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Audit of adherence to NICE Clinical Guideline 64 - "Prophylaxis against infective endocarditis" in adult gastroscopy in Sheffield
e86 bacteria were the causative organism in 42% of episodes. This was higher than previously anticipated. No fungi, vancomycin resistant Enterococci nor extended spectrum beta-lactamase producing bacteria were found. MRSA caused 4 episodes of bacteraemia, identical to the previous evaluation, all of which were resistant to ciprofloxacin.
Abstracts the relevant periods were identified using the Infoflex database of endoscopic procedures. Case notes of those receiving prophylaxis were reviewed to establish the indication for antibiotics; the nature of any cardiac abnormality; the presence of immunocompromise or antibiotic allergy; the presence of infection at the endoscopic site, and whether any discussion had taken place with the patient over the risks and benefits of prophylaxis.
Conclusions The increase in gram-negative organisms means prompt initiation of effective empirical therapy against sepsis should be continued. We recommend tazocin and gentamicin, or tazocin and vancomycin (in those with suspected intravascular device associated sepsis) should continue as first line therapy for oncology patients with suspected sepsis at University Hospital Birmingham. Meropenem should be the alternative therapy in severe sepsis or penicillin allergy (non-severe). Additionally, we recommend improved infection control measures for the insertion and management of intravascular and intra-vesicular devices as these remain the most frequent foci of infection. Enhanced effort is needed to control MRSA infection.
AUDIT OF ADHERENCE TO NICE CLINICAL GUIDELINE 64 - "PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS" IN ADULT GASTROSCOPY IN SHEFFIELDCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL David G Partridge, Kumar Basu, Lisa Ridgway Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
Introduction For many years, antibiotic prophylaxis was given routinely to those with congenital or acquired valvular heart disease undergoing invasive procedures such as endoscopy. The evidence base for such prophylaxis was weak and antibiotic use is associated with increased cost, a risk of adverse drug reactions and may drive the development of antimicrobial resistance. As a result, national guidelines gradually reduced the clinical circumstances in which prophylaxis was recommended. In March 2008, the National Institute for Health and Clinical Excellence (NICE) took this further and published Clinical Guideline 64, recommending against antibiotic prophylaxis for dental work or endoscopic procedures unless the procedure involves an infected site or the patient elects to receive prophylaxis after a full discussion of the risks and benefits. The conclusions of Clinical Guideline 64 have provoked some controversy amongst Microbiologists and Cardiologists. A retrospective audit of antibiotic prophylaxis in gastroscopy was performed examining the periods 1/9/06 - 31/ 3/07 and 1/9/08 - 31/3/09, before and after the publication of NICE Clinical Guideline 64 in March 2008. Patients receiving antibiotic prophylaxis prior to gastroscopy during
Scientific findings September 2006 to March 2007 (pre-NICE): antibiotics administered for endocarditis prophylaxis in 24 of 5899 (0.4%) gastroscopies. Indications for prophylaxis included prosthetic heart valve in 15 cases; acquired valvular disease (7); past history of endocarditis (2); aortic valve repair (1). Discussions about the risks and benefits of antibiotic prophylaxis were not documented in any cases. September 2008 to March 2009 (post-NICE), antibiotics administered for endocarditis prophylaxis in 1 of 5451 gastroscopies - a patient with a prosthetic valve and a past history of prosthetic valve endocarditis. There was no documentation of discussion about risks and benefits of prophylaxis.
Discussion The frequency with which antibiotic prophylaxis is prescribed prior to gastroscopy has reduced markedly since the publication of NICE clinical guideline 64, in spite of dispute about the conclusions of the guideline amongst clinicians. In Sheffield, a local trust guideline to reflect the new NICE guidance was agreed and implemented. A survey of 9 local consultant gastroenterologists performed after this audit, but before dissemination of results, demonstrated that none felt gastroscopy was likely to represent a significant risk for development of infective endocarditis although 3 would consider taking antibiotic prophylaxis prior to endoscopy if they, themselves, had a prosthetic valve.
Conclusions Adherence to NICE clinical guideline 64 within Sheffield Teaching Hospitals was excellent. The fact that even a contentious NICE guideline can provoke such a change in prescribing practices over a short period emphasises the power of the organisation as an agent for change. Involvement of NICE in the production of other guidelines relevant to infection control and antibiotic stewardship should be encouraged.
AUDIT OF THE PERINATAL RECOMMENDATIONS FROM THE ’PERINATAL TRANSMISSION OF HIV IN ENGLAND, 2002-2005’ REPORTCATEGORY: SCIENTIFIC FREE PAPER
Abstracts the relevant periods were identified using the Infoflex database of endoscopic procedures. Case notes of those receiving prophylaxis were reviewed to establish the indication for antibiotics; the nature of any cardiac abnormality; the presence of immunocompromise or antibiotic allergy; the presence of infection at the endoscopic site, and whether any discussion had taken place with the patient over the risks and benefits of prophylaxis.
Conclusions The increase in gram-negative organisms means prompt initiation of effective empirical therapy against sepsis should be continued. We recommend tazocin and gentamicin, or tazocin and vancomycin (in those with suspected intravascular device associated sepsis) should continue as first line therapy for oncology patients with suspected sepsis at University Hospital Birmingham. Meropenem should be the alternative therapy in severe sepsis or penicillin allergy (non-severe). Additionally, we recommend improved infection control measures for the insertion and management of intravascular and intra-vesicular devices as these remain the most frequent foci of infection. Enhanced effort is needed to control MRSA infection.
AUDIT OF ADHERENCE TO NICE CLINICAL GUIDELINE 64 - "PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS" IN ADULT GASTROSCOPY IN SHEFFIELDCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL David G Partridge, Kumar Basu, Lisa Ridgway Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
Introduction For many years, antibiotic prophylaxis was given routinely to those with congenital or acquired valvular heart disease undergoing invasive procedures such as endoscopy. The evidence base for such prophylaxis was weak and antibiotic use is associated with increased cost, a risk of adverse drug reactions and may drive the development of antimicrobial resistance. As a result, national guidelines gradually reduced the clinical circumstances in which prophylaxis was recommended. In March 2008, the National Institute for Health and Clinical Excellence (NICE) took this further and published Clinical Guideline 64, recommending against antibiotic prophylaxis for dental work or endoscopic procedures unless the procedure involves an infected site or the patient elects to receive prophylaxis after a full discussion of the risks and benefits. The conclusions of Clinical Guideline 64 have provoked some controversy amongst Microbiologists and Cardiologists. A retrospective audit of antibiotic prophylaxis in gastroscopy was performed examining the periods 1/9/06 - 31/ 3/07 and 1/9/08 - 31/3/09, before and after the publication of NICE Clinical Guideline 64 in March 2008. Patients receiving antibiotic prophylaxis prior to gastroscopy during
Scientific findings September 2006 to March 2007 (pre-NICE): antibiotics administered for endocarditis prophylaxis in 24 of 5899 (0.4%) gastroscopies. Indications for prophylaxis included prosthetic heart valve in 15 cases; acquired valvular disease (7); past history of endocarditis (2); aortic valve repair (1). Discussions about the risks and benefits of antibiotic prophylaxis were not documented in any cases. September 2008 to March 2009 (post-NICE), antibiotics administered for endocarditis prophylaxis in 1 of 5451 gastroscopies - a patient with a prosthetic valve and a past history of prosthetic valve endocarditis. There was no documentation of discussion about risks and benefits of prophylaxis.
Discussion The frequency with which antibiotic prophylaxis is prescribed prior to gastroscopy has reduced markedly since the publication of NICE clinical guideline 64, in spite of dispute about the conclusions of the guideline amongst clinicians. In Sheffield, a local trust guideline to reflect the new NICE guidance was agreed and implemented. A survey of 9 local consultant gastroenterologists performed after this audit, but before dissemination of results, demonstrated that none felt gastroscopy was likely to represent a significant risk for development of infective endocarditis although 3 would consider taking antibiotic prophylaxis prior to endoscopy if they, themselves, had a prosthetic valve.
Conclusions Adherence to NICE clinical guideline 64 within Sheffield Teaching Hospitals was excellent. The fact that even a contentious NICE guideline can provoke such a change in prescribing practices over a short period emphasises the power of the organisation as an agent for change. Involvement of NICE in the production of other guidelines relevant to infection control and antibiotic stewardship should be encouraged.
AUDIT OF THE PERINATAL RECOMMENDATIONS FROM THE ’PERINATAL TRANSMISSION OF HIV IN ENGLAND, 2002-2005’ REPORTCATEGORY: SCIENTIFIC FREE PAPER