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National Changes in Antibiotic Policy

National Changes in Antibiotic Policy. R. Andrew Seaton Consultant Physician Lead doctor Antimicrobial Management Team, NHS GG&C. SAPG Infection Management Workstream. Developing and applying prudent prescribing principles in hospital and community Hospital infection management guidelines

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National Changes in Antibiotic Policy

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  1. National Changes in Antibiotic Policy R. Andrew Seaton Consultant Physician Lead doctor Antimicrobial Management Team, NHS GG&C

  2. SAPG Infection Management Workstream Developing and applying prudent prescribing principles in hospital and community Hospital infection management guidelines Surgical prophylaxis guidelines Primary care guidelines Prescribing indicators to underpin control of HAI Unintended consequences of change

  3. Clostridium difficile and prescribingin Scotland Adapted from Health Protection Scotland data

  4. CDI Risk and Antibiotic Treatment NB. Any Antibiotic. Duration of therapy

  5. CDI Risk and Antibiotic Treatment UPDATE: Quinolone use is strongly associated with Hyper-virulent, quinolone-resistant 027 strain of C difficile NB. Any Antibiotic. Duration of therapy

  6. Reduced MRSA risk Increased MRSA risk

  7. Clostridium difficile NHS Greater Glasgow and Clyde June 2008 55 CDI / 6 months 18 either primary cause or contributing to death Infection control issues Antibiotic prescribing

  8. AMT response: June 2008 Urgent review of prescribing, guidance (case mix) Stricter restrictions “4 Cs” Cephalosporins Co-amoxiclav Clindamicin Ciprofloxacin (Quinolones) • Promote • Think before you prescribe • Narrow spectrum agents/ simplify • Limit duration • Combination with gentamicin for serious infection • CDI Rx guidelines

  9. www.glasgowformulary.com

  10. Recommended, Restricted and Alert Antibiotics

  11. National Response • Independent review (Vale of Leven Hospital) • “Prudent antimicrobial prescribing implemented and monitored both in the Acute and Communitysectors” • Scottish Government: CEL 30, July 2008 • AMT for Primary care and secondary care in all HBs

  12. Education & Communication Surveillance of Usage Antimicrobial Practice Guidance And Protocols Audit of Practice Antimicrobial Resistance and CDAD Alert Restricted Agents SAPG AMTs AMT

  13. SAPG, Nov 08

  14. Restrictive guidance

  15. Restrictive guidance

  16. Restrictive guidance

  17. HEAT targetto reduce CDI rate in ≥ 65 yrs by ≥ 30% by March 2011:Prescribing indicators: Hospital

  18. Improvement Action Plan for NHS Greater Glasgow and Clyde Southern General Hospital Inspection Date: Monday 8 and Tuesday 9 March 2010 “It is recommended that NHS Greater Glasgow and Clyde implements auditing of 20 patient records each month in all receiving wards”

  19. Unintended consequences • Toxicity • Renal • Oto-vestibular • Treatment failure • ICU admission • Death • Prescribing adaptation • Resistance

  20. National consensus to adopt single national Vancomycin guideline Agreed that boards would adopt either Hartford (7mg/kg) or NHS GGC (5mg/kg) regimens Caution beyond 72 hours On line calculators for dosage SAPG Vancomycin and Gentamicin prescribing Guidelines, Sept 09

  21. Impact of Gentamicin on Renal Replacement Therapy A. Helps et al, 2009

  22. Impact of Gentamicin on VIII nerve toxicity • Discussions with Scottish ENT society • Concern over potential for toxicity • No routine surveillance in place • Retrospective review in NHS GGC • >1,200 patients Rx with gentamicin • No evidence of increase in ENT presentations to date • Prospective review / enhanced surveillance underway

  23. Challenges ahead • Unintended consequences • Including resistance, morbidity and mortality • Changing prescribing pathways • Vigilance with adherence to guidelines • Education • Information • Pharma • Prescribing targets • Organisation, sustainability and collaboration

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