2. Facilitators Notes
Read aims and objectives

3. Facilitator notes: These opening questions are designed to get the participants to think about the fact there is still scope to reduce unnecessary antibiotic use.
Answers:
2015
2. 30%
At least 30% of all antibiotics are unnecessary according to data published in the Journal of the American Medical Association (JAMA) by the Centre for Disease Control and Prevention (CDC) in the US. The study looked at antibiotic use in GP practices and emergency departments (ambulatory care) during and found that most of these unnecessary antibiotics were prescribed for self-limiting RTIs – including common colds, viral sore throats, bronchitis, and sinus and ear infections.
When prescribing for respiratory tract infection alone was looked at, 50% of these deemed to have been prescribed unnecessarily.
These excess prescriptions each year put patients at needless risk of side-effects, allergy, HAI e.g. clostridium difficile, and add to antibiotic resistance. (JAMA. 2016;315(17):
Although this data relates to the US we also still have scope in the UK to reduce prescribing for self-limiting infections.
As a result, government targets to reduce total volumes in primary care continue.
,000 worldwide (25k 2015 projected to rise to 10million worldwide deaths by 2050.
Antimicrobial Resistance

4. Facilitator Notes
The proportion of the Scottish population who received at least one antibiotic item was 29.6% in 2015 and is the lowest proportion on record (2010).
In 2015, the use of systemic antibiotics (excluding dental) was 2.0 items/1000/day: 2.4% lower and 88,490 fewer items than in 2014.
This is the third successive annual reduction and was 374,500 fewer items and 9.5% lower than the highest rate of prescribing observed in 2012.
Only once in the last 20 years (2004) has the prescribing rate been lower than in 2015.
In 2015, there were reductions in the use of co-amoxiclav (4.9%), fluoroquinolones (5.8%) and cephalosporins (6.0%) and these broad spectrum antibiotics together accounted for 8.0% of total antibiotic use in primary care, the lowest proportion on record.
Following its establishment, SAPG supported standardisation of antibiotic prescribing policies in primary care which has had a considerable impact on choice of antibiotic used with a 64.0% reduction in the use of broad spectrum antibiotics since It is increasingly recognised that it is equally important to reduce inappropriate use of broad spectrum antibiotics to preserve their effectiveness and slow the development of antimicrobial resistance AMR.

5. Facilitator Notes
*NOTE you can omit this slide if already discussed in another session*
Although as you can see from the previous slide we have seen reduction in total volumes of prescribing, there is still considerable variation between GP practices in antibiotic prescribing rates. Opportunities remain to reduce unnecessary prescribing.
How do you compare?
Use the practices own prescribing data compared to peers where available. Ask them – ‘what are your thoughts on how you compare?’ to find out if this is where they expected to be.
Additional Information/ Signposting
The following reference contains a summary of the literature (and interventions) in relation to behaviours around antibiotics. It may be useful if anyone wants to know more about this area in relation to what perceptions and behaviours can drive prescribing (page 17 to 20 PHE Behaviour Change for Antibiotic Prescribing )
Prescriber (and public) perceptions is also discussed in the separate ScRAP session on Public Understanding and Expectations

6. Facilitator Notes
This slide illustrates that antimicrobial resistance is a major threat to future healthcare, and has clinical, public health and economic implications

7. Facilitator Notes
Again this slide illustrates the current ‘issues’ we have around antimicrobial resistance (AMR)
Further information/ signposting
The following link has a factsheet on AMR if participants wish further information

8. Facilitator Notes
The following slides explore the association between antibiotic prescribing and resistance and HAI

9. Facilitator Notes
This graph highlights the association between volume of antibiotic usage and resistance.
The graph shows that lower volume and resistance rates are seen in the UK compared to countries like Spain and France where resistance is high due to high levels of prescribing.
Unsurprisingly the conclusion by Goossens et al, was that higher antibiotic usage rates correlate with high rates of resistance.
Later on we will see what these figures are like for Scotland.

10. Facilitator Notes
This study by Butler et at published in the British Journal of General Practice in 2007 studied the impact of resistance on reducing antibiotic prescribing volume at GP practice level.
Taken over a 7 year period, Practices who showed a reduction in antibiotic prescribing were more likely to see a reduction in the number of resistant isolates.

11. Facilitator Notes
Prior to the publication of the Costelloe study in 2010, many clinicians and patients did not see resistance as a reason to refrain from using antibiotics.
This study helps highlight the impact on an individual, and the persistence of resistant organisms

12. Facilitator Notes
This slide helps illustrate (using a case) how resistance can develop in an individual patient.
The first mistake in this was prescribing trimethoprim when there were no symptoms (asymptomatic bacteruria).
This has selected out a trimethoprim resistant organism not apparent previously.
Remember the bugs are in the gut and translocate to the urinary tract to cause infections.
More and more resistant populations (if present) will be selected out with subsequent antibiotic courses – particularly if sub therapeutic dosing of antibiotics are used.

13. Facilitators Notes
The following slides give data on resistance and HAI rates in Scotland

14. Facilitators Notes
Multidrug resistance among gram negative bacteria is a major threat to public health and patient safety and results in higher healthcare costs, increased length of stay, treatment failures and increased mortality.
Carbapenems are a ultra broad spectrum antibiotics used in the hospital environment to treat serious infections and those due to resistant organisms.
The emergence and spread of carbapenemase producing organisms (CPOs) is of particular concern as the enzymes produced by these organisms destroy carbapenem antibiotics which leaves very few therapeutic options.
CPOs have been reported worldwide in both healthcare and community settings with increased intercontinental travel contributing to their spread. They have been increasingly reported over the last 10 years.
In 2015, there 63 reported in Scotland which is also an increasing trend. It is suspected this is an underestimate as more proactive screening and surveillance has only recently been implemented. There is a concern this will continue to grow year on year.

15. Facilitators Notes
UTI is most commonly caused by E coli (followed by K pneumoniae). E. coli is the most common pathogen causing bacteraemia in the community and healthcare settings. E coli Bacteraemia develops usually as a complication of other infections, such as urinary tract infections. It had an incidence rate of 85.5 per population in 2015.
Resistance in UTI is seen as an early warning sign in more serious infections. Some E coli have the ability to produce ESBL enzymes which make beta lactam antibiotics such as penicillins and some cephalosporins ineffective. In 2015, 5.5% of E coli bacteraemias were ESBL producers. Surveillance is being improved to ensure accurate monitoring of these due to concerns.
This slide also shows non-susceptibility to antibiotics which are often last resort for UTI. It is interesting to note that co-amoxiclav saw a 6.1% increase in non-susceptibility during a time when usage increased in secondary care. Again supporting the theory that the more we use, the more resistance results.
The next slide details resistance patterns for other antibiotics including those more commonly used in primary care.

16. Facilitators Notes
This slide shows typical laboratory resistance rates for positive samples
It should be remembered that resistance rates in lab samples will overestimate the population rates of resistance. Only a proportion of the patients with symptoms of UTI will have samples sent, and of them, only a proportion will grow anything.
An observational study done by the POETIC study group (pending publication) found that only 25% of the samples they tested met laboratory criteria for a UTI. Most patients had however been given an antibiotic for suspected UTI. Only 4% of this group had an infection that was resistant to the antibiotic they had been prescribed empirically.
Often there will be risk factors in those patients who have resistant isolates, and susceptibility from previous urine culture may be helpful to inform treatment. Often these patients may have complex histories e.g. recurrent UTI, previous infection with a resistant organism, long term catheter.
Trimethoprim therefore can still have a role empirically in uncomplicated female UTI despite resistance rates in positive samples of around 38% in 2015 as this is from a biased sample of patients.
Amoxicillin resistance now sits at >60% in some areas, however, meaning it is not suitable for empirical treatment of UTI but may still be a useful antibiotic if sensitivity is confirmed via urine culture.
It is noted that empirical choices may vary between health boards and be dependent on local resistance patterns.
It is important to always consider a patient’s previous UTI, response to treatment and any susceptibility/ resistance results when making antibiotic choices empirically.

17. Facilitators Notes
In 2012, one in four bloodstream infections in hospital were due to E.coli.
Surveillance of E. coli bacteraemia has been undertaken since Sept 2015, but became mandatory in April 2016.
Surveillance undertaken to date indicates that community infection is the origin in 44% of cases.
In 33% of E. coli bacteraemia the source is lower urinary tract infection.
This highlights the importance of interventions to improve the management of UTI (see accompanying ScRAP learning sessions).

18. Facilitator Notes
(Note the following slides (18-23) deal with IIP studies. If you are short of time, you may wish to omit the detail of these as long as the key messages are conveyed.)
IIP supports the infection community by providing integrated information on infection (for example, by combining risk factors, demographics, healthcare activity, medicines usage and clinical data) and enabling better analysis of infection information to improve patient outcomes and reduce harm from infection.
By bringing information together in this way, IIP can be used to measure the intended and unintended consequences of antimicrobial stewardship and infection prevention and treatment interventions.
IIP is an innovative approach to enhancing and linking infection data held within NHSScotland in a single secure platform. IIP improves the utility of existing datasets, through a 'collect once, use often' approach.
This slide outlines some examples of work that has been done using data linkage to support clinical practice. We will explore a couple of these in more detail in the next slide (the ones in the light green bubbles).

19. Facilitators Notes
Risk factors for resistance as per slide
Confirmed correlation between cumulative antibiotic exposure and risk of resistance
Additional detail on the study if required
40,984 positive urine samples were examined.
Overall 11,647 (28.4%) urine samples were susceptible, 18,445 (45.0%) were resistant and 10,892 (26.6%) were multi-drug resistant.
Around a quarter of the cases (25.7%) had no antibiotic prescribing in the six months prior to infection.
Older age, increasing comorbidity and care home residence were all found to be associated with resistance and multi-drug resistance.
Cumulative antibiotic exposure had a clear dose-response effect (p<0.001).
Those prescribed 1-7 DDDs of nitrofurantoin in the six months prior to a positive sample were 2.18 times (95% CI: ) more likely to have a multi-drug resistant infection, compared to a susceptible infection, rising to 7.65 times (95% CI: ) for 29+ DDDs.
Those prescribed 29+ DDD of trimethoprim were (95%CI : ) times more likely to have a multi-resistant infection. The next slide looks at the mortality associated with resistant infections.

20. Facilitator Notes
Cases with either a resistant or multi-drug resistant sample were found to be more likely to die within the study period than those with a susceptible sample (note both these lines are very close together on the graph and may be indistinguishable).
Those with a resistant infection had an increased risk of mortality of 1.18 (95% CI ; p<0.001) and those with a MDR also had an increased risk of 1.18 (95% CI ; p<0.001).
The next slide goes on to look at the healthcare associated infection Clostridium Difficile

21. Facilitator Notes
CDI is an important healthcare associated infection which normally causes diarrhoea and contributes to a significant burden of morbidity and mortality. Prevention of CDI is therefore essential and an important patient safety issue.
In 2015 CA-CDI accounted for 28.8% of all reported CDI cases.
The trend is stable over the last 5 years whilst hospital associated has continued to decrease.
We will later look at a data linkage study in Scotland which indicates there are close links between antibiotic use in primary care and CDI.
Other risk factors for CDI include PPI and H2 antagonist use. A recent update to the product characteristics SPC for omeprazole acknowledges that for acid reducing drugs there is a slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and, in hospitalised patients, possibly also Clostridium difficile. Decreased gastric acidity due to any means, including that due to proton pump inhibitors and H2 antagonists, increases gastric counts of bacteria normally present in the gastrointestinal tract.

22. Facilitators Notes
This study helps quantify the scale of the risk of CA-CDI given prior antibiotic exposure in the community.
The increased risk by antibiotic type is given on the next slide.

23. Facilitator Notes
This shows that any antibiotic in the previous 6 months potentially makes you more likely to develop C Difficile.
The greatest association to developing C Diff involves exposure to any 4C antibiotic.
Fluoroquinolone is also notably associated although comparison to the other individual 4Cs is not available.

24. Facilitators Notes
From the previous slide we can see there is a direct association between antibiotic use and risk of C difficile.
This is reinforced by this study which was done in NHS Grampian and looked at the impact of limiting 4C antibiotics through antibiotic stewardship on reducing clostridium difficile rates.
During the study period 4C use reduced by 50%
The prevalence density of C difficile infection fell by 68% in hospitals and 45% in the community during the period of antibiotic stewardship
Falling 4C use predicted rapid declines in multi-resistant ribotypes (R001 and R027)
No significant effects were found with other population level interventions (limiting macrolide indications, alcohol based hand sanitiser, national hand hygiene campaign, hospital audit and inspection of cleanliness, reminders to reduce inappropriate proton pump inhibitors)

25. Facilitator Notes
It is difficult to generalise the risk and effect of resistance due to the number of variables involved
It is therefore important to consider this on an patient by patient basis as well as taking any local infection management guidance into account
Sampling where necessary can be useful to guide choice in appropriate patients (see UTI ScRAP modules for further information on when urinalysis is indicated)
Risk factors for resistant urinary isolates were highlighted on the previous slides.
Signposting references
The article below includes information in positive and negative predictive values for samples still being resistant/ sensitive to commonly used antibiotics at 3 months and up to 12 months

26. Facilitator Notes
Pause here to see what the group think their role is in all of this.
Key areas for prescribers to take ownership of include
Optimising infection control practices
Optimising infection prevention through e.g. improving breastfeeding and vaccination rates
Avoiding unnecessary prescribing
When prescribing -following recommended guidance for antibiotic choice, dose & duration (taking patient factors into account)
Educating patients on risk benefit of antibiotics/ encouraging self-management where appropriate
Educating patients when they are prescribed antibiotics to complete the course, avoiding saving and sharing, safe disposal
Use of rapid diagnostics is currently under review e.g. CRP for lower respiratory tract infection risk assessment
There is some evidence that some prescribers feel their role is minor within the global context with agricultural use etc, but it is worth reinforcing that we all still have a role to play, and reassure that action is being taken in all fronts supported by the UK AMR strategy1 , and reinforced by the report from Jim O’Neil ‘Tackling Drug Resistant Infection Globally’ for the government2. Participants can be signposted to these if they wish more information of the recommendations.
The next slide has an overview of all the elements which are target areas.
Signposting References
UK AMR 5 year strategy
Tackling Drug Resistant Infection Globally UK
Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP2)

27. Facilitators Notes
Visual illustration of the ten key fronts and long term solutions identified by Jim O’Neil in his review of AMR for the UK government
The next slide covers UK One Health collaboration to support this agenda

28. Facilitators Notes
One Health
Recognizes that the health of humans, animals and ecosystems are interconnected. It involves applying a coordinated, collaborative, multidisciplinary and cross-sectoral approach to address potential or existing risks that originate at the animal-human-ecosystems interface. Antibiotics is one of these risks.
Animal health – use of antibiotics
Government regulation & food industry standards are driving progress with reducing unnecessary use but need to ensure animal welfare.
Growth promotion – now banned in many countries
Whole herd treatment – reduced
Individual animal treatment – avoid use of critically important antibiotics for human healthcare
Stewardship
Similar programmes to those for human use needed
Robust data on antibiotic use not available in many countries
Need further engagement with vets, farmers and pet owners to increase awareness
Signposting references
UK One Health Report
If you want to know more about one health

29. Facilitators Notes
Do we all treat antibiotics with the care they deserve given that every time we prescribe for one person we can cause resistant bacteria to occur in someone else…..

30. Facilitators Notes
It is important to get participants to follow through any identified improvements by formulating an action plan and identifying who is doing what and by when
If this is not done on the day it is really important to revisit within a few weeks of this session e.g. at the next practice/ group meeting.