SEL Antimicrobial Awareness Organisations in SEL can adapt this presentation (with local logos/background) for use as part of their antibiotic awareness campaign for 2018/19. SEL Antimicrobial Awareness [insert CCG/Trust] Medicines Optimisation Team/Pharmacy Presented by: [insert name here] [insert role here] *Presentation slides are adapted from the Target Antibiotics presentation, RCGP & PHE

Prof. Dame Sally Davies. CMO, 2013 “ There are few public health issues of potentially greater importance for society than antibiotic resistance” Prof. Dame Sally Davies. CMO, 2013

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

Context If we don’t tackle drug resistant infections now, they could kill an across the world by 2050. In the UK, 80% of antibiotic prescribing occurs in community. extra 10 million people each year

UK Prescribing: 80% of antibiotics are prescribed in general practice DDD = Defined Daily Doses

Europe Prescribing: EU Community Antibiotic Consumption

South East London Primary Care Prescribing: Antibiotic Consumption NHS Target: 1.161 England value: 1.028

South East London Primary Care Prescribing: Antibiotic Consumption NHS Target: 10% England value: 8.7%

South East London Primary Care Prescribing: Antibiotic Consumption

Antibiotic Prescribing in Primary Care vs. European Targets

Why do GP staff prescribe antibiotics? Relief of symptoms Worry about complications/more serious illness Patient pressure

Symptom Benefit from Antibiotics There is a need to convey this message to patients

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 Age<65: NNT >100 NNT = The average number of patients who need to be treated to prevent one additional bad outcome

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.

The TARGET Antibiotic Toolkit

Clinical Scenario: Acute Cough

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

Clinical Scenario Acute Cough: PHE Antibiotic Management Guidance

Clinical Scenario Acute Cough: Feedback 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

Prescribing: Consultations, and amoxicillin prescribing for acute cough & cold has increased Consultation rates related to prescribing In a longitudinal study, practices who reduced prescribing experienced a reduced consultation rate Thus patients can be retrained not to expect antibiotics reducing the number of consultations

The Patient Perspective: What do patients do when they have an RTI?

The Patient Perspective: Why they visited GP with RTI (not cold/runny nose)

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

The Patient Perspective: Back-up/delayed Prescribing: What patients do

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

TARGET: Patient Information Leaflets Treating Your Infection RTI Leaflet

TARGET: e-Bug & TARGET Pictorial TYI Leaflet

TARGET: Resources for clinical and waiting areas

Acute Cough: Reflect on actions your practice can take to improve prescribing

Clinical Scenario: Urinary Tract Infection (UTI)

Evidence: Antibiotic Resistance is Increasing

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 Celcius Has had antibiotics in the past for suspected UTI

Clinical Scenario UTI: Elderly Patient 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

Clinical Scenario UTI: Elderly Patient 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 First line treatment in elderly now nitrofurantoin for 3 days If eGFR <45 ml/min send urine and start pivmecillinam Also look for signs of sepsis – if present then admit.

UTI PHE Guidance: Risk factors for resistance

TARGET: Patient Information Leaflets Treating Your Infection UTI Leaflet

Consider: Audits can help inform your prescribing behaviour

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

How could your practice improve antibiotic prescriptions for UTI?

Possible Solution for You?

Action Planning: Developing priorities, for you now

Veterinary Antimicrobial Use The UK Government’s Veterinary Medicines Directorate monitors and conducts surveillance on antimicrobial usage in animals. Several important milestones have been achieved with regard to antimicrobial usage in animals: Livestock and fish farmed for food antibiotic usage has reduced to an average of 50mg/kg in 2018 from 62mg/kg in 2014 Antibiotic usage in food producing animal species has decreased by 27% to 45mg/kg The total usage of veterinary antibiotic sales of 337 tonnes is the lowest ever recorded since reporting began in 1993. Highest priority critically important antibiotics (HP-CIAs) shown reductions in sales, including an 83% reduction in sales of colistin use for food producing animals. Reductions in antibiotic use of 34% in pigs, 37% in chickens, 57% in turkeys and 60% in ducks in 2016 The pig and poultry industry has reduced HP-CIAs use of 73% and 78% respectively in 2016. For more information on the Veterinary Usage of Antimicrobials please see: UK – Veterinary Antibiotic Resistance and Sales Surveillance Report 2016 (UK-VARSS 2016)

In [Insert CCG/Trust name] [Add localised information on Antimicrobial projects and resources available in your borough]

Thank you.