Mike Jones Vice President, Royal College of Physicians of Edinburgh

Where’s the problem?

So where’s the problem? Oh Dear Lord is he really that stupid?

Acute Medicine and infection “Medicine at the front door” Pneumonia/Infective exacerbation of COPD UTI/pyelonephritis Soft tissue infection “PUO” Sepsis syndromes Therapy guided by ?

Response

Changes in Policy Inevitable Resistance of bacteria New therapies Based on evidence Difficult Communication Pre-conceived ideas Resistance

Antimicrobial practice Failure to implement hospital antimicrobial prescribing guidelines: a comparison of two UK academic centres M. H. Ali 1, P. Kalima 2 and S. R. J. Maxwell 1,* 1 Clinical Pharmacology Unit, University of Edinburgh, Queen's Medical Research Institute, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4TJ, UK; 2 Department of Medical Microbiology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK

Results More patients were admitted (CAP: 78.9% versus 48.4%, P < 0.05) Given antimicrobials intravenously (CAP: 53.4% versus 21.2%, P < 0.05). CAP adherence was significantly higher (83.3% versus 38.0%; P < 0.05). Fewer than half of the doctors surveyed used the local hospital guideline

Poor guideline adherence results from inadequate dissemination of the recommended information Local and national guidelines vary Medical school teaching and senior doctors as major influences

Education and Training is the answer?

Restriction of Use Alert antibiotics E.g. Ertapenem IV Ganciclovir IV (Ophthalmologist, Renal Specialist) Linezolid IV/Oral Meropenem IV (Haematologist, Oncologist, Cystic Fibrosis Specialist) Specific indication antibiotics E.g.Ceftazidime: PD peritonitis, Pseudomonas infection Clindamycin: lung abscess, brain abscess

Challenges for Acute Medicine Role model Consistency of prescribing Evidence based practice Need to balance: Sensitivity of most common causative organisms Risk of antibiotic related illness Consequences of an ineffective antibiotic Association of C.difficile (et al) infection with antibiotic use Accuracy of diagnosis UTI in the elderly

Acute Medical Management Balance use of IP management/ambulatory care/ care in the community Development of OHPAT (out patient and home anti- infective therapy) services where they don’t exist

St Mary's treats hundreds of patients in the community - 21 September 2009 Hundreds of patients needing intravenous antibiotics are being treated at home - assisting their recovery and freeing up hospital beds at St Mary's. Recently published figures have shown that a massive 7,394 in-patient bed days were saved between September 2004 and April 2008 thanks to the pioneering OHPAT (outpatient and home parenteral antimicrobial therapy) service, which allows patients to be managed at home.

Acute Medical Management Balance use of IP management/ambulatory care/ care in the community Development of OHPAT (out patient and home anti- infective therapy) services where they don’t exist Co-operation with services that will benefit: ID, orthopaedics, cardiology, vascular etc Use of evidence base

Summary Need for Acute Medicine to be: Consistent Proactive Collaborative Need for growth in evidence base to assess all aspects of care Acute Medicine can and must help