Antibiotics & Common Infections Stewardship, Effectiveness, Safety & Clinical Pearls October 2016 ANTIMICROBIAL RELATED LINKS ANTIMICROBIAL STEWARDSHIP GETTING STRATEGIES TO WORK - REAL WORLD CANADIAN GUIDELINES There are world-wide efforts that look • Public, patient & provider education for strategies to deal with the challenge of over time to change expectations Bugs & Drugs (Alberta/BC): growing antimicrobial resistance. How can • Realistic appreciation for viral versus http://www.bugsanddrugs.ca/ we all work together to be stewards of this bacterial etiologies important, but limited resource? • Delayed prescriptions for select MUMS Guidelines – “Orange Book” conditions with instructions to fill only (Anti-infective Review Panel): SELECT ANTIBIOTIC RESISTANT if symptoms do not resolve or condition http://www.mumshealth.com PATHOGENS OF MAJOR CONCERN worsens. (Offer to those who value convenience.) PATIENT RESOURCES • methicillin-resistant Staphylococcus aureus (MRSA) • “It’s easy to prescribe antibiotics. It i Canadian Antibiotic Awareness: • multi-drug resistant Streptococcus takes time, energy & trust not to do so.” http://www.antibioticawareness.ca pneumonia (MRSP) Success lies in changing the culture & the which includes: • vancomycin-resistant enterococci (VRE) understanding of antibiotic limitations, • multi-drug resistant Escherichia coli & benefits & harms. 1. Viral Prescription Pad for respiratory other gram negative bacteria (e.g. ESBL) infections (download or order for free); ANTIBIOTIC HARMS – UNDERAPPRECIATED provides information about symptomatic KEY STRATEGIES FOR REDUCING ANTIBIOTICS Q To the Patient relief for viral infections and indicates when • vaccinations to prevent infections and • 1 in 5 emergency room visits for adverse patients should consider a return visit. decrease antibiotic use drug events (ADEs) are from antibiotics. • practice and educate on infection • Antibiotics are the most common cause of 2. Talking with Patients about When to ADEs in children, accounting for 7 of the top prevention (wash hands, avoid touching Use Antibiotics provides communication 15 drugs leading to ADE-related ER visits. eyes, cough etiquette, stay home when tips to effectively address requests for • Antibiotic associated diarrhea, including sick) antibiotics for viral infections. Clostridium difficile diarrhea • avoid antibiotics for infections of Enhanced communication skills reduce • Cardiac - QT interactions: with predominantly viral cause clarithromycin & fluoroquinolones antibiotic prescribing (27% absolute risk • use of point-of-care tools/tests reduction - ARR). • Central nervous system (CNS) adverse • treat infection, not contamination effects (e.g. dizziness, headache, sleep 3. Posters for office A poster displayed • avoid treating positive cultures in disturbance, seizure, encephalopathy) in the practice waiting room stating a the absence of signs/symptoms • Hyperkalemia (cotrimoxazole) commitment to reducing antibiotic use • Skin: minor/major (e.g. cotrimoxazole) STRATEGIES WHEN ANTIBIOTICS INDICATED reduces inappropriate antibiotic use • Tendon rupture (fluoroquinolones) (20% ARR). • Whenever suitable: • Risk of drug interactions (warfarin, statins/ http://www.dobugsneeddrugs.org/wp- • use narrow-spectrum agent macrolides, ...) content/uploads/info-sheet-english.pdf • use shorter duration therapy • r risk of secondary fungal infections • tailor empiric antibiotic choice & dosage • r risk of an untreatable infection in the 4. Handouts for Patients according to local bacterial prevalence patient due to r bacterial resistance http://healthycanadians.gc.ca/drugs- and resistance patterns Q products-medicaments-produits/ To Society • calculate weight-based dose in kids • financial costs of treating adverse buying-using-achat-utilisation/antibiotic- • if patient experiences an adverse resistance-antibiotique/material- reactions (USA: $20 billion in excess reaction, provide patient education and 1 materiel/brochure-eng.php healthcare costs) document details to avoid labelling a side • antimicrobial resistance: more difficult OTHER effect as an “allergy” to treat infections over time, leading • discourage saving of “left-over” www.rqhealth.ca/antimicrobialstewardship eventually to no adequate options antibiotics for future use For more public/patient resource links see: For what’s inside, see 1 http://www.cdc.gov/media/releases/2011/f0407_ www.RxFiles.ca/ABX antimicrobialresistance.pdf Table of Contents, Page 2 Antibiotics & Common Infections – Part 1 Table of Contents Common Infections – Part 1 Acknowledgements (more details online) RxFiles is very pleased to acknowledge those who contributed to Part 1 topic development & review. Stewardship, Effectiveness, Safety & Clinical Pearls ….1 Bronchitis, Acute ….3 Overall ABX topic/project guidance: Lynette Kosar Pharmacist, RxFiles Community Acquired Pneumonia (CAP) ….4 Loren Regier Pharmacist, RxFiles Pharyngitis ….6 Tessa Laubscher Family Physician, Saskatoon Yvonne Shevchuk UofS, College of Pharmacy Sinusitis, Acute ….8 Pam Komonoski RN(NP) UofS Student Health Linda Sulz Pharmacist, RQHR Justin Kosar Pharmacist, SHR Stewardship Oral Antibiotics - General Casey Phillips Pharmacist, RQHR Stewardship Content development – ABX Part 1: Overview ..10 Lynette Kosar* Pharmacist, RxFiles Topic Lead Alex Crawley Pharmacist, RxFiles Pregnancy/Lactation ..10 Andrew Plishka Pharmacy Resident, SHR Rachel Martin Pharmacy Resident, SHR Loren Regier Pharmacist, RxFiles Co-Lead Oral Antibiotics – Drug Comparison Charts Topic input and review: Anne Nguyen Pharmacist, BC Brent Jensen Pharmacist, RxFiles Penicillins ..11 Jessica Minion RQHR Microbiology Cephalosporins ..11 Jill Blaser-Farrukh Family physician, Saskatoon Joe Blondeau SHR Microbiology Macrolides ..12 John Alport Family Physician, Regina Tetracyclines ..12 Jonathan Hey Family Physician, Saskatoon Marlys LeBras Pharmacist, RxFiles Fluoroquinolones ..13 Nora McKee Family Physician, Saskatoon Reid McGonigle Family Physician, Northern SK Antifolates: Sulfamethoxazole, Trimethoprim ..13 Roger Bristol Emergency Med, SHR Other ..14 Shaqil Peermohamed MD, SHR Infectious Disease Tom Smith-Windsor Family Physician, Prince Albert Clindamycin Metronidazole The RxFiles academic detailing team (Zack Dumont, Vaughn Johnson, Tanya Nystrom, Lisa Rutherford, Nitrofurantoin Brenda Schuster, Pam Karlson) Fosfomycin * Although many contributed to this topic workup, Linezolid Lynette Kosar took the lead on the 4 primary therapeutic topic areas, including the overseeing Probenecid (used to prolong effective levels of cefazolin) related resident rotations. Well done Lynette!!! Vancomycin Graphic design: Dealing with Patient’s Expectations & Demands Debbie Bunka, Colette Molloy (designmolloy.com) Coming up next, Spring 2017 Non-antibiotic Rx for Predominantly Viral Infections ..15 ABX – Part 2: We asked some clinicians… Getting patient buy-in. ..16 Skin Infections, Acute Cystitis www.RxFiles.ca DISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the Board or Administration of Saskatoon Health Region (SHR). Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information. Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, its employees, servants or agents. Readers are encouraged to confirm the information contained herein with other sources. Additional information and references online at www.RxFiles.caCopyright 2016 – RxFiles, Saskatoon Health Region (SHR) ACUTE BRONCHITIS: Management Considerations www.RxFiles.ca © Oct 2016 PEARLS for the MANAGEMENT of ACUTE UNCOMPLICATED BRONCHITIS SYMPTOM MANAGEMENT no quality evidence, but anecdotally may help Antibiotics are NOT recommended, as bronchitis is predominantly viral. ↑/maintain hydraon - No evidence for or against. Advise on treatments that will provide symptomatic relief: maintaining hydration ↑ humidity (e.g. PRN - Hydration: caution in HF & CKD patients & ↑ humidity. Cough suppressants may be considered for managing cough, & humidifier to maintain - Humidifier: clean frequently to risk of inhaled bronchodilators if wheezing is present. Honey may help children. 30-50% humidity) bacteria/fungi growth - No strong evidence for or against. Patients should see their prescriber if: 1) symptoms worsen, 2) new symptoms Honey 2.5 to 10mL po HS NONPHARM - Cochrane review (3 RCTs, n=568): better than develop (e.g. dyspnea, fever, vomiting), 3) cough >1month, or 4) >3 episodes/yr. Not recommended in <1yr due to placebo, but inferior to dextromethorphan in concerns with infant botulism PRE-TREATMENT CONSIDERATIONS cough frequency (cough duration not assessed). Inappropriate antibiotic use is driving resistance & leading to a crisis. Please - May number of coughing episodes but does Dextromethorphan (DM) not duration of illness. examine your own prescribing practices. Refer to newsletter cover. e.g. BENYLIN DM, ROBITUSSIN DM - Not recommended in children under 6 years of The majority of acute uncomplicated bronchitis cases are viral (90% in adults & 10-30mg po q6-8hr PRN age due to safety & efficacy concerns. HEALTH COUGH CANADA 95-100% in children). Antibiotics are NOT recommended for acute