NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

Medicines Update Primary Care February 2016

 

Longterm Antimicrobial Prescribing

One of the current areas of focus in antimicrobial management is appropriate long term use of antibiotics. The Scottish Antimicrobial Prescribing Group ( SAPG) has published advice on several areas where local guideline groups have sought clarification see below.
NHSGGC Primary Care Antibiotic Guidance is also available on staffnet.

UTI- Prophylaxis in Men


Very few men, if any, merit long term prophylactic antibiotics.  There is usually an underlying cause such as significant pathology, stones or bladder emptying due to benign or malignant disease. It is rare to find no cause for recurrent UTI in men and prophylactic antibiotics are not advised. Men with recurrent or persistent UTI should be referred to an urologist.
The full SAPG advice is here.


Prostatitis- Antibiotic Course Length


Acute bacterial prostatitis is a serious infection with fever and intense local pain. Following initial parenteral therapy and normalisation of infection parameters, oral therapy can be substituted and continued for a total of 2-4 weeks. In chronic bacterial prostatitis antibiotics should be given for 4-6 weeks after diagnosis. Relatively high doses are needed and oral therapy is preferred. The full SAPG advice is here


Acne and Rosacea- Long Term Antibiotic Use


Long term antibiotics remain the mainstay of treatment for moderate to severe acne. There are no clear criteria for discontinuation but regular review is recommended. In the acute presentation of acne or rosacea, 8 to 12 weeks is needed for an improvement to be seen, so antibiotic treatment should be reviewed every 2-3 months. Many peoples’ symptoms will clear with 6 months of antibiotics, but in others, treatment only controls the condition and treatment may need to continue until the patient 'grows out' of it or sometimes it is life-long.
Patients on long term antibiotics for acne and rosacea should be reviewed at least 6-monthly.
The full SAPG advice is here


 
Primary Care Paediatric Infection Management Guidelines


The infection management guidelines for children have recently been reviewed and updated. The changes to the guideline are as follows:
• Where a macrolide is indicated as a penicillin alternative, clarithromycin is now the macrolide of choice and erythromycin has been removed from the guideline. Clarithromycin is administered twice daily (vs four times a day for erythromycin) and is better tolerated.
Please note: Clarithromycin does have some serious drug interactions and may prolong the QT interval (as does erythromycin).

• For uncomplicated lower urinary tract infections, trimethoprim remains the treatment of choice for a child over 6 months of age. However if a child is currently on trimethoprim prophylaxis, has had previous trimethoprim resistance or has known renal abnormalities then co-amoxiclav is recommended (or nitrofurantoin for those with a penicillin allergy).

The aim of the guideline is to provide the best approach to the treatment of common childhood infections, whilst promoting the safe, effective and economic use of antibiotics and minimising the emergence of bacterial resistance in the community.

The guideline can be accessed:
• via Staffnet
• via GP mailings

If microbiological advice is required please contact either the Microbiology Department at your local hospital, the Paediatric Antimicrobial Pharmacist or Paediatric Infectious Diseases service at the Royal Hospital for Children.


 
Mercaptopurine - Dosing Error Risk

Mercaptopurine is an oral immunosuppressant used in the management of Crohn’s disease at doses ranging from 1 - 1.5mg/kg daily for adults (although some patients may respond to lower doses).  Higher doses are required when mercaptopurine is used in the management of acute leukaemias (initial daily adult dose of 2.5mg/kg).
Historically, practitioners involved in the prescribing of this immunosuppressant have commonly referred to it as ‘6-mercaptopurine’ or ‘6-MP’.  However, it is recognised that as use of the number 6 prefix can lead to dosing errors, it should be prescribed simply as ‘mercaptopurine’.  The case below demonstrates the risk associated with use of the number 6 prefix.

Example case:
A hospital letter recommended ‘6-mercaptopurine 50mg daily’ which was interpreted by the GP practice as a total daily dose of 300mg.  The community pharmacist, on receiving a prescription for 300mg daily, queried the dose and it was changed to 50mg daily.

Key messages:

• Practitioners not routinely involved in the prescribing of mercaptopurine may be unaware that a number prefix may be used.  To prevent confusion and errors, prescribers are advised to use the approved name which is mercaptopurine.
• Where possible, establish the indication, patient’s weight/height and mercaptopurine dosing history.
• High doses should always be discussed with the prescriber:  300mg is a high dose regardless of the indication.

Blood Glucose Testing Strips - Storage and Hygiene- Patient Advice

Blood glucose monitoring is an important part of diabetes management for some patients. Recent safety alerts from the MHRA highlighted the risk of over estimation of blood glucose if the specific testing procedure is not followed or if strips are not stored safely as per the manufacturer’s directions.
NICE recommend that patients with type 1 & type 2 diabetes who are self monitoring their blood glucose levels, have a structured assessment at least annually to include self monitoring skills.
Summarised in this article is advice for the safe storage of blood glucose test strips and good practice guidance on how to self test blood glucose. Similar information is included in product leaflets.

Storage

• Store strips in accordance with manufacturer’s instructions. Heat, cold, humidity and moisture can all affect how the strips work which in turn affects the accuracy of the reading.
• Keep strips in their original sealed container only. Ensure container lid is closed properly after each use.
• Check expiry dates of test strips and control solutions. Do not use if out of date.  Most strip packaging allows the opening or expiry date once opened to be written on the label
• Store the meter and test strips at room temperature. Keep away from direct sunlight & heat. Do not freeze.
• Do not leave test strips in vehicles for extended periods of time as may be subject to temperature extremes.
• Do not bend, cut or alter test strip in any way.

Testing

• Ensure hands are washed with soap and thoroughly dried (with a clean towel) prior to testing. Contaminants on the skin or excess moisture can affect the accuracy of the reading.
• Ensure sufficient blood sample size is applied to the test strip. Do not add more blood after the first drop has been applied.
• Apply fresh blood drop to test strip immediately after blood drop obtained. Not testing promptly can lead to evaporation of blood drop which can affect accuracy of the reading.
• Do not test with a smeared or spread blood drop as this can introduce contaminants. Also, do not wipe or smear the blood drop onto the test strip, simply touch the test strip and blood drop together without excess pressure.
• Ensure patients are aware of what to do if their reading is out with the normal range specified by their diabetes healthcare professional.
A Control Solution (available free from the meter company) contains a known amount of glucose and is used to ensure the meter and strips are working correctly.  It is advised to routinely use the control solution to test the meter and if there are situations where the blood glucose test results are not as expected.