1. National Changes in Antibiotic Policy R. Andrew Seaton Consultant Physician Lead doctor Antimicrobial Management Team, NHS GG&C

2. SAPG Infection Management Workstream Developing and applying prudent prescribing principles in hospital and community –Hospital infection management guidelines –Surgical prophylaxis guidelines –Primary care guidelines Prescribing indicators to underpin control of HAI Unintended consequences of change

3. Clostridium difficile and prescribing in Scotland Adapted from Health Protection Scotland data

4. CDI Risk and Antibiotic Treatment NB. Any Antibiotic. Duration of therapy

5. CDI Risk and Antibiotic Treatment NB. Any Antibiotic. Duration of therapy UPDATE: Quinolone use is strongly associated with Hyper- virulent, quinolone- resistant 027 strain of C difficile UPDATE: Quinolone use is strongly associated with Hyper- virulent, quinolone- resistant 027 strain of C difficile

6. Increased MRSA risk Reduced MRSA risk

7. Clostridium difficile NHS Greater Glasgow and Clyde June 2008 55 CDI / 6 months 18 either primary cause or contributing to death Infection control issues Antibiotic prescribing

8. AMT response: June 2008 Urgent review of prescribing, guidance (case mix) Stricter restrictions “4 Cs” Cephalosporins Co-amoxiclav Clindamicin Ciprofloxacin (Quinolones) Promote –Think before you prescribe –Narrow spectrum agents/ simplify –Limit duration –Combination with gentamicin for serious infection –CDI Rx guidelines

9. www.glasgowformulary.com

10. Recommended, Restricted and Alert Antibiotics StatusOralIV Recommended Amoxicillin Clarithromycin Co-trimoxazole Doxycycline Flucloxacillin Metronidazole Nitrofurantoin Trimethoprim Vancomycin Amoxicillin Clarithromycin Co-trimoxazole Flucloxacillin Gentamicin Vancomycin Restricted Clindamycin Co-amoxiclav Ciiproflaxacin Clindamycin Ceftriaxone Co-amoxiclav “Alert” LinezolidCeftazidime Ciprofloxacin Daptomycin Ertapenem Linezolid Meropenem Piperacillin-Tazobactam Teicoplanin Tigecycline

11. National Response Independent review (Vale of Leven Hospital) –“Prudent antimicrobial prescribing implemented and monitored both in the Acute and Community sectors” Scottish Government: CEL 30, July 2008 –AMT for Primary care and secondary care in all HBs

12. AMT Education & Communication Audit of Practice Surveillance of Usage Antimicrobial Practice Guidance And Protocols Antimicrobial Resistance and CDAD Alert Restricted Agents SAPG AMTs

13. SAPG, Nov 08

14. Restrictive guidance

18. HEAT target to reduce CDI rate in ≥ 65 yrs by ≥ 30% by March 2011: Prescribing indicators: Hospital

20. Improvement Action Plan for NHS Greater Glasgow and Clyde Southern General Hospital Inspection Date: Monday 8 and Tuesday 9 March 2010 “It is recommended that NHS Greater Glasgow and Clyde implements auditing of 20 patient records each month in all receiving wards”

21. Unintended consequences Toxicity –Renal –Oto-vestibular Treatment failure –ICU admission –Death Prescribing adaptation Resistance

22. SAPG Vancomycin and Gentamicin prescribing Guidelines, Sept 09 National consensus to adopt single national Vancomycin guideline Agreed that boards would adopt either Hartford (7mg/kg) or NHS GGC (5mg/kg) regimens –Caution beyond 72 hours On line calculators for dosage

23. A. Helps et al, 2009 PrePost Dialysis196182 Gentamicin41%35% Impact of Gentamicin on Renal Replacement Therapy

24. Impact of Gentamicin on VIII nerve toxicity Discussions with Scottish ENT society –Concern over potential for toxicity –No routine surveillance in place Retrospective review in NHS GGC –>1,200 patients Rx with gentamicin –No evidence of increase in ENT presentations to date Prospective review / enhanced surveillance underway

25. Challenges ahead Unintended consequences –Including resistance, morbidity and mortality –Changing prescribing pathways Vigilance with adherence to guidelines –Education –Information –Pharma Prescribing targets Organisation, sustainability and collaboration