SEL Antimicrobial Awareness

2021
• [insert BOROUGH] Medicines Optimisation Team
• Presented by: [insert name here]
• [insert role here]
*Presentation slides are adapted from the Target Antibiotics presentation, RCGP & PHE
“There are few public health issues of potentially
greater importance for society than antibiotic
resistance”
Prof. Dame Sally Davies. CMO, 2013

2
 Aims of the Workshop

• Brief background

• Discuss some clinical cases where we could improve our

antibiotic prescribing
• Suggest strategies and share materials
• Show evidence for using the material

• Provide evidence showing the link between antibiotic prescribing

and resistance in your patients

• Show how reducing antibiotic prescribing can reduce antibiotic

resistance, and also patient consultations

3
 Context

• If we don’t tackle drug resistant infections now, they could kill

an extra 10 million people across the world each year by
2050.

• In the UK, 80% of antibiotic prescribing occurs in community.

4
UK Prescribing: 81% of
antibiotics are prescribed in
general practice

ESPAUR Report 2018

5
 DDD per 1000 inhabitants per day

0
5
10
15
20
25
30
35
40
Netherlands
Estonia
Sweden
Latvia
Austria
Slovenia
Germany
Consumption

Norway
Hungary
Denmark
Malta
Finland
Europe Prescribing:

Lithuania

© ECDC
United Kingdom
Bulgaria
Croatia
EU Community Antibiotic

Iceland
Portugal

DDD = defined daily doses

EU/EEA
Spain
Slovakia
Poland
Ireland
Luxembourg
Italy
Belgium
Romania
France
Cyprus
6

Greece
South East London Prescribing:
Antibiotic Consumption
Antibacterial items issued per STAR-PU (SEL CCG)
0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0
Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21

Bexley Bromley Greenwich Lambeth

Lewisham Southwark NHSE Target - ≤.871

7
South East London Prescribing:
Antibiotic Consumption
% Co-amoxiclav, Cephalosporins & Quinolones items of all anti-
biotic presciption items (SEL CCG)
0.12

0.11

0.1

0.09

0.08

0.07

0.06
Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21

Bexley Bromley Greenwich Lambeth

Lewisham Southwark NHSE Target - ≤10%

8
Antibiotic Prescribing in Primary
Care vs. European Targets
Ideal Ideal
Actual prescription: prescription:
Condition/syndrome prescription PHE EE ESAC EE
(THIN data) median (IQ acceptable
range) range
Acute cough 40% 10% (6 – 16%) 0 – 30%
Acute bronchitis 92% 13% (6 – 22%) 0 – 30 %
Acute sore throat 60% 13% (7 – 22%) 0 – 20%
(tonsillitis)
Acute rhinosinusitis 92% 11% (5 – 18%) 0 – 20%
Acute otitis media
6mo – 2yr 96% 19% (9 – 33%)
2yr – 18yr 94% 17% (8 – 30%) 0 – 20%
URTI 19% 0 – 20%
UTI 94% 75% (61 – 86%) 80 – 100%

9
 Why do GP staff prescribe
antibiotics?

• Relief of symptoms

• Worry about complications/more serious illness

• Patient pressure

• “Pandemic Panic”

10
Symptom Benefit from
Antibiotics
Total Duration Beneficial NNT for one NNT for one
untreated effect from additional additional
antibiotics patient to adverse effect
benefit

Otitis media 4 -12 days 8-12 hours 18 9

Sore throat 8 days 12-18 hours 6-20 15

Sinusitis 12-15 days 24 hours 18 8

Bronchitis 20-22 days 11-24 hours 10-22 24

NNT = The average number of patients who need to be treated to
prevent one additional bad outcome

There is a need to convey this message to patients

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 Antibiotics and Complications
• Serious complications are rare after URTI (Upper Respiratory Tract Infections)
• Sore throat and otitis media NNT (Numbers Needed to Treat)* >4000
• Pneumonia more common after LRTI (Lower Respiratory Tract Infection)
• Age >65: NNT 39 NNT = The average number of patients who need to be treated to
• Age<65: NNT >100 prevent one additional bad outcome

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Reducing Complication Risk

Empowering clinicians to give:

• Careful clinical assessment, including targeting

treatment to those most at risk (clinical tools).

• Back up/delayed antibiotics.

• Safety netting including patient information leaflets.

13
The TARGET Antibiotic Toolkit

Treat
Antibiotics
Responsibly
Guidance
Education
Tools

Aim is to help clinicians and

commissioners to use antibiotics
responsibly and meet CQC
requirements.

TARGET Antibiotics Toolkit (rcgp.org.uk)

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Clinical Scenario:
Acute Cough

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Clinical Scenario:
Acute Cough

Please consider the following details:

• 45 year old smoker with cough for 1/52, green sputum
• Temperature: 37.8 Degrees Celcius
• Has had several previous episodes of bronchitis and insists
antibiotics ‘always help’
• PEFR (Peak Expiratory Flow Rate) normal
• Scattered coarse creps (crackles, crepitation) and wheeze,
vesicular breath sounds, no focal crepitations

16
Clinical Scenario Acute Cough:
PHE Antibiotic Management
Guidance

17
 Clinical Scenario Acute Cough:
Feedback
45 year old smoker with cough for 1/52, green sputum
Temperature: 37.8 Degrees Celcius
Has had several previous episodes of bronchitis and insists
antibiotics ‘always help’
PEFR (Peak Expiratory Flow Rate) normal
Scattered coarse creps (crackles, crepitation) and wheeze,
vesicular breath sounds, no focal crepitations

• Antibiotic little benefit as no co-morbidity

• Consider no or 7 day back-up antibiotic with safety netting
• Share a leaflet with the patient – e.g. TARGET RTI leaflet
• Advise the patient that symptom resolution can take 3 weeks

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Prescribing: Consultation rates
related to acute cough & cold
have increased
537 UK GP
practices
1995-2011

• Consultation rates related to prescribing

• In a longitudinal study, practices who reduced prescribing experienced a
reduced consultation rate
• Thus patients can be re-trained not to expect antibiotics reducing the
number of consultations
• Amoxicillin prescribing rates have also increased
19
The Patient Perspective:
What do patients do when they
have an RTI?
1,707 16y in England Jan 2017

959, 56% throat, ear, sinus, chest

infection or cough, flu

34% Took OTC medicine for symptoms

33% Carried on most of their usual daily activities / routine
23% Took extra rest
22% Contacted or visited GP surgery
18% Used alternative medicine (honey, herbal) for symptoms
11% Asked pharmacy for advice (increase from 6% in 2011)
5% Got advice from friends/family/colleagues
3% Visited NHS walk in, 3% GP OOH, 2% A&E
3% Visited NHS choices, 1% telephoned NHS 111
0.4% Took left over antibiotics
20
The Patient Perspective:
Why they visited GP with RTI (not
cold/runny nose)
30% Needed treatment to help symptoms
24% Symptoms severe (breathing 11%, sleep 14%)
26% Symptoms lasted longer than I expected
15% Worried illness could get worse
11% Wanted to know the cause
9% I usually go to doctor’s surgery with these symptoms
8% I already have another health condition

What did they expect?

38% Expected antibiotics 18% Advice on need for antibiotics

34% Other treatment for symptoms 17% To find out cause
25% Advice about self-care 13% Rule out more serious illness
13% Information about illness 4% For referral to hospital/specialist
duration

21
The Patient Perspective: A 2017
survey showed patients trust
healthcare professionals advice

22
The Patient Perspective:
Back-up/delayed Prescribing:
What patients do
Women compared with men (6% vs 4%)

Have been given a delayed/back up antibiotic

Not given

42% reported not taking the antibiotic

Acceptability score 1-10. Mean score 8.5

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Evidence: Risk of resistance
persists for at least 12 months
after prescribing

Increased risk of resistant

organism
Antibiotic in past Antibiotic in past
2 months 12 months
RTI 2.4 times 2.4 times
7 studies: n=
2605

A meta analysis of English Primary Care

24
TARGET:
Patient Information Leaflets
Treating Your Infection RTI Leaflet
Educates patient
Sections can
about when to
be
consult GP.
personalised
and added to
by the GP.

Safety netting.

Back up Information
prescription about antibiotics
and resistance.

25
Acute Cough:
Reflect on actions your practice
can take to improve prescribing
Ideas from other GP staff and medicine managers:
• All staff use antibiotic guidance so approach is
consistent
• Use NO or back-up antibiotic and safety net
appropriately
• Use the TARGET leaflet and set up on clinical system
• Consider CRP to guide treatment in difficult cases
• Consider an audit of antibiotic use in acute cough
• Complete the free RCGP RTI clinical course (MARTI)
• Put up antibiotic awareness posters and use as a hook
in consultation
Who will take these things forward and when?
26
Clinical Scenario:
Urinary Tract Infection (UTI)

27
Evidence:
Antibiotic Resistance is Increasing
Trimethoprim resistance by age

47%

37%

28
Clinical Scenario UTI:
Elderly Patient
Please consider the following details:

• 80 year old resident in nursing home

• Strong smelling urine, but clear looking
• Increasing confusion over 2 days
• Positive dipstick – nitrites and leucocytes
• No history of fever, temp 37.4 degrees Celsius
• Has had antibiotics in the past for suspected UTI

What would you ask?

29
Clinical Scenario UTI:
Elderly Patient
80 year old resident in nursing home
Strong smelling urine, but clear looking
Increasing confusion over 2 days
Positive dipstick – nitrites and leucocytes
No history of fever, temp 37.4 degrees Celcius
Has had antibiotics in the past for suspected UTI
Ask about:
• New or worsening urgency/incontinence, frequency
• Suprapubic pain or flank or loin tenderness, or
• Gross haematuria
• Hydration, and fluid intake
• Other symptoms suggesting another infection
• Why was the patient given previous Abx, and were they and for how
long?
• Recent hospitalisation and operations
• Also look for signs of sepsis or pyelonephritis 30
Clinical Scenario UTI:
Elderly Patient
80 year old resident in nursing home

Criteria for initiating antibiotics include:

• Acute dysuria alone OR dementia/delirium
• Fever (>37.9 degrees C or 1.5 degrees C increase above baseline)
• AND ≥ 1 new or worsening urgency/incontinence, frequency, signs of
irritation of the urinary tract such as suprapubic pain or flank or loin
tenderness, or gross haematuria
*Check local guidance for appropriate treatment options*
• First line treatment in elderly now nitrofurantoin for 3 days for women, 7
days for men
• If eGFR <45 ml/min send urine and start pivmecillinam for 3 days for
women, 7 days for men
• Also look for signs of sepsis – if present then admit.

31
UTI PHE Guidance:
Risk factors for resistance
Low risk of resistance:
• Younger women with acute UTI and no resistance risks

Risk factors for increased resistance include:

• Aged over 70 years
• Care home resident
• Recurrent UTI (2 in 6 months; 3 in 12 months)
• Unresolving urinary symptoms
• Hospitalisation for >7 days in the last 6 months
• Recent travel to a country with increased resistance
• Previous UTI resistant to trimethoprim, cephalosporins, or
quinolones.

If risk of resistance: always safety net.

Send urine for culture & susceptibilities.
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TARGET:
Patient Information Leaflets
Treating Your Infection UTI Leaflet

33
Consider:
Audits can help inform your
prescribing behaviour

The TARGET website has an Audit Toolkits section

34
What can you do to learn more
about UTI?
Use TARGET Training Resources

35
How could your practice improve
antibiotic prescriptions for UTI?
1. Implement local guidance for choice of antibiotic and
testing
2. Consider a non-UTI cause in post-menopausal women
3. Remember inflammation due to sexual activity can cause
urinary symptoms due to mild urethritis
4. Consider back-up prescription in women with mild
symptoms who are low risk for complications and without
catheters
5. Always do safety netting especially in the elderly
6. Use computer reminders for leaflets and back-up
prescriptions (i.e. OptimiseRx)
7. Consider a UTI prescribing audit
8. Complete RCGP management of UTI free online course
36
To dip or not to dip?
• QI project by Bath and North
East Somerset CCG to help to
improve management of UTI
in care home residents.
• Encourages the appropriate
use of antibiotics in patients
displaying clinical symptoms
rather than for positive urine
dipstick results.

37
Action Planning:
Developing priorities, for you now
AIM – To continue rolling back inappropriate antibiotic
prescribing and reduce E.coli bacteraemia infections

HOW?
1. Use the leaflets to reduce patient expectations
2. Develop computer prompt to increase use of leaflet
3. Use back up/delayed prescribing (leaflet will help
4. Refer to posters to introduce antibiotics
5. Make sure everyone has access to antibiotic guidance
6. Do an antibiotic audit with action planning
7. Nominate a practice AMS lead

38
Possible Solution for You?

GP Practice

Patient
Evidence

Use the TARGET Antibiotics Toolkit

39
TARGET:
TARGET Pictorial TYI Leaflet

40
TARGET:
Resources for clinical and
waiting areas

41
Antibiotics & COVID-19
COVID-19 rapid guideline: managing COVID-19 (NG 191)

• Antibiotics should not be used for preventing or treating COVID-19 unless

there is a clinical suspicion of additional bacterial co-infection.

• Do not use azithromycin to treat COVID-19.

• Do not use doxycycline to treat COVID-19 in the community.

• Bacterial co-infection was found to occur in less than 8% of people with

COVID-19.

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Antibiotic Guardian
https://antibioticguardian.com

43
SEL’s 5 Point Plan
- Individualised presentation

- Electronic resources to be displayed in patient waiting

areas

- Promote the use of MicroGuide, local formularies and

guidance

- Display relevant formulary and antimicrobial awareness

information on Optimise Rx

- Promotion of antibiotic guardianship and pledging to

become an antibiotic guardian 44
[Insert BOROUGH name]

• [Insert any other local borough plans to promote antimicrobial

awareness HERE]

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Thank you.

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