focal point: antibacterials - cppe · focal point: antibacterials ... antibiotics and their role in...

CENTRE FOR PHARMACYPOSTGRADUATE EDUCATION

A F o c A l p o i n t l e A r n i n g p r o g r A m m e

December 2013FP122/2

BOOK 2

focal point:ANTIBACTERIALS

FP_Antibacterials_Book 2_FP_Anticoag_Book2 25/11/2013 11:56

focal pointAnticoagulation – Book 2

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Content contributorsHayley Berry, tutor, CPPELaraine Clark, tutor, CPPEPhilip Howard, consultant antimicrobial pharmacist, Leeds teaching hospitals NHS TrustJulia Lacey, antimicrobial pharmacist, Derby Hospitals NHS Foundation Trust

CPPE programme developer Sarah Ridgway-Green, regional manager, CPPE

ReviewersDiane Ashiru-Oredope, pharmacist lead, Public Health England and Department of Health AdvisoryCommittee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)David Ladenheim, antimicrobial pharmacist, East and North Hertfordshire NHS Trust

CPPE reviewersAnne Cole, regional manager, CPPEZara Mehra, tutor, CPPE

Piloted by Yinka Kuye, tutor, CPPE

Some content from other CPPE programmes has been used in this learning programme. CPPEacknowledges the developer, writer and contributors of the learning@lunch programme, Antibacterials, andthe open learning programmes, Antibiotics and their role in managing infections and Avoiding antibioticresistance: the role of the pharmacy team.

Edited by Terri Lucas, assistant editor, CPPE

DisclaimerWe have developed this learning programme to support your practice in this topic area. We recommend thatyou use it in combination with other established reference sources. If you are using it significantly after thedate of initial publication, then you should refer to current published evidence. CPPE does not acceptresponsibility for any errors or omissions.

External websites CPPE is not responsible for the content of any non-CPPE websites mentioned in this programme or for theaccuracy of any information to be found there.

All URLs were accessed on 21 November 2013.

Brand names and trademarksCPPE acknowledges the following brand names and registered trademarks mentioned throughout thisprogramme: Calceos®, Mercilon®, Tazocin® and Timentin®.

Published in December 2013 by the Centre for Pharmacy Postgraduate Education, Manchester PharmacySchool, The University of Manchester, Oxford Road, Manchester, M13 9PT. http://www.cppe.ac.uk

ProductionDesign & artwork by Gemini WestPrinted by Gemini Press Ltd

Printed on FSC® certified paper stocks using vegetable based inks.


focal pointAntibacterials – Book 2

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Contents

Learning with CPPE 4

About your focal point event 5

Case studies 6

Clinical vignettes 12

Directing change 14

Putting your learning into practice 15

Suggested answers 19

References 44



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Learning with CPPE The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range oflearning opportunities in a variety of formats for pharmacy professionals from allsectors of practice. We are funded through the NHS Multi-professional Educationand Training Fund from Health Education England to offer continuing professionaldevelopment for all pharmacists and pharmacy technicians providing NHS servicesin England. For further information about our learning portfolio, visit: http://www.cppe.ac.uk

We recognise that people have different levels of knowledge and not every CPPEprogramme is suitable for every pharmacist or pharmacy technician. We havecreated three categories of learning to cater for these differing needs:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialties (CPPE may not be the provider and will direct youto other appropriate learning providers).

This is a learning programme and assumes that you already have someknowledge of the topic area.

Continuing professional development (CPD) - You can use this focal point unit tosupport your CPD. Consider what your learning needs are in this area. Use yourCPD record sheets to plan and record your learning.

Programme guardians - A programme guardian is a recognised expert in an arearelevant to the content of a learning programme. They will review the programmeevery six months to ensure quality is maintained. We will post any alterations orfurther supporting materials that are needed as an update on our website. Werecommend that you check for these updates if you are using a programme morethan six months after its initial publication date.

Feedback - We hope you find this learning programme useful for your practice.Please help us to assess its value and effectiveness by visiting the my CPPE recordpage on our website. Alternatively, please email us at [email protected].



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About your focal point event Before coming along to this event you will have already completed Book 1 to helpyou identify your own learning needs, read the key information and then related it toyour own area of practice and professional development.

This book uses case studies and clinical vignettes to help you apply what you havelearnt so far and encourages you to measure the changes in your practice. We alsoinclude some suggested answers to the learning activities.

At this event you will work through more detailed case studies and some briefclinical vignettes with your professional colleagues, and discuss your approach to theDirecting change exercise from Book 1. You may be attending a CPPE tutor-ledevent or have arranged to meet with your own CPPE learning community.

Just to remind you, in this unit we consider:

� how pharmacy teams can support other health professionals and patients tooptimise patient outcomes in antibiotic therapy, while minimising harm

� the application of antimicrobial guidelines to ensure appropriate antibacterial use

� the issues of antimicrobial resistance and healthcare-associated infections and how

to reduce their impact

� practical issues relating to antibacterial treatment.

This is to certify that

attended the CPPE focal point event on antibacterials on

Location

CPPE pharmacy tutor signature

CPPE tutor name


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Case studies Time to prepare: 15 minutes to review and answer the questions individually orin small groups.

Time to discuss: 15 minutes to discuss the answers with your colleagues.

Case study 1 – NickNick, a 24-year-old male, presents with a dog bite on his left hand, which occurredtwo days ago. It is now red, hot and exuding pus. It is 1:20pm and he asks themedicines counter assistant for an antiseptic cream and a dressing. He explains thathe is in a hurry as he has parked on a yellow line outside and needs to get back towork. The staff member is a bit concerned at the appearance of the bite and callsyou to take a look.

1. What signs of infection might you see or ask about? What willyou advise?

He returns late on in the day with a prescription for flucloxacillin 250 mg fourtimes a day for seven days.

2. Is this an appropriate choice? What reference sources would youuse?


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Approximately three weeks later, a young woman calls in to return some unusedantibiotics for safe disposal. She explains that her partner stopped taking theseafter a couple of days because he had no pain or redness, so he assumed everythingwas fine. He also believed that he couldn’t take antibiotics and have a few drinks ona night out with friends. You recognise the patient’s name on the medicine as theyoung man with the dog bite.

She explains that as a result of stopping the treatment his hand became so swollenand painful that his GP referred him directly to hospital, and he ended up havingto attend the hospital daily to have antibiotics by injection. He has now had hisfinal injection.

3. In which antibacterials should alcohol be avoided? What are theconsequences of not completing a course of antibiotics?


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Case study 2 – Mrs DuncanMrs Duncan is an 81-year-old lady. She is a customer who has a regularprescription for her rheumatoid arthritis and atrial fibrillation:

� Methotrexate 12.5 mg once weekly

� Prednisolone 7.5 mg daily

� Omeprazole 20 mg daily

� Amiodarone 200 mg daily

� Warfarin 1 mg tablets - taken as directed by anticoagulant clinic

Today she has presented a prescription for doxycycline 200 mg single dose, then100 mg daily for seven days in total.

1. What, if any, concerns do you have?

On questioning, Mrs Duncan tells you that she doesn’t really like to bother her GPbut she has had a bad productive cough for the past week and is feeling generallyunwell compared to her normal self. The doctor said she has a chest infection,possibly pneumonia, and has sent off sputum samples today.



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2. Is this a suitable choice of antibacterial? Would yourecommend an alternative and if so, what?

3. What advice would you give to help her prevent furtherinfection?


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Case study 3 – Mrs DesaiMrs Desai is a 78-year-old lady who regularly attends the pharmacy to collect herprescriptions. Today she brings in a prescription for nitrofurantoin 100 mg fourtimes a day for five days. She complains that she has “another waterworksinfection”. On checking her patient medication record (PMR) you can see that herregular medication is as follows:

� Calceos - two tablets daily

� Alendronate 70 mg once a week

You can also see from the PMR that she has had courses of trimethoprim andcefalexin in the last six months.

She asks if there is anything she can do to prevent the water infections.

1. What questions would you ask her?

2. What advice would you give regarding prevention?


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Mrs Desai tells you that the GP sent off a water sample and he said that the

infection is resistant to the usual antibiotics, so he has given her this one.

3. What, if any, concerns do you have about Mrs Desai usingnitrofurantoin 100 mg four times a day for five days?

4. What counselling points would you give to this patient?



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Clinical vignettesTime to prepare: 15 minutes to review and answer the questions individually orin small groups.

Time to discuss: 15 minutes to discuss the answers with your colleagues.

In this section of focal point, we look at brief clinical scenarios and particularly focuson decision making and communication. Review each of the clinical vignettes andcome up with a suitable response to manage the situation. You may wish to practisethese responses using role play.

Clinical vignette 1

Natalie is a 21-year-old female student on no medication except Mercilon. She hashad a sore throat for six days and her GP has advised that he doesn’t believeantibiotics are indicated at present.

However, the weekend is approaching, so, in line with the practice policy, he has senta prescription to be left for her at the pharmacy. The GP advised that if hersymptoms do not settle in the next three days, she should get the prescriptiondispensed. She presents at your pharmacy the next day and asks to take it now, “justin case I need it and if I don’t, it will be handy to have it for next time”.

How would you respond?

Clinical vignette 2

Janine Stanton presents at the pharmacy with a prescription for cefalexin 500 mgtwice a day for 14 days. She is 15 weeks pregnant and has been prescribed theantibiotic for an “infection in my water”. When counselling Janine about the use ofthe antibiotic, you ask about allergies and she says that she had a “bad reaction” topenicillin previously.

What would your response be?



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Clinical vignette 3

Sonia Pascal has just been to the surgery with her 1-year-old daughter, Matilde, whohas ear ache in both ears, with discharge. She has been given a prescription foribuprofen 50 mg three to four times a day as required and amoxicillin 125 mg threetimes a day for five days. She is not keen on her daughter taking antibiotics, as shehas heard a lot in the press about overuse and is concerned that if Matilde keepstaking courses of antibiotics they will stop working.

How would you explain the idea of antibiotic resistance to Sonia?

Clinical vignette 4

Justin Marshall comes to collect the following prescription, sent from the GP:

� Nasal mupirocin - apply three times a day for five days

� Chlorhexidine body wash daily for five days and as a hair wash on Days 2 and 5.

He has been told that he has to do this before going into hospital for a kneeoperation. Justin is worried about MRSA. How did he get it? Should he have hisoperation?

What would you say to him?



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Directing change Time to prepare: none – you should have done this before the event.

Time to discuss: 15 minutes to discuss your solution with your colleagues.

Revisit your notes in Book 1. Discuss the solutions and ideas you developed withyour colleagues. What would you do differently now as a result of your learning?

You have reached the end of the activities for this focal point event. The remainder ofthis book contains follow-up activities and the suggested answers. You may wish tospend some time after the event looking through these with colleagues.



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After your focal point event: putting yourlearning into practice

Now it’s time to assess your learning, determine your readiness to change and put your new knowledge into practice.



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Putting your learning into practice There are four actions you should undertake to ensure that what you have learnt inthis focal point unit influences your future practice.

1. Work through the practice activities listed below.

2. Evaluate your learning by revisiting the Moving into focus questions.

3. Complete the CPPE online e-assessment.

4. Reflect on the Steps for change outlined on page 18.

1. Practice activities (45 minutes)

You might wish to start to put some of your learning into practice by undertakingthe following activities.

� Source information to help run a campaign, aimed at patients, to supportappropriate use of antibacterials. You may choose to focus on a particular area,such as managing coughs and colds or sore throats.

� Plan and undertake a training session with your pharmacy team to enable them tounderstand the concerns of overuse of antibiotics and antimicrobial resistance sothat they can discuss this with patients.

� Review the counselling that is provided in the pharmacy to patients collectingprescriptions for antibacterials.

When will you complete these activities?

2. Evaluate your learning (15 minutes)

The second step is to revisit the Moving into focus questions.

1. Which antibiotics should be used with caution in a patient who says they areallergic to penicillin?

2. What is the TARGET antibiotics toolkit?

3. List five clinical or biochemical indicators of infection.

4. List three common organisms associated with healthcare-associated infections.

5. List five patient factors that could affect the choice of antibacterial.



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Can you answer these now?

3. Access e-assessment (30 minutes)

The next step in assessing your learning is to access the online e-assessment on ourwebsite.

� Go to: http://www.cppe.ac.uk

� Choose login and complete the login process. If you are a new user you will needto click on register with CPPE, gain your password and follow the instructions tosign up.

� When you have logged in, go to assessment in the top menu bar, click on e-assessment portfolio, and then scroll down to find the e-assessment entitled,Antibacterials focal point.

� Click on the icon and follow the on-screen instructions.

� If you complete the e-assessment successfully you will be able to print your owncertificate of achievement.

When will you access the e-assessment?



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Reflection – steps for change (15 minutes)

The final step is to think about the following statements and note down how you feelabout them. This should help you determine any requirements for your furtherdevelopment.

I have achieved the personal learning objectives that I set myself on page 12 inBook 1.

Strongly disagree Disagree Agree Strongly agree

I have identified additional learning I need to undertake to improve myknowledge of the management of antibacterials.


I would like to follow up a best practice idea expressed by a colleague at the focal

point event/within my learning community.


After reflecting on these statements, what steps will you take now to make themreality?



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Suggested answers to:� Moving into focus questions

� Practice points

� Talking points

� Case studies

� Clinical vignettes

Please remember that these answers aresuggestions only. You should also refer to local guidelines when managing patients’antibacterial therapy.



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These are the authors’ suggested responses to the learning activities and they shouldbe used as a guide during your focal point event. Where possible, use your own localguidelines and policies to inform the discussion and answers. We have provided shortanswers to the questions and case studies and, where appropriate, these are followedby discussion points that provide a little more detail.

Moving into focus 1. Which antibiotics should be used with caution in a patient who says theyare allergic to penicillin?

Penicillins, including those in co-formulations, should not be used in patients withtrue allergy. The nature of the allergy, the timing and the severity of the reactionshould be investigated to confirm true allergy.

Cross reactivity between penicillins and cephalosporins may be lower thanthought and about 0.5-6.5 percent of penicillin-sensitive patients may also beallergic to the cephalosporins.

Discussion points

� The most important side-effect of penicillins is hypersensitivity, which causesrashes and anaphylaxis and can be fatal. Allergic reactions to penicillins occur inone to ten percent of exposed individuals. Anaphylactic reactions occur in fewerthan 0.05 percent of treated patients.1

� The allergic reaction is commonly due to the basic structure of the beta-lactamring or side chain within penicillin. Patients who report an allergic reaction to onetype of penicillin may therefore be allergic to all of them. This includescarbapenems, broad spectrum penicillins (such as amoxicillin and ampicillin) andpenicillinase-resistant penicillins (such as flucloxacillin and temocillin). It alsoincludes penicillins found in co-formulations, for example, co-amoxiclav, Tazocinand Timentin.

� Cross reactivity between penicillins and cephalosporins was believed to beapproximately ten percent. However, Pegler and Healy2 contested this figure as anoverestimate, suggesting the risk is closer to 0.5 percent for first generationcephalosporins, in patients with true penicillin allergy. While the extent of crosssensitivity between penicillins and cephalosporins is under debate and due caremust be taken when using cephalosporins in those with known allergy topenicillins, second and third generation cephalosporins (which have a differentside chain in their structure) can be considered in those where alternativeantibiotics would be suboptimal, provided adequate supervision is provided.1



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2. What is the TARGET antibiotics toolkit?

The TARGET (treat antibiotics responsibly guidance and education tools)antibiotics toolkit provides a central resource of information regarding antibioticprescribing in primary care. It is accessible via the Royal College of GeneralPractitioners (RCGP) website: http://www.rcgp.org.uk/TARGETantibiotics/

The TARGET toolkit, developed by the RCGP, the Health Protection Agency(HPA*) and the Antimicrobial Stewardship in Primary Care (ASPIC) group,with other stakeholders, aims to provide a central resource of informationregarding antibiotic prescribing. (*The HPA transferred functions in April 2013to become part of Public Health England.)

The resources include the quick reference guide, Management of infection guidance

for primary care for consultation and local adaptation.3 This guidance forms thebasis of most local policies and is an invaluable resource. The toolkit also includesa useful patient leaflet, Antibiotic information leaflet, a number of quick referenceguides for specific infections, such as urinary tract infections (UTIs), trainingresources and resources for clinicians.

3. List five clinical or biochemical indicators of infection.

Clinical signs and symptoms of infection

� Fever, aches and pain

� Presence of pus, swelling or redness in the potentially infected site

� Confusion, of new onset, particularly in older people

� Drowsiness, irritability, poor appetite in children

� Worsening renal function

� Changes in blood pressure, heart rate, respiratory rate

Biochemical indicators of infection

� Raised or depressed white blood cells

� Raised neutrophils

� Altered platelet levels

� Raised C-reactive protein

� Raised erythrocyte sedimentation rate



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Discussion point

� We may see patients who are acutely unwell but do not yet have a diagnosis ofinfection. In a community setting we may suspect infection, based on a range ofclinical signs but are unlikely to have access to biochemical tests, which would alsoindicate the likelihood of an infection being present.

4. List three common organisms associated with healthcare-associated

infections.

You could choose any three of the following:

Meticillin-resistant Staphylococcus aureus (MRSA)

Clostridium difficile

Extended-spectrum beta-lactamase (ESBL) producing organisms

AmpC cephalosporinase producing organisms

Glycopeptide-resistant enterococci (GRE)

Discussion points

� A healthcare-associated infection is any infection that is acquired in hospital orfrom a healthcare intervention.

� Public Health England monitors the incidence of some infections throughmandatory and voluntary surveillance schemes. The schemes involve reporting ofbacteraemia caused by Staphylococcus aureus, both meticillin-resistantStaphylococcus aureus (MRSA) and meticillin-sensitive Staphylococcus aureus

(MSSA), Escherichia coli, GRE and Clostridium difficile infection. The number ofreported cases of both MRSA and Clostridium difficile have reduced in recentyears. See section 3.2 of Book 1 for more information.

� Urinary tract infections caused by catheter insertion are one of the most commontypes of healthcare-associated infection leading to overprescribing ofantibacterials. Escherichia coli is the most common causal pathogen.

5. List five patient factors that could affect the choice of antibacterial.

The patient factors that could affect the choice of antibacterial include age,allergies, weight, immune status, renal function, hepatic function, pregnancy orbreastfeeding, previous antibiotic treatment, other conditions, other medicationand available routes of administration.

Revisit sections 2.3, 2.4 and 2.5 of Book 1 to read more about these factors.



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Practice and talking pointsTalking point A

If you were developing a new antibacterial, list the ideal properties youwould like it to have.

What ideal properties would a patient want an antibacterial to have?

We think that the ideal properties for a new antibacterial would be broadspectrum, no development of resistance by bacteria, safe, non-toxic, stable, non-allergenic, low cost, high therapeutic index, no monitoring needed, nointeractions, oral and intravenous forms available, good oral absorption, low riskfor Clostridium difficile.

If you were a patient you may want an antibacterial that works and makes youfeel better, has an easy dose regimen (once or twice a day), tastes nice, worksquickly so you don’t need to take it for too long, has no side-effects and doesn’taffect other medicines.

Discussion point

� In recent years new antibiotics that have been produced have been focused onGram-positive cover, particularly MRSA, but there have been fewer with goodactivity against Gram-negative infections, such as the ESBLs.

Practice point 1

Make a note of the most common infections that you see in your practice.What symptoms do patients describe that would make you consider thatthey have an infection?

This will depend on local variations but the most common infections seen in thecommunity are upper respiratory tract infections, lower respiratory tractinfections, urinary tract infections, gastrointestinal tract infections, skin infections,eye infections and genital tract infections.

Irrespective of the site of infection patients will describe a variety of symptomsthat would make you consider that they have an infection. These could include:

� fever, aches, pain

� presence of pus, swelling, and/or redness in a potentially infected site

� confusion, of sudden onset, particularly in older people

� drowsiness, irritability, poor appetite in children.

Continued on next page



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Also, the duration of symptoms, such as a cough or sore throat, and whether thecondition is improving or deteriorating should be established.

The Antibiotic information leaflet from the TARGET toolkit4 is useful to helppatients know when their condition should be referred.

Practice point 2

Access the Health Protection Agency guideline,

Management of infection guidance for primary care for

consultation and local adaptation:

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCare

Guidance/

What would be recommended for an acute exacerbation of chronicobstructive pulmonary disease (COPD)?

If possible, obtain your local guideline and see whether therecommendation would be any different.

According to the HPA guideline, the following is recommended for an acuteexacerbation of COPD:

� amoxicillin 500 mg three times a day for five days or

� doxycycline 200 mg single dose, then 100 mg daily for five days in total or

� clarithromycin 500 mg twice a day for five days.

If there is resistance, co-amoxiclav 625 mg three times a day for five days issuggested.

Local guidelines may suggest a preference for one of these agents. Localguidelines are most likely to be available from medicines management teamswithin clinical commissioning groups. They are usually based on the HPAguideline but there may be local resistance patterns and other agents may berecommended.


http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/


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Practice point 3

Write down four common drug interactions you see with antibacterials. What action would you take for each?

This will depend on local variation.

Sources of information include appendix 1 in the British National Formulary

(BNF),1 Stockley’s drug interactions,5 or the manufacturer’s summary of productcharacteristics.

Some common drug interactions

Macrolides and simvastatin

Trimethoprim and methotrexate

Metronidazole and alcohol

Macrolides and digoxin

Quinolones also have several drug interactions, eg, theophylline and iron.

The BNF 1 and Stockley’s drug interactions5 provide information on action thatyou could take if you see a possible drug interaction.

It is important to also consider interactions between drugs and disease state, suchas fluoroquinolones in epilepsy.

Discussion points

� Many antibacterials have drug interactions that may lead to antibacterial therapyfailure or increase the risk of an adverse event.

� Revised guidance on oral contraceptives and antibiotics is available from theFaculty of Sexual and Reproductive Healthcare.6 See the discussion points inClinical vignette 1 for more information.



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Talking point B

Clostridium difficile and MRSA have become major infections because ofinappropriate antibacterial use.

Discuss this statement.

Antimicrobial use is considered to be an important contributing factor inselecting for resistant microbes. We know that within a couple of years from thelaunch of a new antimicrobial, resistance starts to develop in the target microbesand inappropriate use of antibiotics affects the resistance pattern of microbes fora community as a whole. Resistance is inevitable but can be reduced byappropriate use of antibacterials.

Inappropriate use includes prescribing antibacterials for non-bacterial infections,not prescribing antimicrobials for infections that require treatment, using a broadspectrum agent instead of a narrow spectrum agent, prescribing for too long ortoo short a duration, prescribing incorrect doses or prescribing via aninappropriate route.

Discussion points

� Microbes develop resistance to antimicrobial agents as soon as they have beendeveloped. The apparent rapidity with which resistance develops is due to therapid reproduction cycle of bacteria. As antibiotics become used more commonly,the incidence of resistance increases.

� The following factors contribute to antimicrobial resistance.

� Patients’ demand for antibiotics for inappropriate infections.

� Failure of patients to complete the prescribed course of antimicrobials.

� General availability of antibiotics without a prescription in some countries.

� Overuse and misuse of antimicrobials in humans, animals and agriculture.

� The use of antimicrobial resistance surveillance and increased awareness of theappropriate use of antibacterials has an impact on reducing the incidence ofhealthcare-associated infections with these organisms.



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Practice point 4

For the next ten patients who present with a prescription for antibiotics,note down the counselling points that you make.

The following points should be discussed with the patient.

Dose

Frequency

Duration

If the medicine should be taken before/with/after food

Possible side-effects and what to do about them

Advice on specific interactions (eg, erythromycin and statins)

Antibacterial-specific points (eg, change in colour of urine or interaction withalcohol).

The patients can also be informed of other measures to control symptoms.

Patients should be informed that prescribed antimicrobials are intended fortheir use only, they should complete the course even if feeling better, theincorrect use of antibacterials can lead to the emergence of resistantorganisms, what to do if an infection does not resolve or recurs, how to reducethe spread of infection.



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Case study 1 – Nick Nick, a 24-year-old male, presents with a dog bite on his left hand, which occurredtwo days ago. It is now red, hot and exuding pus. It is 1:20pm and he asks themedicines counter assistant for an antiseptic cream and a dressing. He explains thathe is in a hurry as he has parked on a yellow line outside and needs to get back towork. The staff member is a bit concerned at the appearance of the bite and callsyou to take a look.

1. What signs of infection might you see or ask about? What willyou advise?

The site of the dog bite appears red, feels hot and is exuding pus.

You may ask about body temperature, pain, whether the condition isworsening. You should observe how far the redness has spread and askif the patient feels generally well.

The area of the bite appears to be infected and requires antibiotictreatment. The patient needs to see the GP as soon as possible andthe hand needs to be looked at, cleaned and dressed.

Discussion points

� Clinical signs of infection include fever, aches, pain, presence of pus, swelling,redness in the potentially infected site, confusion in older people, drowsiness,irritability, poor appetite in children, worsening renal function, and changes inblood pressure, heart rate or respiratory rate.

� It is important to thoroughly irrigate the area following a bite.

� The patient should also be assessed for risk of tetanus and rabies.

He returns late on in the day with a prescription for flucloxacillin 250 mg four timesa day for seven days.



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2. Is this an appropriate choice? What reference sources would youuse?

This is not an appropriate choice.

Co-amoxiclav 375-625 mg three times a day for seven days is therecommended treatment for dog (or human) bites.

The reference sources you could use are the BNF 1 or the HealthProtection Agency guideline, Management of infection guidance for

primary care for consultation and local adaption3 or your localguidelines.

Discussion points

� Co-amoxiclav is recommended for animal bites. The mouths of dogs contain awide range of pathogens, including Gram negatives, Gram positives andanaerobes. A broad spectrum of cover is needed.

� You will need to discuss this prescription with the prescriber. A replacementprescription could be supplied or you may be asked to make a supply at therequest of the prescriber.

� If the patient is allergic to penicillin, metronidazole plus doxycycline is suggested.

� The response to treatment should be reviewed at 24 and 48 hours.

Approximately three weeks later, a young woman calls in to return some unusedantibiotics for safe disposal. She explains that her partner stopped taking these aftera couple of days because he had no pain or redness, so he assumed everything wasfine. He also believed that he couldn’t take antibiotics and have a few drinks on anight out with friends. You recognise the patient’s name on the medicine as theyoung man with the dog bite.

She explains that as a result of stopping the treatment his hand became so swollenand painful that his GP referred him directly to hospital, and he ended up having toattend the hospital daily to have antibiotics by injection. He has now had his finalinjection.



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3. In which antibacterials should alcohol be avoided? What are theconsequences of not completing a course of antibiotics?

A disulfiram-like reaction (flushing, headache, palpitations, nausea,vomiting and breathing difficulties) can occur when alcohol is takenwith metronidazole or tinidazole.1 A cautionary message (such as,'Warning, do not drink alcohol’) should appear on the dispensinglabel and the patient should be counselled accordingly.

There is an increased risk of convulsions with alcohol and cycloserine(used in treatment of tuberculosis).1

The consequences of not completing a course of antibiotics includetreatment failure and the risk of resistant organisms developing.

Discussion points

� Interaction of antibiotics with alcohol is a commonly held belief by the public andmay affect adherence.

� In this case the infection became more serious and more expensive in terms of thepatient’s time and for the NHS as a consequence of the patient not completing thecourse of antibiotic treatment.

� Another consequence of not completing a course of antibacterials would be therisk of resistant organisms developing, which would not respond to the usualtreatment options.

� In some areas outpatient antibacterial treatment (OPAT) may be available via acommunity-based team. Do you know if this is available in your area?



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Case study 2 – Mrs Duncan Mrs Duncan is an 81-year-old lady. She is a customer who has a regularprescription for her rheumatoid arthritis and atrial fibrillation:

� Methotrexate 12.5 mg once weekly

� Prednisolone 7.5 mg daily

� Omeprazole 20 mg daily

� Amiodarone 200 mg daily

� Warfarin 1 mg tablets - taken as directed by anticoagulant clinic

Today she has presented a prescription for doxycycline 200 mg single dose, then100 mg daily for seven days in total.

1. What, if any, concerns do you have?

Does Mrs Duncan have an infection that needs treating? How wouldyou establish that?

This patient is at high risk of infections as she isimmunocompromised.

There is a drug interaction of doxycycline with warfarin andmethotrexate.

Discussion points

� You should initially question Mrs Duncan to see what her diagnosis is and ifcultures were sent for sensitivity.

� If doxycycline is prescribed with warfarin the patient would need to be consideredfor more frequent international normalised ratio (INR) monitoring even thoughthe BNF suggests that this is not a clinically significant interaction.1 There is a riskof increased toxicity when methotrexate is given with doxycycline. This could beavoided by omitting the methotrexate dose for the duration of treatment or byincreasing monitoring. Further information on these interactions and theirsignificance is available in Stockley’s drug interactions.5

On questioning, Mrs Duncan tells you that she doesn’t really like to bother her GPbut she has had a bad productive cough for the past week and is feeling generallyunwell compared to her normal self. The doctor said she has a chest infection,possibly pneumonia, and has sent off sputum samples today.



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2. Is this a suitable choice of antibacterial? Would you recommendan alternative and if so, what?

This could be a lower respiratory tract infection orcommunity-acquired pneumonia.

Doxycycline 200 mg single dose, then 100 mg daily for seven days intotal would be a suitable choice for a lower respiratory tract infectionor community-acquired pneumonia3 in the absence of culture andsensitivity to confirm the infection.

An alternative antibiotic would be amoxicillin 500 mg three times aday for seven days, but this would also have a potential interactionwith warfarin.

Discussion points

� Mrs Duncan has suspected community-acquired pneumonia. Treatment should beguided by NICE clinical guideline 69: Respiratory tract infection – antibiotic

prescribing.7 Cultures and sensitivity will confirm required treatment. This case isan example of when prescribers may need to start empirical treatment beforeconfirmation of infection and sensitivity.

� Antibiotics are of little benefit for acute cough or bronchitis if the patient has noco-morbidity. Symptom resolution can take up to three weeks. According to theNICE clinical guideline 69, immediate antibiotics should be considered if thepatient is over 80 years old and has ONE of the following: hospitalisation in thelast year, is taking oral steroids, has diabetes or congestive heart failure OR if thepatient is over 65 years old with two of the above.7 Mrs Duncan is 81 years oldand is taking oral steroids, so she meets the criteria for treatment.

� CRB65 score is a tool that can be used to assess patients for pneumonia. Each ofthe following scores a point: confusion, respiratory rate above 30/minute, over 65years of age, BP systolic of less than 90 or diastolic less than or equal to 60. If apatient scores 0 they are suitable for home treatment, if they score 1-2 they shouldreceive assessment for hospital admission and a score of 3-4 requires urgenthospital admission.3

� If amoxicillin was prescribed the patient would still need to be considered formore frequent INR monitoring even though the BNF suggests that this is not aclinically significant interaction.1 There is a risk of increased toxicity whenmethotrexate is given with amoxicillin. This could be avoided by omitting themethotrexate dose for the duration of treatment or by increasing monitoring.Further information on interactions and their significance is available in Stockley’s

drug interactions.5



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3. What advice would you give to help her prevent furtherinfection?

Recommend annual influenza vaccination and ensure she has had apneumococcal vaccination.

Discussion point

� Immunisation is an important factor in the prevention of infectious diseases.Patients should be encouraged to receive all relevant immunisations. Furtheradvice on immunisation is available in the BNF 1 or Immunisation against infectious

disease, otherwise known as the Green Book.8



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Case study 3 – Mrs Desai Mrs Desai is a 78-year-old lady who regularly attends the pharmacy to collect herprescriptions. Today she brings in a prescription for nitrofurantoin 100 mg fourtimes a day for five days. She complains that she has “another waterworksinfection”. On checking her patient medication record (PMR) you can see that herregular medication is as follows:

� Calceos - two tablets daily

� Alendronate 70 mg once a week

You can also see from the PMR that she has had courses of trimethoprim andcefalexin in the last six months.

She asks if there is anything she can do to prevent the water infections.

1. What questions would you ask her?

How often do you get the infections?

When was the last time you had one?

What treatment have you taken for them?

Did the previous antibiotics work?

Do you know what might cause or trigger the infections?

What have you tried to prevent recurrence of them?

Discussion point

� The decision to treat an episode of UTI as a single episode or a recurrent UTIwill depend on the frequency, severity and impact of the infections.



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2. What advice would you give regarding prevention?

Confirm appropriate use of previous antibiotic treatments – was thecourse completed, were urine samples provided?

Lifestyle factors, such as increasing water intake, changing hygienemeasures and consuming cranberry products, may help.

An infection diary may be useful to identify triggers.

Prophylactic antibiotics can be used if necessary – see discussionpoint below.

Discussion points

� Long-term low-dose daily prophylaxis may be needed in some patients to preventrecurrent UTIs. It should be considered in patients with three or more UTIs in ayear. Nitrofurantoin 50-100 mg at night or trimethoprim 100 mg at night are usedfor prophylaxis.3

� A Cochrane review suggests that continuous prophylaxis for 6-12 months reducesthe rate of UTIs during prophylaxis, compared to placebo (numbers needed totreat = two), but side-effects include vaginal and oral candidiasis andgastrointestinal symptoms.9

� According to the NICE clinical knowledge summary on lower UTIs in women,there is insufficient evidence to recommend urine alkalinising agents or cranberryproducts for relief of symptoms. Pain can be controlled with paracetamol oribuprofen. Cranberry products with over 200 mg cranberry extract can reduce therecurrence rate of cystitis.10

� Without antibiotics, symptoms can be expected to resolve in 4-9 days. Antibioticsreduce this by about one day.10

Mrs Desai tells you that the GP sent off a water sample and he said that theinfection is resistant to the usual antibiotics, so he has given her this one.



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3. What, if any, concerns do you have about Mrs Desai usingnitrofurantoin 100 mg four times a day for five days?

Nitrofurantoin should be used with caution in patients with renalimpairment, which declines with age. It should be avoided if MrsDesai’s estimated glomerular filtration rate (eGFR) is less than60ml/minute.

In acute, uncomplicated UTIs, 50 mg every six hours for three daysshould be sufficient. This can be increased to seven days if previoustreatments have failed.

The microbes causing Mrs Desai's infection could be resistant tonitrofurantoin – sensitivity should have been confirmed withmicrobiology.

Discussion points

� It is difficult to predict a patient’s renal function. You could ask the patientwhether they have been told of any problems with their kidneys or contact the GP.

� Nitrofurantoin will be ineffective if eGFR is less than 60 ml/minute because ofinadequate urine concentrations.

� Other options, if eGFR is less than 60ml/minute, include pivmecillinam (penicillinallergy), ciprofloxacin (Clostridium difficile risk, tendinopathy, cardiac risk),fosfomycin (unlicensed medicine - given as a single oral dose).

� Prevalence of ESBL producing organisms causing UTIs is increasing. They areresistant to most common antibiotics, eg, trimethoprim, penicillins,cephalosporins, fluoroquinolones, and often only respond to a cephalosporin andfosfomycin or sometimes nitrofurantoin or an aminoglycoside.

� Bacteria in a patient prescribed an antibiotic for a UTI can develop resistance tothat antibiotic, which can persist for up to 12 months after treatment.11

� The HPA’s guideline recommends treating UTIs with nitrofurantoin 100 mgmodified release taken twice a day, rather than nitrofurantoin 50 mg four times aday.3 This regimen may also improve compliance.

You decide to check the prescription with the GP before dispensing. The GPconfirms that the patient’s renal function is fine (eGFR is 65 ml/minute) and themicrobiology showed that the organism was resistant to trimethoprim and cefalexinbut sensitive to nitrofurantoin. You suggest reducing the course to three days and theGP agrees, as it is a couple of months since her previous UTI.



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4. What counselling points would you give to this patient?

You should give Mrs Desai the following advice.

� Complete the course.

� Take after food to reduce nausea.

� The medicine can change the colour of urine (yellow or brown).

� Increase water intake.

� Try other lifestyle changes (discussed above).

� Keep an infection diary and return to GP if infection does not clearor recurs.

Discussion point

� It should be noted that nitrofurantoin is only suitable for lower UTIs (ie, cystitis)and not upper UTIs or pyelonephritis.



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Clinical vignettesClinical vignette 1

Natalie is a 21-year-old female student on no medication except Mercilon. She hashad a sore throat for six days and her GP has advised that he doesn’t believeantibiotics are indicated at present.

However, the weekend is approaching, so, in line with the practice policy, he has senta prescription to be left for her at the pharmacy. The GP advised that if hersymptoms do not settle in the next three days, she should get the prescriptiondispensed. She presents at your pharmacy the next day and asks to take it now, “justin case I need it and if I don’t, it will be handy to have it for next time”.

How would you respond?

The bottom lineSore throat due to a viral or bacterial cause is self-limiting and would normallyresolve in a week in the majority of people. Natalie should wait until the specifiedtime has passed unless her condition has deteriorated. She should not take theantibiotics for future use as the antibacterial may not be appropriate for theinfection.

Why? Delayed prescriptions are used as part of a strategy to reduce inappropriate useof antibiotics but they should only be dispensed when a patient’s condition is notimproving or deteriorates within a certain time.

Supporting the statements

� Sore throat due to a viral or bacterial cause is a self-limiting condition. Symptomsresolve within three days in 40 percent of people and within one week in 85 percentof people, irrespective of whether or not the sore throat is due to a streptococcalinfection.12

� Group A beta-haemolytic streptococcus (GABHS) is the most common bacterialcause of sore throat. The Centor criteria can be used to help predict bacterialinfection in people with acute sore throat (GABHS). The four criteria used are:history of fever, presence of tonsillar exudate, tender anterior cervicallymphadenopathy or lymphadenitis, and absence of cough. If a patient presents withthree or four of these clinical signs, this is suggestive of GABHS (40-60 percentchance) and the patient may benefit from treatment with antibiotics. The absence ofthree or four of these suggests that the patient is unlikely to have a bacterial infectionand antibiotic treatment is unlikey to be necessary.12



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� Delayed antibiotic prescriptions are part of a strategy to reduce the use of antibiotics,while allowing patients whose conditions do not improve to obtain antibiotics withouthaving to return to see the prescriber. Usually a patient would be advised to use theantibiotic prescription only if their condition has deteriorated within three days or notimproved after three days. This can be done by post-dating a prescription andkeeping it at the surgery or pharmacy, or giving a prescription to the patient withinstructions to have it dispensed at a later date.

� Revised guidance on interaction between oral contraceptives and antibacterials hasbeen produced by the Faculty of Sexual and Reproductive Health, at the RoyalCollege of Obstetricians and Gynaecologists. The recommendation is that noadditional contraceptive precautions are required when combined oral contraceptivesare used with antibacterials that do not induce liver enzymes, unless diarrhoea orvomiting occurs. Antibacterials that are enzyme inducers are rifampicin-like drugs(eg, rifampicin, rifabutin).6



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Clinical vignette 2

Janine Stanton presents at the pharmacy with a prescription for cefalexin 500 mgtwice a day for 14 days. She is 15 weeks pregnant and has been prescribed theantibiotic for an “infection in my water”. When counselling Janine about the use ofthe antibiotic, you ask about allergies and she says that she had a “bad reaction” topenicillin previously.

What would your response be?

The bottom lineHypersensitivity reactions are rare and you need to question the patient to findout whether she had a true allergic reaction previously. Ask Janine to describe thereaction and the timing of the reaction in relation to starting penicillin. If a patienthas had a hypersensitivity reaction to penicillin, there is a possibility ofhypersensitivity to other cephalosporins but the incidence of cross sensitivity isnot as high as previously thought.

Why?Hypersensitivity reactions are rare and the patient may have had a side-effectsuch as diarrhoea, which they describe as an allergy. If the patient has a truehypersensitivity, penicillin should be avoided.

About 0.5-6.5 percent of penicillin-sensitive patients will also be allergic tocephalosporins.1 Patients with a history of immediate hypersensitivity to penicillinshould not receive a cephalosporin, unless essential because an alternativeantibacterial is not available. See below for further information.


� Symptoms suggestive of a true hypersensitivity reaction include rash, breathingdifficulties, drop in blood pressure, swelling in the throat or tongue. Patients with ahistory of a minor rash or a rash that occurs more than 72 hours after penicillinadministration are probably not allergic.1

� Some cephalosporins are more likely to have cross sensitivity with penicillin. If apatient has had a hypersensitivity reaction to penicillin and a cephalosporin isessential because a suitable alternative is not available, cefixime, cefotaxime,ceftazidime, ceftriaxone or cefuroxime can be used with caution. The firstgeneration (cefalexin, cefradine, cefadroxil) and second generation (cefaclor)cephalosporins should be avoided.1



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� Alternative suggestions for the prescriber could be nitrofurantoin or trimethoprim,both for seven days. Sensitivity should be checked with a mid-stream urinesample. If trimethoprim is used in the first trimester, a folic acid supplementshould be given and trimethoprim should not be given if the patient has a lowfolate status or is taking a folate antagonist, such as antiepileptics. Amoxicillin is analternative if the organism is sensitive, but should not be used in this patient dueto penicillin allergy.3

� A seven-day course is important to treat a UTI in pregnancy.



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Clinical vignette 3

Sonia Pascal has just been to the surgery with her 1-year-old daughter, Matilde, whohas ear ache in both ears, with discharge. She has been given a prescription foribuprofen 50 mg three to four times a day as required and amoxicillin 125 mg threetimes a day for five days. She is not keen on her daughter taking antibiotics, as shehas heard a lot in the press about overuse and is concerned that if Matilde keepstaking courses of antibiotics they will stop working.

How would you explain the idea of antibiotic resistance to Sonia?

The bottom lineReassure Sonia that if Matilde needs to take an antibiotic for an infection that isfine – her symptoms meet the criteria for treatment. Explain that bugs try tosurvive by changing to stop antibiotics killing them, but she can take simple stepsto reduce incidence of this by giving Matilde her medicine regularly, as directedand finishing the course, even if she appears to feel better.

Why?There is a balance between patients requesting antibiotics when not required andreceiving appropriate treatment when needed.

Organisms try to survive by changing to stop antibiotics killing them. If a patientuses antibiotics appropriately the risk of resistant organisms developing isreduced. Discussing this with the patient is key.


� Guidelines and sensitivity advice should be followed by prescribers to decide whento treat and which antibacterial to use. This meets HPA guidance for treatment, asthe patient is under 2 years old and has bilateral acute otitis media.3 The choice ofantibiotic, dose and duration of treatment are appropriate.

� Chronic ear infections can lead to hearing loss, which if prolonged, can result indelay of language development in children.13

� Counsel the patient (or parent) to ensure antibiotics are used appropriately: takethe antibiotic regularly as directed, finish the course even if you feel better orsymptoms resolve, discard unused antibiotics (for example if you need to changefollowing side-effects or sensitivity reports), do not use out-of-date antibiotics, donot take antibiotics that have been prescribed for someone else.3

� The booklet, When should I worry? - Your guide to coughs, colds, earache and sore

throats, is available as part of the TARGET toolkit and is useful for parents.4



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Clinical vignette 4

Justin Marshall comes to collect the following prescription, sent from the GP:

� Nasal mupirocin - apply three times a day for five days

� Chlorhexidine body wash daily for five days and as a hair wash on Days 2 and 5.

He has been told that he has to do this before going into hospital for a kneeoperation. Justin is worried about MRSA. How did he get it? Should he have hisoperation?

What would you say to him?

The bottom lineMRSA is just a normal skin organism that happens to be resistant to some usualantibiotics. It can be picked up from other people. Using these products, asprescribed, before going into hospital will reduce the risk of post-operativeinfection. Prophylactic antibiotics, eg, teicoplanin, will also be given at the start ofsurgery.

Why?Pre-operative suppression reduces the bacterial load to minimal levels during thesurgical period, although it will return. MRSA is often spread amongst families(and pets). The incidence is less than 2 percent in the general population but upto 10-20 percent in residential homes. There are varying levels of mupirocinresistance and there will be local processes for reporting this.


� Patients who are admitted to hospital for elective surgery are usually swabbed tosee if they are colonised with MRSA. If patients are found to have MRSA, asuppression regimen is given prior to surgery and involves topical/nasal antibioticointments (mupirocin) and washes and shampoos (chlorhexidine). Proper use ofthe suppression regimen is needed. It is important to leave the chlorhexidine,undiluted, on the skin for at least one minute before rinsing it off. Finish theregimen the night before surgery. Povidone or triclosan and other alternatives tochlorhexidine may be used in local guidelines.

� Regimens aim to reduce MRSA to below detection level at the time of risk todecrease the chance of infection and spread. Suppression should take place in thefive days leading up to the surgery.

� For further information see the HPA guide, Meticillin-resistant Staphylococcus

aureus (MRSA) screening and suppression quick reference guide for primary care – for

consultation and local adaptation, available from: www.hpa.org.uk



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References1. Joint Formulary Committee. British National Formulary 66. London: Pharmaceutical Press;

2013.

2. Pegler S and Healy B. In patients allergic to penicillin, consider second and third generationcephalosporins for life threatening infections. BMJ 2007;335: 991.

3. Health Protection Agency. Management of infection guidance for primary care for consultationand local adaptation. Health Protection Agency. Revised: 2012.http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance

4. Royal College of General Practitioners et al. TARGET antibiotic toolkit. http://www.rcgp.org.uk/TARGETantibiotics/

5. Baxter K and Preston C. Stockley’s drug interactions. Tenth edition. London: PharmaceuticalPress; 2013.

6. Faculty of Sexual and Reproductive Healthcare. Drug interactions with hormonalcontraception. Faculty of Sexual and Reproductive Healthcare. Updated: 2012.

7. National Institute for Health and Clinical Excellence. Clinical guideline 69: Respiratory tractinfections – antibiotic prescribing: prescribing of antibiotics for self-limiting respiratory tractinfections in adults and children in primary care. 2009.http://publications.nice.org.uk/respiratory-tract-infections-antibiotic-prescribing-cg69

8. Salisbury D et al (Editors). Immunisation against infectious disease. Department of Health.2013

9 Albert X et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnantwomen. The Cochrane Database of Systematic Reviews 2004;(3): CD001209. http://www.ncbi.nlm.nih.gov/pubmed/15266443

10. National Institute for Health and Clinical Excellence. Clinical knowledge summaries: urinarytract infection (lower) – women. http://cks.nice.org.uk/urinary-tract-infection-lower-women#!topicsummary

11. Costelloe C et al. Effect of antibiotic prescribing in primary care on antimicrobial resistancein individual patients: systematic review and meta-analysis. BMJ 2010;340: c2096.http://www.bmj.com/content/340/bmj.c2096

12. National Institute for Health and Clinical Excellence. Clinical knowledge summaries: sore throat– acute, management. http://cks.nice.org.uk/sore-throat-acute#!topicsummary

13. National Institute for Health and Clinical Excellence. Clinical knowledge summaries: otitismedia – acute. http://cks.nice.org.uk/otitis-media-acute#!scenario:1



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