Mike JonesVice President, Royal College of

Physicians of Edinburgh

Where’s the problem?

So where’s the problem?

Oh Dear Lord is he really that stupid?

Acute Medicine and infection“Medicine at the front door”

Pneumonia/Infective exacerbation of COPDUTI/pyelonephritisSoft tissue infection“PUO”Sepsis syndromes

Therapy guided by ?

Response

Response

Response

Changes in PolicyInevitable

Resistance of bacteriaNew therapiesBased on evidence

DifficultCommunicationPre-conceived ideasResistance

Antimicrobial practice

Failure to implement hospital antimicrobial prescribing guidelines: a comparison of two UK academic centres

M. H. Ali1, P. Kalima2 and S. R. J. Maxwell1,* 1 Clinical Pharmacology Unit, University of Edinburgh, Queen's Medical Research Institute, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4TJ, UK; 2 Department of Medical Microbiology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK

ResultsMore patients were admitted (CAP: 78.9%

versus 48.4%, P < 0.05)Given antimicrobials intravenously (CAP:

53.4% versus 21.2%, P < 0.05). CAP adherence was significantly higher

(83.3% versus 38.0%; P < 0.05). Fewer than half of the doctors surveyed used

the local hospital guideline

Poor guideline adherence results from inadequate dissemination of the recommended information

Local and national guidelines varyMedical school teaching and senior doctors

as major influences

Education and Training is the answer?

Restriction of UseAlert antibiotics

E.g. Ertapenem IV Ganciclovir IV (Ophthalmologist, Renal Specialist) Linezolid IV/Oral Meropenem IV (Haematologist, Oncologist, Cystic

Fibrosis Specialist) Specific indication antibiotics

E.g.Ceftazidime: PD peritonitis, Pseudomonas infection

Clindamycin: lung abscess, brain abscess

Challenges for Acute MedicineRole modelConsistency of prescribingEvidence based practice

Need to balance: Sensitivity of most common causative organisms Risk of antibiotic related illness Consequences of an ineffective antibiotic Association of C.difficile (et al) infection with

antibiotic useAccuracy of diagnosis

UTI in the elderly

Acute Medical ManagementBalance use of IP management/ambulatory

care/ care in the community Development of OHPAT (out patient and

home anti-infective therapy) services where they don’t exist

St Mary's treats hundreds of patients in the community - 21 September 2009

Hundreds of patients needing intravenous antibiotics are being treated at home - assisting their recovery and freeing up hospital beds at St Mary's. 

Recently published figures have shown that a massive 7,394 in-patient bed days were saved between September 2004 and April 2008 thanks to the pioneering OHPAT (outpatient and home parenteral antimicrobial therapy) service, which allows patients to be managed at home. 

Acute Medical ManagementBalance use of IP management/ambulatory

care/ care in the community Development of OHPAT (out patient and

home anti-infective therapy) services where they don’t existCo-operation with services that will benefit:

ID, orthopaedics, cardiology, vascular etc Use of evidence base

SummaryNeed for Acute Medicine to be:

ConsistentProactiveCollaborative

Need for growth in evidence base to assess all aspects of care

Acute Medicine can and must help