F1 Microbiology SessionF1 Microbiology Session

Matt RogersMatt Rogers

Consultant MicrobiologistConsultant Microbiologist

August 2009August 2009

Session PlanSession Plan

Brief InductionBrief Induction Prescribing an antibioticPrescribing an antibiotic Antibiotic PolicyAntibiotic Policy Infection Control HighlightsInfection Control Highlights

Microbiology Services 1Microbiology Services 1 Pathology Dept 4Pathology Dept 4thth Floor West Wing Floor West Wing

BacteriologyBacteriology VirologyVirology ParasitologyParasitology MycologyMycology EnvironmentalEnvironmental

See pathology handbook for service detailsSee pathology handbook for service details Lab opening hours 8am-7pm for examination of Lab opening hours 8am-7pm for examination of

routine specimens (9am-11.30am Saturday)routine specimens (9am-11.30am Saturday) Specimens should be at transport collection Specimens should be at transport collection

points no later than 4.30pm Rugby and 5.30pm points no later than 4.30pm Rugby and 5.30pm Walsgrave to be processed that day, 10am on Walsgrave to be processed that day, 10am on SaturdaySaturday

Microbiology Services 2Microbiology Services 2 Urgent specimens should be notified to the lab Urgent specimens should be notified to the lab

in normal hours and labelled EMERGENCY in normal hours and labelled EMERGENCY SPECIMEN, forward ASAP to Path reception SPECIMEN, forward ASAP to Path reception UHCW or Specimen Reception RugbyUHCW or Specimen Reception Rugby

EMERCENCY SERVICE out of hoursEMERCENCY SERVICE out of hours Technical advice/specimen processingTechnical advice/specimen processing Please contact switchboard and ask to speak to Please contact switchboard and ask to speak to

Microbiology Biomedical Scientist on callMicrobiology Biomedical Scientist on call ResultsResults

CRRS should be used to review results in the first CRRS should be used to review results in the first instanceinstance

Bacteriology Bacteriology x25428x25428 VirologyVirology x25468x25468

Clinical serviceClinical service Clinical adviceClinical advice

Normal hoursNormal hours UHCW 25446/x25487UHCW 25446/x25487 GE 5325GE 5325 SWH 4227SWH 4227 Ask to speak to a MedicAsk to speak to a Medic Out of HoursOut of Hours Contact duty Medical Microbiologist via switch (24hrs Contact duty Medical Microbiologist via switch (24hrs

365 days/year)365 days/year) Ward roundsWard rounds

UHCW/SWH/GEHUHCW/SWH/GEH Conduct daily ward rounds Mon-Fri on GCC/ITUConduct daily ward rounds Mon-Fri on GCC/ITU UHCW includes Cardiothoracic Critical Care, also follow UHCW includes Cardiothoracic Critical Care, also follow

up review requests on other wardsup review requests on other wards

GentamicinGentamicin Levels done round the clock by Levels done round the clock by

BiochemistryBiochemistry Dose of Gent in this Trust is 5mg/kg od Dose of Gent in this Trust is 5mg/kg od

iv (Lean Body Mass)iv (Lean Body Mass) 24hrly if CC >61ml/min24hrly if CC >61ml/min 36hrly if CC 41-60 ml/min36hrly if CC 41-60 ml/min 48hrly if CC 21-40 ml/min48hrly if CC 21-40 ml/min Check a random level at 48hr if CC <21 Check a random level at 48hr if CC <21

ml/minml/min Check level before 2Check level before 2ndnd or 3 or 3rdrd dose should be dose should be

less than 1mg/lless than 1mg/l

VancomycinVancomycin

Levels done round the clock by Levels done round the clock by BiochemistryBiochemistry

Standard adult dose 1g bd ivStandard adult dose 1g bd iv If CC normal 1g bdIf CC normal 1g bd If CC 50ml/min give 1g 24hrlyIf CC 50ml/min give 1g 24hrly If CC 25ml/min give 1g 48hrlyIf CC 25ml/min give 1g 48hrly Check pre dose level before 4Check pre dose level before 4thth or 5 or 5thth

dosedose Pre dose levels should be 12-15mg/lPre dose levels should be 12-15mg/l

Diseases notifiable (to Local Authority Proper Diseases notifiable (to Local Authority Proper Officers) under theOfficers) under the

Public Health (Infectious Diseases) Public Health (Infectious Diseases) Regulations 1988Regulations 1988

Health Protection Agency Unit Contact number Health Protection Agency Unit Contact number 01926 493491 x30701926 493491 x307

Outside normal hours please contact switch and ask Outside normal hours please contact switch and ask them to put you through to the Public Health Doctor on them to put you through to the Public Health Doctor on callcall

Do not hesitate to contact either the Public Health Do not hesitate to contact either the Public Health Doctor on call, or On call Medical Microbiologist if Doctor on call, or On call Medical Microbiologist if further advice is required further advice is required

Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery FoodAcute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Foodpoisoning Leptospirosis Malaria Measles Meningitis (poisoning Leptospirosis Malaria Measles Meningitis (meningococcal pneumococcal meningococcal pneumococcal

haemophilushaemophilusInfluenzae viral other specifiedunspecified)Influenzae viral other specifiedunspecified) Meningococcal septicaemia (without Meningococcal septicaemia (without

meningitis) meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever

RubellaRubellaScarlet fever Smallpox Tetanus Scarlet fever Smallpox Tetanus TuberculosisTuberculosis Typhoid fever Typhus fever Viral Typhoid fever Typhus fever Viralhaemorrhagic fever Viral hepatitis haemorrhagic fever Viral hepatitis Hepatitis A Hepatitis B Hepatitis C other Hepatitis A Hepatitis B Hepatitis C other WhoopingWhoopingcough Yellow fever Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Deptcough Yellow fever Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Dept

TBTB

Increased burden of TBIncreased burden of TB Several Cases of TB in Trust have been Several Cases of TB in Trust have been

undiagnosed for a period of time leading undiagnosed for a period of time leading to large look back exercisesto large look back exercises

Suspicion of/or confirmed TB MUST be Suspicion of/or confirmed TB MUST be notified to Health Protection Agency Unitnotified to Health Protection Agency Unit

Please contact Infection Control Please contact Infection Control immediately and isolate the patientimmediately and isolate the patient

Complete form found on Intranet under Complete form found on Intranet under Clinical Support>TB data collectionClinical Support>TB data collection

Antibiotic PolicyAntibiotic Policy

Is the antibiotic policy Is the antibiotic policy relevant 1relevant 1

Yes!Yes! Core policy in The Health Act 2006: Code of Core policy in The Health Act 2006: Code of

practice for the prevention and control of practice for the prevention and control of healthcare associated infectionshealthcare associated infections

Minimise the use of broad spectrum antibioticsMinimise the use of broad spectrum antibiotics Longer the hospital stay, greater chance of Longer the hospital stay, greater chance of

acquisition of HAIacquisition of HAI Ensure only those needing antibiotics receive Ensure only those needing antibiotics receive

them and that they get the appropriate durationthem and that they get the appropriate duration Minimise the use of iv antibioticsMinimise the use of iv antibiotics Iv/oral switch a central strategyIv/oral switch a central strategy Certain antibiotics are associated with particular Certain antibiotics are associated with particular

HAIsHAIs

Is the antibiotic policy Is the antibiotic policy relevant 2relevant 2

C.difficileC.difficile Cefuroxime clearly Cefuroxime clearly

associated with associated with C.difficileC.difficile Trusts that have abolished Trusts that have abolished

its use have seen dramatic its use have seen dramatic reduction in rates (Stoke reduction in rates (Stoke Mandeville)Mandeville)

Other antibiotics such as Other antibiotics such as ciprofloxacin have been ciprofloxacin have been associated with Outbreaksassociated with Outbreaks

MRSA/ESBLsMRSA/ESBLs Ciprofloxacin usage is Ciprofloxacin usage is

related to selection of related to selection of resistant organismsresistant organisms

Evidence of antibiotic Evidence of antibiotic prescribing problems prescribing problems

within the trustwithin the trust Antibiotic audit evidenceAntibiotic audit evidence C.difficile rates need to be reducedC.difficile rates need to be reduced Pharmacy monitoring continues to Pharmacy monitoring continues to

show use of antibiotics outside of the show use of antibiotics outside of the Hospitals Antibiotic PolicyHospitals Antibiotic Policy

MAU AuditMAU AuditZoe Campbell F2 SHOZoe Campbell F2 SHO

Only those with Severe Only those with Severe pneumonia according pneumonia according to CURB criteria should to CURB criteria should receive IV antibioticsreceive IV antibiotics

18 out of 25 patients 18 out of 25 patients received IV antibioticsreceived IV antibiotics

18 patients were 18 patients were classified mild/mod (? classified mild/mod (? Oral antibiotics)Oral antibiotics)

7 patients were 7 patients were classified severe (? IV classified severe (? IV antibiotics)antibiotics)

I.V.

Oral

Mild/mod

Sev

MAU Audit: IV/Oral MAU Audit: IV/Oral SwitchSwitch

Only 2 out of 25 Only 2 out of 25 (8%) patients had (8%) patients had an IV to oral an IV to oral switch or a switch or a review/stop date review/stop date specified on initial specified on initial clerkingclerking

No date specified

Date specified

Current HAI impactCurrent HAI impact MRSAMRSA

Impact on patients quality of life of an acquired Impact on patients quality of life of an acquired infection can be hugeinfection can be huge

Associated with significant morbidity/mortalityAssociated with significant morbidity/mortality Trust performance managed on MRSA bacteraemia Trust performance managed on MRSA bacteraemia

figuresfigures Clostridium difficileClostridium difficile

Impact on patients quality of life of an acquired Impact on patients quality of life of an acquired infection can be hugeinfection can be huge

Associated with significant morbidity/mortalityAssociated with significant morbidity/mortality 40 cases/month at £4500 each can cost Trust up to 40 cases/month at £4500 each can cost Trust up to

£180,000/month£180,000/month Trust now performance managed on C.difficile figuresTrust now performance managed on C.difficile figures PCTexpect a 20% reduction in rate in C.difficile PCTexpect a 20% reduction in rate in C.difficile

New policyNew policy This evidence made it clear that we This evidence made it clear that we

needed a new fit for purpose policyneeded a new fit for purpose policy

Key PrinciplesKey Principles Evidence based policyEvidence based policy Improve guidance on diagnosis of Improve guidance on diagnosis of

infection, specimen collection etc.infection, specimen collection etc. Improve guidance on when to use Improve guidance on when to use

of oral or iv antibioticsof oral or iv antibiotics Improve guidance on iv to oral Improve guidance on iv to oral

switchswitch Provide guidance on duration of Provide guidance on duration of

treatmenttreatment

Key antibiotic changesKey antibiotic changes Stop use of cefuroxime throughout the TrustStop use of cefuroxime throughout the Trust

Use lower risk augmentin (but monitor Use lower risk augmentin (but monitor C.difficileC.difficile rates)rates)

Reduce use of ciprofloxacin (consider penicillin Reduce use of ciprofloxacin (consider penicillin allergy)allergy)

Antibiotic policy available under Clinical Antibiotic policy available under Clinical Guidelines on the intranetGuidelines on the intranet

Antibiotic guideline credit cards distributedAntibiotic guideline credit cards distributed

Cefuroxime Spend by UHCW NHS Trust

£0

£500

£1,000

£1,500

£2,000

£2,500

£3,000Ap

r-07

May-

07

Jun-

07

Jul-0

7

Aug-

07

Sep-

07

Oct-0

7

Nov-

07

Dec-

07

Jan-

08

Feb-

08

Mar-0

8

Apr-0

8

May-

08

Jun-

08

Jul-0

8

Aug-

08

Sep-

08

Oct-0

8

Nov-

08

Dec-

08

Jan-

09

Feb-

09

Mar-0

9

Apr-0

9

May-

09

Jun-

09

Jul-0

9

Aug-

09

Sep-

09

Oct-0

9

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar-1

0

Expe

nditu

re

Diagnostics and Service Division

Medicine and Emergency Division

Rugby St Cross

Specialised Networks Division

Surgery Division

TRUST TOTAL

Total Oral Ciprofloxacin spend by UHCW NHS Trust(Includes inpatient, TTO & outpatient issues)

£0

£100

£200

£300

£400

£500

£600

£700Ap

r-07

May-

07

Jun-

07

Jul-0

7

Aug-

07

Sep-

07

Oct-0

7

Nov-

07

Dec-

07

Jan-

08

Feb-

08

Mar-0

8

Apr-0

8

May-

08

Jun-

08

Jul-0

8

Aug-

08

Sep-

08

Oct-0

8

Nov-

08

Dec-

08

Jan-

09

Feb-

09

Mar-0

9

Apr-0

9

May-

09

Jun-

09

Jul-0

9

Aug-

09

Sep-

09

Oct-0

9

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar-1

0

Expe

nditu

re

Diagnostics and Service Division

Medicine and Emergency Division

Rugby St Cross

Specialised Networks Division

Surgery Division

TRUST TOTAL

Oral Ciprofloxacin Costs for inpatient use at UHCW NHS Trust

£0

£25

£50

£75

£100

£125

£150

£175

£200

£225

£250Ap

r-07

May

-07

Jun-

07

Jul-0

7

Aug-

07

Sep-

07

Oct

-07

Nov-

07

Dec-

07

Jan-

08

Feb-

08

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-

08

Sep-

08

Oct

-08

Nov-

08

Dec-

08

Jan-

09

Feb-

09

Mar

-09

Apr-0

9

May

-09

Jun-

09

Jul-0

9

Aug-

09

Sep-

09

Oct

-09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar

-10

Expe

nditu

re

Ciprofloxacin Suspension 250mg/5ml

Ciprofloxacin Tablets 250mg

Total IV Ciprofloxacin Spend by UHCW NHS Trust

£0

£100

£200

£300

£400

£500

£600

£700Ap

r-08

May-

08

Jun-

08

Jul-0

8

Aug-

08

Sep-

08

Oct-0

8

Nov-

08

Dec-

08

Jan-

09

Feb-

09

Mar-0

9

Apr-0

9

May-

09

Jun-

09

Jul-0

9

Aug-

09

Sep-

09

Oct-0

9

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar-1

0

Expe

nditu

re

Diagnostics and Service Division

Medicine and Emergency Division

Rugby St Cross

Specialised Networks Division

Surgery Division

TRUST TOTAL

Antibiotic prescribingAntibiotic prescribingWhat’s important?What’s important?

WhenWhen Is there an infection?Is there an infection?

HowHow To diagnose. What specimens?To diagnose. What specimens?

WhyWhy What is the indication/Likely pathogens?What is the indication/Likely pathogens?

WhatWhat What antibiotic/route/durationWhat antibiotic/route/duration

When?When?

Diagnosing infection is a CLINICAL skillDiagnosing infection is a CLINICAL skill ““Hello it’s the SHO here I’ve got this pt, Hello it’s the SHO here I’ve got this pt,

could you tell me if they have an could you tell me if they have an infection”infection”

Basic signs and symptoms of infectionBasic signs and symptoms of infection Please remember apart from sterile Please remember apart from sterile

sites (urine/csf/blood etc) most areas sites (urine/csf/blood etc) most areas you culture WILL grow bacteriayou culture WILL grow bacteria

When not to ‘classics’When not to ‘classics’

CSU-urine cloudyCSU-urine cloudy Chest-we think they’ve got CCF but Chest-we think they’ve got CCF but

thought we’d give some coverthought we’d give some cover Wound with serous exudateWound with serous exudate Sloughy UlcersSloughy Ulcers Isolated spikes of tempIsolated spikes of temp To treat a high WCCTo treat a high WCC

How?How?

How to diagnose Infection???How to diagnose Infection??? What specimens do you need to What specimens do you need to

take?take? What investigations do you need to What investigations do you need to

ask for?ask for?

Why?Why?

Know your basic MicrobiologyKnow your basic Microbiology The indication (UTI/LRTI etc)The indication (UTI/LRTI etc) The setting (Pt+environment)The setting (Pt+environment)

Hospital v Community (feasibility)Hospital v Community (feasibility) Why are we giving AntibioticsWhy are we giving Antibiotics

Empirical/Prophylactic/TargetedEmpirical/Prophylactic/Targeted The likely pathogens (CRRS)The likely pathogens (CRRS)

What?What?

Where, When and Why have been Where, When and Why have been addressedaddressed

Now What is the Most appropriate choice Now What is the Most appropriate choice of therapyof therapy Pharmacokinetics/Interactions/Allergy/Side Pharmacokinetics/Interactions/Allergy/Side

effectseffects What routeWhat route What durationWhat duration

5-7 days for MOST infections5-7 days for MOST infections What outcome expectedWhat outcome expected

Also How much?Also How much?

Unfortunate but Healthcare Unfortunate but Healthcare economics are always a economics are always a considerationconsideration

Particularly with some newer drugsParticularly with some newer drugs AntifungalsAntifungals AntibacterialsAntibacterials AntiviralsAntivirals

What must an antibiotic What must an antibiotic prescription include?prescription include?

Must be documented with review Must be documented with review dates in the patients notesdates in the patients notes

Length of course or a Review dateLength of course or a Review date (all i/v antibiotics must be reviewed at 48 hours (all i/v antibiotics must be reviewed at 48 hours

and changed to oral where clinically appropriate)and changed to oral where clinically appropriate) IndicationIndication All antibiotics must be reviewed All antibiotics must be reviewed

dailydaily

A few casesA few cases

Case 1Case 1

Case OneCase One A 65 year old lady admitted 10 days A 65 year old lady admitted 10 days

ago with a Community Acquired ago with a Community Acquired Pneumonia has had 10 days of IV Pneumonia has had 10 days of IV Amoxicillin 1g tds.Amoxicillin 1g tds.

Now presents with cellulitis around Now presents with cellulitis around venflon site.venflon site.

Case 2Case 2

Case TwoCase Two A 72 year old lady presenting to A 72 year old lady presenting to

MAU with confusionMAU with confusion Says she has previous history of Says she has previous history of

UTIsUTIs

Case 3Case 3

Case ThreeCase Three A 17 year old male University A 17 year old male University

student presenting to GP then the student presenting to GP then the Emergency Department with Emergency Department with Meningitis (non-blanching rash / Meningitis (non-blanching rash / headache /photophobia)headache /photophobia)

Case 4Case 4

Case FourCase Four A 32 year old female IVDU A 32 year old female IVDU

presenting with Groin abscess and presenting with Groin abscess and new heart murmurnew heart murmur

Case 5Case 5

Case FiveCase Five A year old man treated on W12 for a A year old man treated on W12 for a

mild pneumonia with Co-amoxiclav mild pneumonia with Co-amoxiclav and erythromycinand erythromycin

Develops diarrhoea ?C.difficileDevelops diarrhoea ?C.difficile

Handwashing auditHandwashing audit

Conducted by F1/F2s last yearConducted by F1/F2s last year Covert observation of handwashing Covert observation of handwashing

practices on ward roundspractices on ward rounds Noting Hand decontamination Noting Hand decontamination

procedures between each patient procedures between each patient visitvisit

The resultsThe results Contact and correct HDCContact and correct HDC

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1 2 3 4 5 6 7 8 9

10

11

12

13

14

15

16

17

18

19

20

Me

an

Clinical Team

Results: SpecialityResults: Speciality

Contact and Contact and correct HDCcorrect HDC

Patient Patient contact and contact and any HDCany HDC

Medicine Medicine (432)(432) 39.2%39.2% 82.9%82.9%

Surgery (156)Surgery (156) 9.6%9.6% 64.9%64.9%

Others (82)Others (82) 52.4%52.4% 89.7%89.7%

Results: GradeResults: Grade

Contact and Contact and correct HDCcorrect HDC

Patient Patient contact and contact and any HDCany HDC

Consultants Consultants (429)(429) 36.1%36.1% 80.9%80.9%

Junior Staff Junior Staff (241)(241) 31.2%31.2% 72.0%72.0%