopy? Asthma?
• If acute bronchitis, only patients over 55yrs
  would benefit from Rx (pneumonia/exacerbation of
  CORD)

30
UTI Case1

• A 14 yr old male with a first UTI is referred to
  the Paediatrician for review. The GP has put him
  on prophylactic antibiotics pending renal
  ultrasound.
• What do you think?
• What information do you need to complete the
  picture?
• Does he need to be on antibiotics?

31
UTI Case 2

• Information provided female 5mth old History of
  first UTI, asymptomatic at 4 months, 10,000,000 e
  coli.
• 2 further asymptomatic UTIs since then no
  culture results
• Referred pending imaging studies- (what is
  necessary to rule out VUR?)
• On prophylaxis ceclor 125mg/d

32
UTI Prophylactic antibiotics-

• Should they be used
• a) while awaiting results of imaging studies
  (several weeks in NZ)
• Current Starship UTI Guideline (2005)
• b) to prevent recurrent UTI in children who have
  Vesicoureteric reflux? For what grade of reflux?
  for how long?
• One RCT 218 kids 3mth-18yrs- antibiotics do not
  decrease recurrence of UTI with or without
  VURGrade 1-111 ( no indications that this
  predisposes to recurrent UTI,pyelo or renal
  scars.
• Resistance a concern in prophylactic group
  Garin et al(2006)

33
UTI- prophylactic antibiotics

• Of 74.974 children (gt6yrs) from 27 general
  paediatric practices in New Jersey (primary care)
  611 kids with first UTI, 83 recurrent UTI
• Antibiotic prophylaxis post first UTI
• Did not reduce incidence of recurrent UTI
• led to a 7.5 times increase in resistant
  infection
• Recommendation further studies.. But discuss
  risks and unclear benefits of antibiotic
  prophylaxis
• Conway (2007) JAMA

34
Evidence changes practice

• ie evidence is pointing practice in the
  direction of not using prophylaxis
• This will be reflected in the 2007 Starship UTI
  guidelines

35
Vaccinations change antibiotic prescribing
practice too.

• Eg Fever of undetermined source under 3 yrs
• In a toxic appearing child ( tgt39.5C miserable,
  not playful or smiling, weak cry, sleepy, pale ,
  dry mouth,
• Intervention and treatment depend on probability
  of poor outcome from SERIOUS BACTERIAL ILLNESS
• Influenced by disease prevalence, whether disease
  is rapidly progressing ( eg MeNZ B) and
  vaccination status

36

• Haemophilus Influenzae
• MeNZB
• And now
• Prevnar (strep pneumoccal vaccine)
• Mean that a toxic appearing child who once had
  a 5 chance of SBI will only have a 0.04 chance
  hence vastly reducing the need for antibiotic
  before cultures known

37
In conclusion to prescribe antibiotics WELLNP
prescribers need
38
1) Best practice evidence at fingertips!

• Up-To- Date.com
• MD Consult / First Consult
• BPAC NZ
• BMJ Clinical Evidence
• Pharmac
• Cochrane corner (NZFP)
• P.E.A.R.L.S ( from Cochrane Primary Care group)
  
• Prodigy.nhs.uk

39
Topical treatments for chronically discharging
ears with underlying eardrum perforations (CSOM)
are better than systemic antibiotics  
40
(No Transcript)
41
2) Multi-sector collaboration Public Education
campaigns Use of the Media Eg the Wise Use of
Antibiotics Campaign

• Pharmac led
• supported by Independent Practitioners
  Associations, RNZCGP, The Pharmaceutical Society
  Plunket and the Pharmacy Guild
• Wise Use of Antibiotics Campaign
• http//www.pharmac.govt.nz/information_campaigns.a
  sp
• www.kickthatbug.org.nz

42
And 3) Interactive peer review Of Prescribing
Practice

• Can an education campaign promote appropriate
  treatment of URTI and reduce Rx of viral
  infections with antibiotics? (BPAC Issue 5. May
  2007)

43
Before And After BPAC Resp infections Campaign
July 2006 Scores On a Scenario Based Quiz re
Appropriate Antibiotic use In respiratory Infecti
ons
44
The BPAC campaign has improved my knowledge of
treating respiratory infectionsMain changes
(self report) Rx less broad spectrum antibiotics.
Applying caution, using back pocket Rx
45
References

• In handout (see associated word document on
  College of Nurses Website
• Thankyou