ScRAP Sc ottish R eduction in A ntibiotic P rescribing P rogramme

1. ScRAPScottish Reduction in Antibiotic Prescribing Programme Prescriber Learning Event “Reducing the unnecessary prescribing of antibiotics” “Can we ScRAP the unnecessary antibiotic prescription?” October 2013 edition

2. Introduction & contents • Aim of ScRAP • Facilitator led DVD presentation & discussion session • What will be covered? • What are the barriers to decreasing antibiotic use? • Resisting resistance – Presenting the evidence • – Local prescribing data • Patient expectations – Examining a typical patient consultation • Managing complications – Targeted use of antibiotics • – Myth busters • – Alternative strategies – delayed prescriptions • Event closure

3. What are the barriers to decreasing antibiotic use?

4. http://www.youtube.com/watch?v=m5N3dcPmxW0

5. Introduction & contents • Aim of ScRAP • Facilitator led DVD presentation & discussion session • What will be covered: • What are the barriers to decreasing antibiotic use? • Resisting resistance – Presenting the evidence • – Local prescribing data • Patient expectations – Examining a typical patient consultation • Managing complications – Targeted use of antibiotics • – Myth busters • – Alternative strategies – delayed prescriptions • Event closure

6. What are the barriers to reducing antibiotic prescribing? • Understanding reality of antimicrobial resistance? • Concern of unintended harm as a result of not prescribing an antibiotic? • Demands, expectations and previous experience of patients and their representatives?

7. Resisting resistance –presenting the evidence

10. Antibiotic usage at a European population level ESAC data 2003 Surveillance of antimicrobial consumption in Europe, 2003 ESAC data 2010 Surveillance of antimicrobial consumption in Europe, 2010 United Kingdom United Kingdom United Kingdom Sweden Sweden

11. Antibiotic resistance at a European population level Goossens et al. Lancet 2005; 365: 579-587 Outpatient antibiotic use in Europe and association with resistance: a cross-national database study

12. Antibiotic resistance at practice population level Butler et al. Br J Gen Pract 2007; 57, 785 Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices. Reduction (%) in resistance to ampicillin & trimethoprim over a 7-year period, by quartile of reductions in total antibiotic prescribing

13. Antibiotic resistance at patient level Costelloe et al. BMJ 2010:340 c2090 Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis • Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic • The effect is greatest in the month immediately after treatment but may persist for up to 12 months • This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community

14. Facilitator lead discussion • What information did you already know? • What information was new? • What has the information added to your understanding of antimicrobial resistance? • How do you think this might affect how you interact with patients in the future?

15. Resisting resistance – local prescribing data

16. Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

17. Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

18. Antibiotic usage at a national level Scottish Medicines Consortium / Scottish Antimicrobial Prescribing Group. Report on Antimicrobial Use and Resistance in Humans in 2011

19. Facilitator lead discussion • Antibiotic use at local level • How does your antibiotic usage compare with other local practices in your health board? • Was your antibiotic use higher or lower than you expected? • How has your antibiotic usage changed over time? • Was the change in your antibiotic usage more or less than you expected? • Key points from local guidelines

20. Patient expectations – examining a typical patient consultation

21. Expectations – but whose are they really?

22. Expectations – but whose are they really? V Duijn et al. Br J Gen Pract. 2007 July 1; 57(540): 561–568. Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms • Health care professionals over-estimate patient demand for antibiotics • In patients with bronchitis, antibiotic prescribing had no effect on patient satisfaction scores • Whereas careful physical examination did

23. Patient consultation video

24. Facilitator lead discussion • ICE approach • (Matthys et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing Br J Gen Pract. 2009 January 1; 59(558): 29–36) • Examination and its role in patient satisfaction • Treating concerns not desires • Explanation – not a battle of wills • Explanation – natural history of infection • Safety net option • Any changes to consultation technique?

25. Managing complications –targeted use of antibiotics

26. Targeted use of antibiotics Van Duijn et al.Br J Gen Pract. 2007 Jul;57(540):561-8. Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms • The antibiotic revolution should be more focused... • “Our mission is not to prescribe as few antibiotics as possible, but to identify that small group of patients who really need antibiotic treatment and to explain, reassure and educate the large group of patients who don’t.”

27. Targeted use of antibiotics National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) • The following subgroups of patients in whom an immediate antibiotic strategy should be considered depending on clinical assessment of severity; • Bilateral acute otitis media in children younger than two years • Acute otitis media in children with otorrhoea • Acute sore throat / acute pharyngitis / acute tonsillitis where three or more Centor Criteria* are present • A delayed prescription or no prescription strategy may also be considered • *Centor criteria • Tonsillar exudate • Tender anterior cervical lymphadenopathy • History of fever • Absence of cough

28. Targeted use of antibiotics National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) • An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations: • Systemically very unwell • Symptoms and signs suggestive of serious illness and/or complications(particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) • High risk of serious complications because of pre-existing comorbidity eg significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely

29. Targeted use of antibiotics National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) • If patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: • Hospitalisation in previous year • Type 1 or type 2 diabetes • History of congestive heart failure • Current use of oral glucocorticoids • For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered

30. Facilitator lead discussion • Does this information help you understand more clearly the place in therapy of antibiotics in respiratory tract infections? • Are there instances where you have treated patients out with these criteria? • Do you feel more confident in not prescribing an antibiotic out with the criteria?

31. Managing complications – myth busters

32. Myth busters – value of antibiotics in RTI Acute sore throat Spinks et al. Antibiotics for sore throat. Cochrane database for systematic review issue 4 2006 • Without antibiotics 40% will resolve after 3 days and 90% after 7 days • The NNT (Number Needed to Treat) was 6 to half pain at day 3

33. Myth busters – value of antibiotics in RTI Acute Rhinosinusitis Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database for systematic reviews issue 2 2008 • 80% resolve in 14 days with no antibiotics • Antibiotics have a small benefit after 7 days of illness (NNT = 15) • There was no additional benefit of antibiotics in older patients, more severe pain or longer duration of symptoms

34. Myth busters – value of antibiotics in RTI Acute Rhinosinusitis Ahovuo-Saloranta et al. Antibiotics for acute maxillary sinusitis. Cochrane database for systematic reviews issue 2 2008 • 66% of children are better within 24 hours and antibiotics have no effect on symptoms • 90% of children are better in 2 to 7 days and antibiotics have only a small effect on reducing pain by 16 hours (NNT =15)

35. Myth busters – value of antibiotics in RTI Acute Cough / Bronchitis Fahey et al. Antibiotics for acute bronchitis. Cochrane database for systematic reviews issue 4 2004 • Antibiotics reduced symptoms by only one day in an illness lasting up to 3 weeks

36. Myth busters – value of antibiotics in RTI Acute Otitis Media Sanders et al. Antibiotics for acute otitis media in children. Cochrane database for systematic reviews issue 1 2004 • 66% of children are better within 24 hours and antibiotics have no effect on symptoms • 90% of children are better in 2 to 7 days and antibiotics have only a small effect on reducing pain by 16 hours (NNT =15)

37. Myth busters – preventative value ofantibiotics in RTI Sore throat and quinsy Peterson et al. Protective Effects of antibiotics.BMJ 2007;335:982-984 Centor et al. The diagnosis of Strep throat in adults in the emergency room. Med Decision Making 1981;1:239-46 • Overall NNT > 4000 to prevent one case of quinsy • Centor score of 3 or 4 = 1:60 chance of quinsy • Centor criteria: • Tonsillar exudate • Tender anterior cervical lymphadenopathy • History of fever • Absence of cough

38. Myth busters – preventative value ofantibiotics in RTI Rheumatic Fever Howie et al. Antibiotics, sore throat and rheumatic fever. BJGP 1985; 35 : 223-224 • It would take 12 working life times of a GP to see one case of Rheumatic Fever • Treating sore throats with antibiotics has no effect on risk of developing Rheumatic Fever

39. Myth busters – preventative value ofantibiotics in RTI Glomerulonephritis Taylor et al. Antibiotics, sore throat and acute nephritis. BJGP 1983; 33 : 783-786 • Glomerulonephritis is a rare condition (2.1 per 100,000 children) and is not prevented by treating sore throats with antibiotics

40. Myth busters – giving an antibiotic does no harm? The harm of antibiotics British National Formulary 2013;64 • The benefits of antibiotics have to be carefully balanced against their harm • Most antibiotics can cause gastrointestinal effects such as nausea, vomiting and diarrhoea in some patients • In addition, a number can cause serious rashes and skin reactions The harm of antibiotics Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Review. 2004 • Reviews of antibiotics in people with respiratory tract infections have found that, for every 16 people treated with antibiotics, rather than placebo, 1 person will suffer an adverse event

41. Facilitator lead discussion • Does this information help you understand more clearly the place in therapy of antibiotics in respiratory tract infections? • Are their instances where you have treated patients with an antibiotic in these clinical situations? • Do you feel more confident in not prescribing an antibiotic in these clinical situations as a result of the evidence?

42. Managing complications- alternative strategies: delayed prescriptions

43. Delayed prescriptions Spurling et al. Cochrane Database of Systematic Reviews 2007, Issue 3.Cochrane 2007 Delayed antibiotics for respiratory infections. • Delayed prescriptions substantially reduce antibiotic use but might slightly worsen some symptoms compared with immediate prescriptions • Delayed prescriptions might also reduce re-consultation rates • For mild upper respiratory tract infections delayed prescriptions are not associated with important negative consequences

44. Delayed prescriptions Spurling et al. Cochrane Database of Systematic Reviews, Issue 4.Cochrane 2013 Delayed antibiotics for respiratory infections. Update of 2007 • Most clinical outcomes show no difference between strategies • Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%) but not compared to none (87% versus 83%) • In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics

45. Delayed prescriptions National Institute for Health and Clinical Excellence. Respiratory tract infections – Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical Guideline 69) • When using delayed antibiotic prescriptions, patients should be offered: • Reassurance that antibiotics are not needed immediately since likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash • Advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs • Advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription. • A delayed prescription with instructions - either given to patient or left at an agreed location to be collected at a later date.

46. Facilitator lead discussion • Any experience of delayed prescriptions? • How important is patient information in a delayed prescription strategy? • Is a delayed prescription strategy worthwhile trialling in this practice?

47. Event closure

48. Facilitator lead discussion • Next steps • What strategy are we going to take to move forward? • Changes to consultation style and/or delayed prescriptions? • Can we reach a practice consensus? • How we can measure progress? • Evaluations (health board specific & CPD)