case presentations misuse of antibiotics课件

JudiciousUseandMisuseofAntibiotics casesfromthefrontline Primary familyhealthcarefocus PaulaRenouf MS NP FCNANPNZ20thOctober2007Auckland Outline JudicioususeofantibioticsMisuseofantibioticsCases Judicioususe Awarenessofantibioticresistance crossresistanceandmultidrugresistance current localandnational internationaltrendsKnowledgeofimpactonNNTofvaccinesegHIB MeNZB PrevnarUseofpharmacokineticanddynamicprinciplestomakerationalantibioticchoicesKnowledgeofcurrentevidencebasedtreatmentguidelinesforcommoninfectionsetgENTandRespiratorySeeBPACNZQuizesPHARMAC Abilitytomanagepatientexpectationanddemands successfuleducation healthpromotionstrategies culturallyappropriateandaddressinghealthliteracylevelofclientqualityclinician clientinteraction non prescription pads SeeJudiciousUseofAntibiotics AguideforOregonCliniciansPHARMAC WhatISantibioticmisuse Consumerunderstandings misuse PressurisingdoctorstoprescribeantibioticsNotcompletingcourseoftreatmentHoardingandselftreatingAcquiringandselfprescribing rifeindevelopingcountrieswhichhavenotadoptedWHOessentialmedicineslistsandwhereallmedicationsareavailableOTC Increasedknowledgeisnotclearlyrelatedtoprudentuse McNultyetal 2007 n 7120facetofaceinterviewsinBritain Prescribermisuse Treatingviruseswithantibiotics especiallyURTIs bronchitis BPACNZ2006 7Treatingbenignself limitingbacterialinfectionswithantibioticsEBN2007Treatingpatientdemand expectationratherthanasusceptiblebacteriaNotkeepingupwithevidenceregardinglengthanddoseoftreatment changingrecommendationsegreprophylaxisConwayetalJAMA2007 Bradley StevensonetalBMJClinicalEvidence2007 Antibioticmisuse contributingfactors Habitsandexpectationshardtochange culturalfactors LackofknowledgererisksMoreknowledgeassociatedwithselfmedicationandnon completion McNultyetal 2007 Educatingpublicwithoutengineeringprescribingpracticechangenotnecessarilyeffective andviceversa McNultyetal 2007 Lackofcontroloveraggressivemarketingindevelopingcountries WHOEssentialDrugList thereareonly20antibioticsbutthereareover200antibioticpreparationssoldinMalaysiaandotherdevelopingcountriesSubsetsofimmigrantswithagreatinsistanceforRx peopleimportingownantibiotics Paediatrics isn tthatjustgivingamoxil aGPrecently Resultsofmisuse overuse AntibioticresistantorganismsRiskofharmfulsideeffectsImpactonclientcostandexpectationof treatment CosttoclientCosttohealthsystemCosttonationseehandout worddocPharmac p2 Untowardsideeffects AmpicillinrashwithEBV RationaleuseofantibioticsinENTURTIinfections ButthesnotisgreenButshe sbeencoughingreallybadforawholeweekButtheschoolwontletherbackuntilshegetsanantibioticfor pinkeye Butitcouldbebacterialwhataboutrheumaticfever ENTCase1 5yroldURTI leftearache T37 5 nasalcongestioncopiousthickandgreenam clearslaterinday redlefteardrum 2Previousearinfections NKDA whichantibioticswouldyouprescribe Amoxicillin Amox Clavulanate Erythromycin PenV noantibiotic BPACRespiratoryquiz ENTCase1 Answer 60 GPsandexpertpanelNOantibiotics37 thoughtAmoxilComment panelwouldencourageNOTtouseantibioticasunlikelysignificantbenefitButnegociable considerSES smoking BackpocketRx andgoodnoseblowing pamol warmpacksforsoreear hygiene nutrition Bulgingeardrum notjustred FeverunwelllookingBilateralotitisOtorrhea benefitfromantibiotics Factsaboutcoughinkids Trueorfalse Majorityofcoughsresolvewithin1week5 ofcoughslastlongerthan4weeksFamilymemberswithpersistantcough 4weekssuggestspossiblepertussisHonkingcough 4weeksabsentduringsleepsuggestshabitcoughPostviralcoughisthemostfrequentcauseofcough 4weeks Case1AcuteInfectiveConjunctivitis Athreeyearoldhasa2dayhistoryofpurulentleftconjunctivitis Keptoutofkindy presentsafebrile rubbingeye injectedbulbarandpalpebralconjunctivae TMsnormal mildclearcoryza shottyL preauricularnode active playing Acousinandsibhavehadsame Doesheneedantibiotics ConjunctivitisneedingantibioticsGonococcalPneumococcusBulbartoiris uveitis Conjunctivitis delayed immediateornoantibiotics Studiesshowmostinfectiveconjunctivitisresolvesspontaneouslyafter1wkAntibioticsimproveclinical bacterialremissionPrescriptionchloramphenicolimprovesdurationofmoderatesymptoms by1 5days NodifferenceinsymptomseverityonDay1 3AntibioticversusnonEverittetalBMJ2006 RenoufEBN2007Henceperhaps delayed or backpocket Rxisbest Plussoothing hygienemeasures However consider Whobenefitsfromimmediateversusdelayedornoantibioticprescription 80 ofAcuteinfectiveConjunctivitisinchildrenunder6yrsISbacterial oppositeforadults viral Consideralsounderlyingillhealth otitis conjunctivitis Fever spreadofinfection schoolandworkdaysmissed accesstohealthsetting andOTCantibiotics needforpatientedorwillusemore resistance RenoufEBN2007 Pharyngitis Case1 An18yroldCaucasianAucklandretailassistantpresentswith4dsorethroatandfever Shefeelsunwell doesn twanttotaketimeoffwork Shehas38 2C exudativepharyngitis enlargedanteriorcervicalnodes NoallergiesWouldyougetathroatswab Whichantibioticwouldyouprescribe Amoxil erythromycin amoxicillin clavulante PenecillinVornoantibiotic BPACRESPQuizCase3p5 PharyngitisCase2 A6yroldTonganchildpresentswithTemp37 8 pulse80 clearcoryzaandcough dayandnight Nolymphnodetendernessorenlargement heiscomplainingofaverysorethroat day2 tonsils3 red noexudate LivesinAucklandinNZDep10 Whatotherinformationwouldbeimportant Doesheneedathroatswab Whatantibioticwouldyougive NewNZGuideforSoreThroatManagementFeb2007 refertoyourhandout SeeAlgorithm4forsorethroatmanagementRoutineantibioticsAntibioticsforrecurrentinfectionCase1pharyngitisAnswer Swab backpocketRx ConsiderSexualhealthhx Gonorrhea chlamydia Case2 FamilyRheumFever ifnot noswab noRx RiskfactorsforRF Maori Pacific 3 45yrs lowerSESNorthIsland PasthxacuteRFCriteriatoswab treat Temp 38 nocough swollentenderAnteriorcervicalnodes tonsilarswelling exudate2007SoreThroatGuidelineNZ Case1LowerRespiratory 30 8 07a8yroldIndianboy Ht WT50th5ilepresentstoyouwithdrynightcough nowheeze lastVentolinuse2 07 Hismedicalhistoryofthelast8monthsconsistsof6presentationstoGPGivenRedipredandAmoxicillineachtimefor cough bilateralcrepschest Bronchitis Whatdoyouthink Whatwouldyoudo Considerations Othersigns symptoms Nofever coughnon productive someexerciseinducedcough wheezeO E Nofever ENTnegexceptclearcoryza lungssymA Enowheeze occasionalcreps coughnonproductive Nosuchthingas bronchitis inyoungchildren Patient family educated toexpectantibioticsforviralillnessesDiscussionofviralversusBacterial trialofventolinnocte beforeexercise backpocket Rx Case2LowerRespiratory Apreviouslywell30yroldofficeworkerhascough greenproductivesputumfor7days cameinwithCCofShortnessofbreathplayingweeklysquashgame O Escatteredwheeze temp37 7CNKDA Whichantibioticdoesheneed Amoxicillin Amox clavulanate Erythromycin PenV noantibiotic BPACRespQuizQ6 P6 Case2 63 prescriberssaidnoantibioticGPexpertpanelequivocal Time oneweekofcoughversus3wksDifficultyexcluding atypicalpneumonia versusviralbronchitis mostlikely Morehxneeded smoker Atopy Asthma Ifacutebronchitis onlypatientsover55yrswouldbenefitfromRx pneumonia exacerbationofCORD UTICase1 A14yroldmalewithafirstUTIisreferredtothePaediatricianforreview TheGPhasputhimonprophylacticantibioticspendingrenalultrasound Whatdoyouthink Whatinformationdoyouneedtocompletethepicture Doesheneedtobeonantibiotics UTICase2 Informationprovided female5mtholdHistoryoffirstUTI asymptomaticat4months 10 000 000ecoli 2further asymptomaticUTIs sincethennocultureresultsReferredpendingimagingstudies whatisnecessarytoruleoutVUR Onprophylaxisceclor125mg d UTIProphylacticantibiotics Shouldtheybeuseda whileawaitingresultsofimagingstudies severalweeksinNZ CurrentStarshipUTIGuideline 2005 b topreventrecurrentUTIinchildrenwhohaveVesicouretericreflux Forwhatgradeofreflux forhowlong OneRCT218kids3mth 18yrs antibioticsdonotdecreaserecurrenceofUTIwithorwithoutVURGrade1 111 noindicationsthatthispredisposestorecurrentUTI pyeloorrenalscars Resistanceaconcerninprophylacticgroup Garinetal 2006 UTI prophylacticantibiotics Of74 974children 6yrs from27generalpaediatricpracticesinNewJersey primarycare 611kidswithfirstUTI 83recurrentUTIAntibioticprophylaxispostfirstUTI DidnotreduceincidenceofrecurrentUTI ledtoa7 5timesincreaseinresistantinfectionRecommendation furtherstudies ButdiscussrisksandunclearbenefitsofantibioticprophylaxisConway 2007 JAMA Evidencechangespractice ie evidenceispointingpracticeinthedirectionofnotusingprophylaxisThiswillbereflectedinthe2007StarshipUTIguidelines Vaccinationschangeantibioticprescribingpracticetoo EgFeverofundeterminedsourceunder3yrsIna toxicappearingchild t 39 5Cmiserable notplayfulorsmiling weakcry sleepy pale drymouth InterventionandtreatmentdependonprobabilityofpooroutcomefromSERIOUSBACTERIALILLNESSInfluencedbydiseaseprevalence whetherdiseaseisrapidlyprogressing egMeNZB andvaccinationstatus HaemophilusInfluenzaeMeNZBAndnowPrevnar streppneumoccalvaccine Meanthata toxicappearingchild whooncehada5 chanceofSBIwillonlyhavea0 04 chance hencevastlyreducingtheneedforantibioticbeforeculturesknown Inconclusion toprescribeantibioticsWELLNPprescribersneed 1 Bestpracticeevidenceatfingertips Up To DMDConsult FirstConsultBPACNZBMJClinicalEvidencePharmacCochranecorner NZFP P E A R