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Changing UTI Management Across Nottinghamshire

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Changing UTI Management Across Nottinghamshire Changing UTI management across Nottinghamshire Dr Annie Joseph Consultant Microbiologist & Education Lead for Antimicrobial Stewardship Nottingham University Hospitals NHS Trust @ajosephnotts Background Greater Nottingham • 4 CCGs with a with population of ~700,000: • 149 GP practices • 1x Teaching Hospital, 1x Community, 1x MHU • 3 private hospitals • Nottinghamshire Area Prescribing Committee • County-wide guidelines • The Nottinghamshire Antimicrobial Stewardship Group formed in 2015 • Community Infection Doctor The Nottinghamshire Antimicrobial Stewardship Group • Priority areas: • Public & Patient Engagement • Antibiotic Allergy • Improve UTI The Nottinghamshire Antimicrobial Stewardship Group • Priority areas: • Public & Patient Engagement • Antibiotic Allergy • Improve UTI UTIs: Where were we? Local resistance rates Percentage trimethoprim resistance in community E.coli urine isolates 2012-14 45 40 Under 16 16-29 35 30-49 30 50-64 65-79 25 Over 80 20 Percentage trimethoprim resistance trimethoprim Percentage 2012 2013 2014 * not sentinel surveillance Review Approach antibiotic guidelines Review Antibiotic Guidelines Community antibiotic guidelines for UTIs across Nottinghamshire (FY14/15): First-line: Trimethoprim or Nitrofurantoin • Trimethoprim use = 67% vs. England average of 65% Second-line: Co-amoxiclav Proportion of broad-spectrum antibiotics 11% vs. England average 11% Source: Nottinghamshire Shared Medicines Management Team PHE Fingertips AMR Review Antibiotic Guidelines Empirical lower UTI treatment (changed Q2 2015): First-line: Nitrofurantoin Second-line: Choice dependant on risk factors for resistance ≥65yrs or any risk factor for resistance: Pivmecillinam <65yrs with no risk factors for resistance: Trimethoprim Third-line: Ciprofloxacin Replaced with: Fosfomycin (Q4 2017) Review Antibiotic Guidelines • Empirical upper UTI (pyelonephritis) : • Removed co-amoxiclav • Changed to Cefalexin or Ciprofloxacin • Or trimethoprim if proven culture-sensitive • New county-wide guidelines for Management of Recurrent UTIs in Primary Care (Q4 2017): • Formalised approach to use of prophylactic antibiotics • Alternatives promoted (conservative, stand-by, methenamine) • 6 month trial and stop • Review of any pt on ABx >12 months Review Approach antibiotic guidelines Guidelines for Recurrent UTI Review Approach antibiotic guidelines Guidelines for Recurrent UTI Educating Prescribers Education Support community Wider educational guideline update: programme: Launch events at GP Non-medical prescribers protected learning Community nurses e.g. Sessions for CCG matrons, DNs Pharmacists & Advisers GP registrars Review community pharmacy PGDs Continence advisers Newsletter, hints&tips Nurse Practitioners Review Approach antibiotic guidelines Guidelines for Recurrent UTI Educating Prescribers Review Approach antibiotic guidelines Guidelines for Recurrent UTI Educating Prescribers Improve Laboratory Methods Laboratory methods Agar plate-based culture and sensitivity method ID & sens ~ 48h Semi-automated commercial microtitre based method ID & sens ~ 24h Introduce testing for pivmecillinam, ertapenem and fosfomycin Review Approach antibiotic guidelines Guidelines for Recurrent UTI Educating Prescribers Improve Laboratory Methods Review Approach antibiotic guidelines Guidelines for Recurrent UTI Get the Educating diagnosis right Prescribers Improve Laboratory Methods To Dip Or Not To Dip? • Quality Improvement Project for UTI diagnosis in Care Homes • NHS Bath & North East Somerset • Elizabeth Beech & Mandy Slatter • Investment in IPC Team to deliver across 6 CCGs: • Public Health in Nottinghamshire County Council • Started Jan 2016 – work in progress! • Antibiotic prescribing decreased by 50-60% in pilot homes To Dip Or Not To Dip? Review Approach antibiotic guidelines Guidelines for Recurrent UTI Get the Educating diagnosis right Prescribers Improve Laboratory Methods Review Approach antibiotic guidelines Measure Guidelines for impact Recurrent UTI Get the Educating diagnosis right Prescribers Improve Laboratory Methods Antibiotic prescribing in South Nottinghamshire GPs 2015-18 14000Impact on Prescribing 12000 10000 8000 Trimethoprim 6000 Number of items prescribed items ofNumber 4000 2000 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Antibiotic prescribing in South Nottinghamshire GPs 2015-18 14000 12000 10000 8000 Trimethoprim 6000 Nitrofurantoin Number of items prescribed items ofNumber 4000 2000 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Antibiotic prescribing in South Nottinghamshire GPs 2015-18 14000 12000 10000 8000 Trimethoprim Nitrofurantoin 6000 Pivmecillinam Number of items prescribed items ofNumber 4000 2000 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Antibiotic prescribing in South Nottinghamshire GPs 2015-18 14000 12000 10000 8000 Trimethoprim Nitrofurantoin 6000 Pivmecillinam Co-amoxiclav Number of items prescribed items ofNumber 4000 2000 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Antibiotic prescribing in South Nottinghamshire GPs 2015-18 14000 12000 10000 8000 Trimethoprim Nitrofurantoin Pivmecillinam 6000 Co-amoxiclav Fosfomycin Number of items prescribed items ofNumber 4000 2000 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Total ‘UTI’ antibiotics prescribed by South Nottinghamshire GPs 2015-18 14000 25000 -13% 12000 20000 10000 15000 Trimethoprim 8000 Nitrofurantoin Pivmecillinam 6000 Co-amoxiclav 10000 Fosfomycin Total Number of items prescribed items ofNumber 4000 5000 2000 0 0 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 Review Approach antibiotic guidelines Measure Guidelines for impact Recurrent UTI Get the Educating diagnosis right Prescribers Improve Laboratory Methods Impact on Resistance Rates • No England / UK-wide Sentinel Surveillance for Urine Resistance • Changes to local laboratory methodology: • Move from testing only the multi-resistant isolates, to testing all isolates • Over-estimate pivmecillinam and fosfomycin resistance • Testing reliable for E. coli only • Ertapenem plate picking up CPEs (Carbapenem-Producing Enterobacteriacae) that may have otherwise been missed E. coli urine isolates from South Nottinghamshire GPs 2015-2018 70% 60% 50% 40% 35% 30% 26% p=0.001 20% Percentage of isolates RESISTANT isolates of Percentage 10% 0% 1% 1% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 E. coli urine isolates from South Nottinghamshire GPs 2015-2018 70% 60% 50% 40% 35% 30% 26% p=0.001 20% Percentage of isolates RESISTANT isolates of Percentage 10% 10% 6% 0% 1% 1% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 E. coli urine isolates from South Nottinghamshire GPs 2015-2018 70% 60% 50% 40% 35% 30% 26% p=0.001 20% Percentage of isolates RESISTANT isolates of Percentage 10% 11% 10% 6% 9% 0% 1% 1% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 E. coli urine isolates from South Nottinghamshire GPs 2015-2018 70% 60% 50% 45% 40% 35% 31% p=0.001 30% 26% p=0.001 20% Percentage of isolates RESISTANT isolates of Percentage 10% 11% 10% 6% 9% 0% 1% 1% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 E. coli urine isolates from South Nottinghamshire GPs 2015-2018 70% 63% 60% 50% 45% Trim:Nitro proportion 40% 35% 31% p=0.001 30% 26% p=0.001 20% Percentage of isolates RESISTANT isolates of Percentage 20% 10% 11% 10% 6% 9% 0% 1% 1% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar 15 15 15 15 16 16 16 16 17 17 17 17 18 E. coli bloodstream infections • 46% were UTI source in Nottinghamshire • Earlier appropriate treatment reduce bacteraemias? Community-onset E. coli BSIs Greater Nottinghamshire 2015-18 160 140 120 100 80 60 Number of E. coli BSIs coli E. of Number 40 20 0 Jan - Mar 15Apr - Jun 15 Jul - Sep 15 Oct - Dec 15Jan - Mar 16Apr - Jun 16 Jul - Sep 16 Oct - Dec 16Jan - Mar 17Apr - Jun 17 Jul - Sep 17 Oct - Dec 17Jan - Mar 18 E. coli bloodstream infections • Three out of four CCGs met the 10% reduction target 2017/18 • Estimated cost saving of £120,000 in avoided bacteraemias • Offset against additional drug costs? e.g. Nitrofurantoin spend: 6 months pre-guideline change = £130,966.56 6 months post-guideline change = £204,590.08 • Cases of nitrofurantoin-related patient harm • Estimated avoided E. coli BSI deaths (16/17 - 17/18) = 12 Review Approach antibiotic guidelines Measure Guidelines for Impact Recurrent UTI Get the Educating diagnosis right Prescribers Improve Laboratory Methods Review Approach antibiotic guidelines Guidelines for Future? Proactive cycling of Recurrent UTI antibiotics Mixing approach: equal first-line choices Reintroduce Measure Educating trimethoprim Impact Prescribers first-line (improve cost-effectiveness) Sentinel surveillance Get the Improve diagnosis Laboratory right Methods Learning • UTIs are not easy! • Getting UTI management right requires a multi-pronged approach • Diagnosis • Testing • Resistance • Engagement with clinicians • Tailored, local approach can reduce resistance and maybe E.
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