1. Antibiotics Medicines Management Team October 2008

2. Antibiotics – Good news • Trafford 4th lowest frequency prescriber of antibiotics in the NW SHA

3. Antibiotics – Bad news • Trafford is expensive - 3rd highest costs for antibiotics in the NWSHA

4. TSC – Main Culprits • Azithromycin • Quinolones • Minocycline • Clindamycin • Cefalexin

5. Azithromycin - NWSHA

6. Azithromycin - TSC

7. Azithromycin • On Trafford guidelines as treatment for Chlamydia only • Although, recommended by SMUHT respiratory physicians for some patients with Bronchiectasis • Need to ensure appropriate indications

8. Quinolones - NWSHA

9. Quinolones - TSC

10. Quinolones • On Trafford guidelines for; • 1st line – Acute prostatitis • 2nd line with Metronidazole – Acute or chronic rhinosinusitis • Only if patient allergic to penicillin – Acute pyelonephritis • Only if patient allergic to penicillin with Metronidazole – Pelvic Inflammatory Disease

11. Quinolones • Trafford are the No 1 prescribers in NWSHA! • Associated with the virulent 027 strain of C Difficile • Need to ensure used for appropriate indications only

12. Minocycline - NWSHA

13. Minocycline - TSC

14. Minocycline • No longer recommended in Trafford guidelines • Minocycline can cause hepatotoxicity and pigmentation (sometimes irreversible) when used long term. If it is to be used for more than six months then three-monthly monitoring for hepatotoxicity, pigmentation and systemic lupus erythematosus is recommended.

15. Minocycline • A meta-analysis of tetracycline efficacy in the treatment of acne showed no difference in efficacy between first generation tetracyclines, Doxycycline, Minocycline and Lymecycline. Using a tetracycline with a low acquisition cost first line would therefore appear to be a reasonable strategy for treatment of acne – Lymecycline now considered tetracycline of choice for acne • Review any person currently taking Minocycline and change to a more appropriate therapy

16. Clindamycin - NWSHA

17. Clindamycin - TSC

18. Clindamycin • Only recommended as a second line therapy or if patient has spreading cellulitis • If Clindamycin is prescribed please ensure that patient is counselled that if they experience any abdominal pain or diarrhoea that they should stop treatment and seek advice immediately • Seek microbiology advice if needed

19. Clindamycin • However, clindamycin is strongly associated with antibiotic‑associated colitis (C. difficile) infections and therefore high prescribing rates of clindamycin may be associated with C. difficile rates. Information on local (hospital) MRSA and C. difficile rates can be found on the Health Protection Agency website. (www.hpa.org.uk)

20. Cefalexin - NWSHA

21. Cefalexin - TSC

22. Cephalosporins - TSC

23. Cephalosporins - TSC • On Trafford guidelines only for; • 2nd line – Uncomplicated UTI, depending on susceptibility • 2nd line – UTI in pregnancy or men • After Trimethoprim or Nitrofurantion in UTIs in children • The HPA has recommended that broad spectrum antibiotics, including co-amoxiclav, quinolones and cephalosporins, are best avoided when narrow spectrum antibiotics remain effective, because they increase the risk of C. difficile, MRSA and resistant urinary tract infections. • Hospital lab no longer reporting on Cefalexin