Combating AMR in Primary Care

practical antimicrobial therapy for common infection in primary care setting

Dr Leong Kar Nim MBBS (India) MRCP (Ireland) Consultant Infectious Diseases Infectious Disease Unit Hospital Pulau Pinang

Percentage of Abs usage

Acute bronchitis 78% Acute phranyngitis 65% Acute sinusitis 81% Nonspecific URI 33%

Broad spectrum Abs 56%

Family Medicine 2006; 38(5):349-54

cs (infant deaths, life expectancy) are roughly equivalent, reports and personal files. Papers in ch allowed us to assume that at least in terms of general French were reviewed. Antibiotic use o th indicators both countries could be judged to be compa- expressed as defined daily doses (DDD e (4). We reviewed recent epidemiologic data about antibi- agents per 1,000 inhabitants per day, on ERSPECTIVE resistance in clinically relevant pneumococcal isolates of dard daily dose of an antibiotic agent for ents in Germany and France and explored different otheses to explain the observed differences between the Epidemiology of Resistant Pneumoco countries. The main questions addressed are: 1) Do imporAmong all clinical isolates of S. differences exist in antibiotic-prescribing practices in the from patients of all ages throughout atient setting? 2) Do the factors influencing decisions on (n=168) were susceptible to penicillin biotic use differ? 3) Are these differences related to socio- Germany, whereas only 47% of Fre ural and other macro-level determinants? In particular, we remained fully penicillin-susceptible (6) ght to offer potential methods for future international com- tional study, 4% and 47% of pneum sons designed to aid in developing effective strategies for erythromycin-resistant (MIC >1 mg/ Stephan Harbarth,* Werner Albrich, and Christian Brun-Buisson easing the spread of antibiotic-resistant microorganisms in France, respectively. A national survei The prevalence of penicillin-nonsusceptible pneumococci is sharply prevalence divided between (43%) and community. ofFrance penicillin-resistant S. p Germany (7%). These differences may be explained on different levels: antibiotic-prescribing practices for from patients with respiratory tract in respiratory tract infections; patient-demand factors and health-belief differences; social determinants, from 1998 to 1999 showed that of 961 is differing child-care practices; and differences in regulatory practices. Understanding these deterversity ofincluding Geneva Hospitals, Geneva, Switzerland; Beth Israel minants is crucial for the success of possible interventions. Finally, we emphasize the overarching imporsusceptible to penicillin G and 6% had oness Medical Boston, Massachusetts, USA; and Uni- in tance of Center, a sociocultural approach to preventing antibiotic resistance the community. bility (7). Three strains expressed high-l ty Hospital Henri Mondor, Crteil, France

Outpatient Antibiotic Use and Prevalence of AntibioticResistant Pneumococci in France and Germany: A Sociocultural Perspective

T 0

he epidemiology of antibiotic-resistant Streptococcus Methods pneumoniae varies tremendously between different coun- Diseases A computer-based was undertaken with the Emerging Infectious Vol. 8,literature No. 12, review December 2002 es and continents (1). In Europe, high rates of penicillin- MEDLINE database from 1980 to the present. While references sistant pneumococci have been recorded in France and were sought by using specific subject headings related to differ-

Strep pneumo sensitivity pattern in Germany vs France

he ay of

of flu. Most notably, 82% of French mothers expected antibiotics for their childs earache (36). In another recently published survey, French parents agreed more strongly than physicians that all ear infections should be treated with antibiotics (38).

Out patient antibiotic utilization data

re rkal nt

of tas y, ne nt

Figure 3. Outpatient antibiotic utilization (18,19), France and Germany, 19851997. DDD, daily defined doses.

es

Vol. 8, No. 12, December 2002

Findings:
In Germany :
lower antibiotic consumption narrow-spectrum antibiotics higher dosing of amino-penicillins better treatment compliance

Lower rates of resistant pneumococcus

MANAGEMENT OF COMMON INFECTION IN PRIMARY CARE SETTINGS

Adapted from CDC and UK guidelines

Aim :
A simple, empirical approach to the treatment of common infections which require antibiotics in outpatient setting Promote the safe, effective and economic use of antibiotics Minimise the emergence of bacterial resistance in the community

General principles:
Lower threshold for antibiotics in immunocompromised hosts or those with multiple morbidities; consider culture and seek advice

Prescribe an antibiotic only when there is likely to be a clear clinical benefit

Consider NO antibiotic strategy for acute self-limiting upper respiratory tract infections

 Use narrow spectrum antibiotics when possible Avoid broad spectrum antibiotics eg co-amoxiclav, quinolones and cephalosporins Avoid widespread use of topical antibiotics e.g. fusidic acid Where a best guess therapy has failed or special circumstances exist, seek advice from Physicians/ID/Clinical Microbiologists.

Common RTI in Primary Care

Acute pharyngitis Non specific URTI/ILI

Acute bacterial rhinosinusitis

Acute bronchitis

Acute pharyngitis
Only 5-15% of adult cases of acute pharyngitis are caused by GABHS (Group A -haemolytic strep) Antibiotic therapy of GABHS hastens resolution by 1-2 days if initiated within 2-3 days of symptom onset.

Centor criteria :

History of fever Lack of cough Tonsillar exudates Tender anterior cervical adenopathy

 Patients with none or only one of these findings should NOT be tested or treated for GABHS. Rapid streptococcal antigen test (RAT) is recommended for patients with two or more criteria, with antibiotic therapy only if test is positive Treatment : Penicillin V 500 mg 1 gm QID 10 days Clarithromycin 250-500 mg BD 5 days Extended BL-BLI / FQ are not indicated

Non specific URTI

The common cold is caused by viral pathogens eg rhinovirus, parainfluenza, adenovirus, RSV and influenza Bacterial rhino-sinusitis complicates only about 2% of cases. Symptoms may last up to 14 days with an average of 7 to 11 days Purulent nasal secretions do not predict bacterial sinusitis

 Common cold resolves without antibiotic treatment. Treatment with an antibiotic does NOT shorten the duration of illness nor prevent bacterial rhinosinusitis. Patients with purulent green or yellow secretions do not benefit from antibiotic treatment. Cough suppressants have limited efficacy for relief of cough Acute cough associated with the common cold may be relieved by antihistamines and decongestants

Suspected Influenza
Annual vaccination is essential for all those at risk of influenza.
Pregnant (including 2 weeks post partum) > 65 years chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised diabetes mellitus chronic neurological renal or liver disease

Treat only at risk patients within 48 hours of onset or in a care home where influenza is likely. Oseltamivir 75 mg bd x 5 days Zanamivir 10 mg BD (2 inhalations by diskhaler) x 5 days

Acute bacterial rhino-sinusitis

Acute maxillary and ethmoid rhinosinusitis Most cases of acute rhinosinusitis are due to uncomplicated viral infections Most rhinovirus colds last 7 to 11 days (J Clin Microbiol 1997; 35:2864; JAMA 1967; 202:158). Bacterial rhinosinusitis may be present if symptoms have been present >7 days and there is localization to the maxillary sinus.

 Most patients will improve without antibiotic treatment. About 81% of antibiotic-treated patients and 66% of controls improved at 10-14 days (absolute benefit of 15%). Patients with mild symptoms should NOT receive antibiotics. Use a narrow spectrum agent that covers S. pneumoniae and H. influenzae
Amoxicillin 500 mg TDS X 7 days Doxycycline 100 mg BD X 7 days Consider second line agent if no improvement or worsening after 72 hours. Co amoxy Clav 625 mg TDS X 7 days

Acute bronchitis
Acute coughing illness last for 3 weeks Greater than 90% of cases of acute cough illness are nonbacterial. Viral etiologies include influenza, parainfluenza, RSV, and adenovirus. Bacterial agents include Bordatella pertussis, Mycoplasma pneumoniae, and Chlamydophila pneumoniae. Purulent sputum not predictive of bacterial infection. >95% of patients with purulent sputum do not have pneumonia (J Chron Di 1984; 37:215)

 Empiric antibiotic treatment is not indicated for acute bronchitis. Meta-analyses of randomized, controlled trials all concluded that routine antibiotic treatment is not justified (BMJ 1998;316:906; Chest 2006;129:95S-103S). Antibiotic treatment decreases transmission but has little effect on symptom resolution. If influenza therapy is considered, it should be initiated within 48 hours of symptom onset for clinical benefit. Treatment: Amoxycillin 500 mg TDS X 5 days Doxycycline 200 mg stat and 100 mg OD X 5 days

Acute exacerbation of COPD

Treat exacerbations promptly with antibiotics only if purulent sputum and increased shortness of breath and/or increased sputum volume Risk factors for antibiotic resistant organisms (penicillin R) include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months Treatment: 5 days
Amoxicillin Doxycyline Clarithromycin co-amoxiclav 500 mg TDS 200 mg / 100 mg BD 500 mg BD 625 mg TDS

If resistance risk factors:

Urinary Tract Infection

Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI Do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity, especially elderly patient Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely

 UTI in women with severe symptoms (fever, dysuria and flank pain): treat with empirical antibiotic Women mild/or 2 symptoms: use dipstick to guide treatment.
Nitrite & blood/leucocytes has 92% positive predictive value ; -ve nitrite, leucocytes, and blood has a 76% NPV

Men: send pre-treatment MSU culture OR if symptoms mild/non-specific, use ve nitrite and leucocytes to exclude UTI Empirical Therapy : 3-5 days in women ; in men 7 days
Co Amoxy Clav Unasyn Cefuroxime

TIPS for not overusing antibiotics in primary care

Tell patients that antibiotic use increases the risk of an antibiotic- resistant infection. Identify and validate patient concerns. Recommend specific symptomatic therapy. Spend time answering questions and offer a contingency plan if symptoms worsen. Provide patient education materials on antibiotic resistance.

REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.