Antibiotic Guidelines

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Antibiotic Guidelines Powered By Docstoc
					Antibiotic prescribing
      at NSMC

    Sue Neal / Steve Newell
           16/5/03
Plan for the meetings:
   Enough material for 2 meetings
   Consider some research
   Look at antibiotic prescribing at
    NSMC
   For respiratory illnesses
   For UTI in children
    What are the problems?

 Do antibiotics work?
  – EBM to support their use?
  – For what conditions?
 Huge amounts of time used
 Huge costs involved
 Prescribing legitimises consultation
 Help-seeking behaviour reinforced
Antibiotic Guidelines
An examination of antibiotic
prescribing with reference to
new guidelines and minor
ailments
    Conditions
 Acute Sinusitis
 Sore Throat
 Otitis Media
 Cough
 LRTI
 UTI
    Sources
 Antimicrobial Prescribing
  Guidance for Primary Care
 SMAC
 Clinical Evidence
    Acute Sinusitis – the
      evidence base
 Antibiotics may be effective in
  PROVEN acute sinusitis
 The adult with ‘sinusitis – like
  symptoms’ in primary care does not
  need immediate antibiotics
 Any effects may be minimal/modest
    The guidelines say
 Many cases are viral
 Reserve Rx for severe
  illness/persistant symptoms
 Penicillin V 500mg QDS 3-7 days or
 Erythromycin 250 QDS
Primary-care-based randomised placebo-controlled trial of
  antibiotic treatment in acute maxillary sinusitis.
Lancet. 1997 May 17;349(9063):1476
van Buchem FL, Knottnerus JA, Schrijnemaekers VJ, Peeters MF

BACKGROUND: The value of antibiotics in acute rhinosinusitis is
  uncertain. Although maxillary sinusitis is commonly diagnosed and
  treated in general practice, no effectiveness studies have been done
  on unselected primary-care patients. We used a randomised,
  placebo-controlled design to test the hypothesis that there would be
  an improvement associated with amoxicillin treatment for acute
  maxillary sinusitis patients presenting to general practice.

METHODS: Adult patients with suspected acute maxillary sinusitis
  were referred by general practitioners for radiographs of the
  maxillary sinus. Those with radiographic abnormalities (n = 214)
  were randomly assigned treatment with amoxicillin (750 mg three
  times daily for 7 days; n = 108) or placebo (n = 106). Clinical course
  was assessed after 1 week and 2 weeks, and reported relapses and
  complications were recorded during the following year.
FINDINGS: After 2 weeks, symptoms had improved substantially or
   disappeared in 83% of patients in the study group and 77% of
   patients taking placebo. Amoxycillin did not influence the clinical
   course of maxillary sinusitis nor the frequency of relapses during
   the 1-year follow-up. Radiographs had no prognostic value, nor
   were they an effect modifier. Side-effects were recorded in 28% of
   patients given amoxycillin and in 9% of those taking placebo (p <
   0.01). The occurrence of relapses was similar in both groups (21
   vs 17%) during the follow-up year.

INTERPRETATION: Antibiotic treatment did not improve the clinical
   course of acute maxillary sinusitis presenting to general practice.
   For these patients, an initial radiographic examination is not
   necessary and initial management can be limited to symptomatic
   treatment. Whether antibiotics are necessary in more severe cases
   warrants further study.
    Practice at NSMC
 58 cases of acute sinusitis
  examined across all clinicians
 Symptoms
 Prescribing
 Other Rx
              Findings
   Wide variety in prevalence indicating
    diagnostic variability

   Symptoms - 4 = no history
             - 12 post URTI
             - 22 pain
             - 23 tenderness
             - congestion / discharge
                   / fever
   Duration   - 33 had a comment
                    regarding duration
               - less than 1 week = 8
               - 2 weeks to 1 year
   Prescribing - 100% (1 deferred, 1 nasal spray)
              - Amoxicillin / Ampicillin /
                       Erythromycin
              - Trimethoprim & Doxycycline

            For - 3 days
                - 5 days
                - 7 days ( 35)
                - 10 days
                - Other regimes
        Questions
 What syndrome are we treating?
 Are the treatments evidence
  based?
 Do we need to make any changes
  to treatments?
    Other treatments
 Steaming
 Nasal sprays
 Analgesia
 5 went onto second ABX
  courses, X-ray or referral
Sore throat – the evidence base
     Most sore throats are viral and self-
      limiting
     Strep is isolated in 30% of sore throats
      BUT
     Asymptomatic carriage can be as high as
      40%
     Typical features only present in 15% of
      patients with strep throat
     Recent studies do not support antibiotics
      as preventative of non-suppurative
      complications which are rare anyway
     The guidelines say
    - indications to treat
 Severely inflamed throat AND
  marked systemic upset
 Conformed strep infection
 Scarlet fever
 Impaired immunity
 PH non-suppurative complications
 Evidence of obstruction with ENT
  referral
               With
 Penicillin V 500mg QDS for 7 –10
  days
 Erythromycin if allergic 250 QDS
 Deferred script to use if no better 3
  days
Otitis Media – the evidence base
  Approx 80% of acute OM resolves in 3
   days without Rx
  ABX do not influence subsequent OM or
   deafness at 1 month
  May reduce no of children still in pain 2-7
   days but for each 1 improved 3 will
   develop ABX related side effects
  Repeated courses may make recurrent
   infection more likely
UTI in children
BMJ 1996;312:961-964 (13 April)
  Education and debate: ABC of Urology:
  URINARY INCONTINENCE AND URINARY
  INFECTION
Chris Dawson, Hugh Whitfield

Urinary tract infection: Management in children

Collecting urine specimens to confirm the diagnosis of
urinary tract infection is [..] difficult in children. A
midstream sample can be collected from older children,
but in younger children a sterile bag placed over the
genitalia to catch the urine may be needed. Suprapubic
aspiration of the bladder is seldom required.
..1% of boys aged under 11 years develop a urine
infection, but the incidence is three times as high in girls.
Most such infections occur in the first 12 months of life.
The greatest danger in such children is the development
of upper tract infection and subsequent renal scarring.

Vesicoureteric reflux accompanies urinary tract infection
in children in 20-50% of cases. Although reflux may be the
cause of infection, episodes of infection may lead to
transient reflux. Vesicoureteric reflux alone is not
sufficient to cause renal cortical scarring - infection must
also be present
Treating uncomplicated infections for 3-5 days with
antibiotics usually suffices.

All children with a urinary infection should be
Investigated:
  An ultrasound scan or intravenous urogram will show
  abnormalities of the upper tracts.
  A voiding cystourethrogram should be performed to
  look for bladder outlet obstruction or vesicoureteric
  reflux.

Sexual abuse as a cause of urinary infection in children
should not be forgotten.
Repeated infections should be treated accordingly:
  Prophylactic antibiotics may be needed if more than
  three infections occur during six months.
  Preventive measures [..] include adequate fluid intake
  and the avoidance of constipation.

If vesicoureteric reflux is discovered then conservative
management is appropriate initially. Higher grades of
reflux are unlikely to settle spontaneously, but lower
grade reflux – i.e. not reaching the renal pelvis – may
settle without intervention. Surgery is likely to be needed
if repeated infections occur while the child is taking
prophylactic antibiotics, if antibiotic compliance is low, or
if reflux persists after lengthy surveillance.
BMJ 1999;319:1173-1175 ( 30 October )
  Clinical review: Clinical evidence
  Urinary tract infection in children
James Larcombe, general practitioner.
Sedgefield, County Durham TS21 3BN

This review of the effects of treatment for urinary tract
infection in children and of preventive interventions is
one of over 60 chapters in the first issue of Clinical
Evidence, published by the BMJ Publishing Group.
Key messages:

Treating symptomatic acute urinary tract infection in
  children with an antibiotic is accepted clinical practice
  and trials would be considered unethical

We found little evidence on the effects of delaying
 treatment while awaiting microscopy or culture results,
 but retrospective observational studies suggest
 delayed treatment may be associated with increased
 rates of renal scarring

One systematic review of randomised controlled trials
  (RCTs) has found that antibiotic treatment for seven
  days or longer is more effective than shorter courses
We found no convincing evidence of benefit from routine
  diagnostic imaging of all children with a first urinary tract
  infection, but subgroups at increased risk of future
  morbidity may benefit from investigation. Because such
  children cannot currently be identified clinically,
  investigating all young children with urinary tract
  infection may be warranted
Two small RCTs found that prophylactic antibiotics
  prevented recurrent urinary tract infection in children,
  particularly during the period of prophylaxis. The long
  term benefits of prophylaxis have not been adequately
  evaluated, even for children with vesicoureteric reflux.
  The optimum duration of treatment is unknown
One systematic review and a subsequent multicentre RCT
  found no difference between surgery for vesicoureteric
  reflux and medical management in preventing recurrence
  or complications from UTI
        Practice at NSMC
 33 cases of Hx entry UTI over 3 years
 Age range 1year – 14years
 Symptoms including abdo pain, dysuria,
  frequency, vomiting, fever, wetting
 15% no symptoms recorded
 72% urine dip recorded, 7 did not, 2
  noted not possible
 All those with urine dip reported positive
         Prescribing for UTI
               NSMC
   Of all positive dips all but 2 had ABX
    immediately
   2 positive dips awaited MSU before Rx
   Where dip not possible 2 awaited MSU
    before Rx
   17 had Trimethoprim, 9 Amox/Amp, 1 Cipro
   Length of Rx ranged from 3 – 10days
    (Trimethoprim 10 days, Amp 5 days)
               MSU
 63% had MSU result
 21% had MSU mentioned in Hx but not
  result appeared
 39% MSU positive
              Referral
 50% positive MSUs were referred on
  first infection
 2 negative MSUs were referred
 4 were referred after subsequent
  infections
 3 investigated in house with USS
 1 not referred (seen at hospital)
                Issues
 Hx entries, symptom recording
 Prescribing
 MSUs
 FU and referral – esp from hospital
 In house investigation?
 Haematuria??
Consider the issue of
antibiotic prescribing
in sore throat ~
What is the problem?
 Double blind RCTs suggest
  antibiotics give only marginal
  benefit when prescribed for
  common acute respiratory illnesses
 Yet antibiotics are still widely
  prescribed in this situation
 Is the problem that doctors do not
  feel that RCTs are applicable to the
  usual practice setting?
    Paper for discussion:
   “Open randomised trial of prescribing
    strategies in managing sore throat”
    Little et al, BMJ 1997, 314, 722 (8th
    March)

   The objective of this study was to
    assess three prescribing strategies for
    sore throat – antibiotics, no antibiotics
    or deferred prescription for antibiotics
Description of paper - 1

 Objective – to assess three
  prescribing strategies for sore
  throat
 Open randomised follow-up
  study – involved discussion with
  patients
 Provides another model for
  clinical management
    Description of paper - 2
 Setting – 11 practices in South and West
  Region
 716 patients with ST and an abnormal
  physical sign in the throat – 84% had
  “tonsillitis” or “pharyngitis”
 Patients randomised to three groups:
  antibiotics for 10/7 (246), no prescription
  (230), prescription to be used if symptoms
  were not settling after 3/7 (238) – in fact
  add to 714
     Results - 1
10
 9
 8
 7
 6                        Days of Rx
 5
                          Illness duration
 4
                          Days off
 3
 2
 1
 0
     Rx   No Rx   Defer
  Results - 2
100%
 90%
 80%                        Better at 3/7
 70%
 60%                        Pt satisfied
 50%
 40%                        Thought Rx
 30%                        effective
 20%                        Intended to
 10%                        come in future
  0%
       Rx   No Rx   Defer
             Results - 3
 69% of patients in deferred group did
  not use the prescription
 Legitimisation of illness for school or
  work (60%) was an important reason
  for consultation
 Patients who were more satisfied
  with the way the doctor dealt with
  them got better more quickly
      Conclusion in paper
   “Prescribing antibiotics for sore
    throat only marginally affects the
    resolution of symptoms but
    enhances belief in antibiotics and
    intention to consult in future when
    compared with the acceptable
    strategies of no prescription or
    delayed prescription”.
       Another paper
 “A RCT of delayed antibiotic
  prescribing as a strategy for
  managing uncomplicated respiratory
  tract infection in primary care”.
  Dowell et al, BJGP, 2001, 464, 200
  (March)
 Reached similar conclusions.
    What this means

 Antibiotics are not always needed
  for sore throat to resolve
 Strategy of deferred prescription
  can reduce antibiotic usage
 Patients can be managed in this
  way and still remain happy with
  their care
    Next steps
 Can this idea be generalised?
 What about acute cough?
 What about conjunctivitis?
 What about otitis media?
 What about sinusitis?
 Other conditions?

				
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