Published: 12 November, 2021
Contents
World Antimicrobial Awareness Week (WAAW) – 18 – 24th November
The theme for this year’s WAAW is “Spread Awareness, Stop Resistance”. Details of this global initiative from
the World Health Organization are available
here.
WAAW is a chance for healthcare professionals to reflect, and act, on the multidisciplinary responsibility for antimicrobial
stewardship (AMS), including the role of patient education. The overarching goal of AMS is to improve the appropriate
use of antimicrobials and minimise antimicrobial-related harms, including resistance and adverse effects. AMR is a global
crisis and disproportionately impacts our most vulnerable populations.
General principles of antimicrobial stewardship include:
- In most cases, only prescribe antibiotics if symptoms are likely to be due to a bacterial infection and:
- Are significant or severe; or
- Have a high risk of complications; or
- Are not resolving or are unlikely to resolve
- Follow local guidelines and select the recommended antibiotic, dose, route and duration
- Reserve broad spectrum antibiotics for when narrower spectrum options are not appropriate
- Talk with patients about responsible use of antibiotics, including the potential harms of using an antibiotic when
it is not indicated
A New Zealand initiative to raise awareness about incorrect penicillin allergy labelling
District Health Boards (DHBs) across New Zealand are working collaboratively via Antimicrobial Stewardship and Infection
Pharmacists to raise awareness about the potential for incorrect penicillin allergy labelling and the associated harms.
DHBs are inviting patients who think that they have penicillin allergy to talk to their healthcare team – so be prepared!
Read more
Despite being the most common adverse reaction reported, nine out of ten people who believe they have a penicillin
allergy, do not actually have an immune-mediated allergy. Incorrect labelling of penicillin allergy can result in the
use of second-line antibiotics that may be less effective, broader spectrum and associated with an increased risk of
adverse effects, e.g. antimicrobial resistance, Clostridium difficile-associated diarrhoea, longer hospital
stays, surgical site infections and an increased risk of mortality.
When prescribing an antibiotic, consider the accuracy of an allergy label as:
- Immune systems change over time; approximately 50% of people who had a positive skin prick test to penicillin are
no longer allergic after five years and approximately 85% are no longer allergic after ten years.
- Allergy labels may not always be correct. In many cases, the "allergy" was an adverse effect, and patients
may find they can tolerate the antibiotic after an initial reaction.
An allergy label may be able to be removed following questioning and a review of notes and allergy history. Establish
what antibiotic caused the reaction, the severity and timing of the reaction, which antibiotic(s) have since been tolerated
and the risk of a penicillin challenge.
Click
here for further details on how to assess the risk of a true immune-mediated
allergy. If there is a risk of true allergy, an oral challenge, e.g. with amoxicillin, in controlled conditions or a skin prick test
may be required. Formal referral pathways for these are not yet established for primary care. Focusing on patients
with negligible risk of penicillin allergy (without the need for oral amoxicillin challenge or engagement with speciality
services) might be the most straight forward way of incorporating this into practice currently.
For resources and further information on this initiative,
click here
Local resources for antibiotic awareness including posters and patient education are available from
the Ministry
of Health website.
End of Life Choice Act 2019
With the introduction of the End of Life Choice Act 2019 on 7 November, 2021, many clinicians will be considering
how these regulatory changes will affect them and their patients. The Medical Council of New Zealand has
published
a resource that aims to provide further understanding of key provisions in the Act. The Council has summarised some
of the relevant sections of the Act and alongside these they have applied the existing Council statements and standards.
The aim of this document is to help clinicians understand the Act and their potential role. The Medical Council caution
that the resource document is a summary only - to access and
read the full text of the
Act click here.
Further information on the assisted dying service is available from the Ministry of Health. This
link takes you to the “landing page” which is a good place to start when
looking for information for both health professionals and patients. N.B. this page also includes instructions on how to lodge a conscientious objection.
Baclofen oral suspension – HQSC Medication Alert
Baclofen is a muscle relaxant used in both adults and children for conditions related to spasticity. Only injectable* and
tablet forms are funded in the community. This means that if a child requires an oral liquid, this must be extemporaneously
compounded by a pharmacist. Until recently, the concentration of the standardised batch sheet for compounded baclofen
was 10 mg/mL. Doses for paediatric patients can be small (less than 10 mg), translating to very small volumes of the
10 mg/mL suspension. As a result, the concentration may have been adjusted to make it easier for caregivers to measure
and administer a dose. Thus, concentrations compounded have ranged from 1 mg/mL to 10 mg/mL. The differences in concentration have
caused medicine errors when transitioning between hospital and community treatment and between pharmacies.
As of 1 November, 2021, the standardised batch sheet for compounded baclofen suspension is 1 mg/mL. This will align with the concentration of the proprietary oral liquid (1 mg/mL)
available in hospitals and therefore reduce the potential for medicine errors. N.B. baclofen tablets can alternatively be crushed and dispersed in water immediately before
administration if the prescribed dose would necessitate a large amount of oral suspension or liquid.
Read more about the alert and
actions
to take here.
* Funded by endorsement only when used in a programmable pump
Brand change for long-acting diltiazem
PHARMAC has advised that the current brand of
long-acting diltiazem (Apo-Diltiazem) will be delisted from the Pharmaceutical Schedule on 1 February, 2022. An alternative brand
of diltiazem 120 mg, Accord, will be listed from 1 December, 2021, however, it does not have Medsafe approval and will need to be prescribed and supplied under Section 29.
An alternative
brand of 180 mg and 240 mg diltiazem tablets (Cardizem) has been available and funded since October, 2021.
N.B. As covered in Bulletin 18,
30 mg and 60 mg diltiazem tablets (Dilzem) were discontinued earlier this year; stock of 30 mg tablets has now run out and they have
been delisted, 60 mg tablets will be delisted by 1 January, 2022.
Prazosin supply issue
PHARMAC advise
that supply of the new funded brand of prazosin, Apo-Prazosin S29, has been delayed, but is expected to arrive shortly. We reported on prazosin in
Bulletin 29,
where it was announced that all formulations of Apo-Prazosin were to be discontinued and delisted from the Pharmaceutical Schedule in May, 2022;
doxazosin may be a suitable alternative.
PHARMAC has since secured 18 months’ supply of Apo-Prazosin S29 and are working to secure longer-term supply. Previously, prazosin was restricted to people who had been
taking it before 1 August, 2021, however, this restriction has now been removed. Apo-Prazosin S29 does not have Medsafe approval and will need to be prescribed
and supplied under Section 29.
PHARMAC funding treatments for COVID-19
There have been several recent
announcements regarding medicines that PHARMAC is funding for treatment of patients with COVID-19. While some of these treatments
will not be used in a community setting, they may be of interest to our audience:
Read more
Tocilizumab
is a monoclonal antibody. It can be used to treat moderate to severe cases of COVID-19, subject to specific criteria.
Tocilizumab does not have Medsafe approval for this indication (it is approved for the treatment of rheumatoid arthritis). In clinical trials, tocilizumab
has been shown to reduce the severity of COVID-19 infection and length of stay in hospitalised patients. There is currently a
worldwide
supply issue with tocilizumab and new stock is not expected to be available in New Zealand until January, 2022 (current supply is being closely managed).
Remdesivir
is an antiviral medicine. It can be used for the treatment of hospitalised patients with
moderate to severe COVID-19, subject to specific criteria. Remdesivir does not have Medsafe approval. It will be listed for hospital supply only.
Molnupiravir is an oral antiviral medicine. It may be used to treat mild to moderate symptoms of COVID-19, subject to it receiving Medsafe
approval. Interim clinical trial results show that people treated with molnupiravir have reduced rates of hospitalisations and death from COVID-19. The initial
supply agreement is for 60,000 courses of treatment, suggesting that this will be used in the community.
Ronapreve (casirivimab and imdevimab) is a combination monoclonal antibody. It can be used for the prevention and treatment of COVID-19;
it is intended for people exposed to COVID-19 who are at high risk of developing severe symptoms (it is not a substitute for vaccination).
It does not have Medsafe approval.
Baricitinib is a Janus kinase (JAK) inhibitor. It can be used to treat moderate to severe cases of COVID-19. It does not have Medsafe approval.
In clinical trials, people hospitalised with COVID-19 who have taken barictinib have less severe symptoms, a shorter length of time spent in hospital and increased survival rates.
Paper of the Week: Improving the early identification of COVID-19 pneumonia
This week in the BMJ,
Dr Dan Goyal and colleagues from the United Kingdom have contributed a review of clinical studies on the early detection of symptoms and signs likely to lead
to COVID-19 pneumonia, when monitoring patients in the community. The growing global body of evidence and experience in treating COVID-19 is helping researchers develop clinical methods
to limit progression and severity of infection. So far, interventions with the most evidence include timely and optimal oxygen treatment and the administration of steroids.
The authors of this BMJ review have searched the evidence to identify clinical parameters that are early indicators of a patient with COVID-19 who is likely to deteriorate.
These assessments can be carried out with basic clinical questions and measurements.
Read more
Summary of key findings and advice:
- Most people with COVID-19 will have resolution of symptoms without a significant clinical event
- Typical symptoms are similar to the common cold or influenza and begin to improve within two to three days
- The early detection and correction of hypoxia is likely to be one of the key determinants of disease progression
- A patient with any of the following symptoms requires urgent clinical contact: shortness of breath, confusion,
persistent fever
- Other symptoms with a predictive value for disease progression are: dyspnoea, fatigue, dry cough, chest tightness,
abdominal pain, diarrhoea, vomiting
- In COVID-19 pneumonia, low oxygen levels can sometimes occur without breathlessness; this can be detected by pulse
oximetry and requires urgent medical attention. This is termed “silent hypoxia” and may be associated with other
symptoms such as confusion, altered mental state or severe/exertional fatigue. People with silent hypoxia appear
to have a poorer prognosis.
- Observations including pulse, respiratory rate, blood pressure, temperature and oxygen saturations are likely
of high value in detecting a patient who is deteriorating due to COVID-19 or other presentations, e.g. bacterial
pneumonia, sepsis, pulmonary embolism; oxygen saturations are the most predictive of COVID-19 progression
- Chest x-ray has limited clinical value in a community setting
- Clinical examination is of uncertain value, but an "eye ball" assessment is useful
- Blood tests are usually not required but monitoring CRP can be useful, especially if point-of-care testing is
available; a level >30 mg/L may indicate progression and a risk of viral pneumonia, it is less reliable in people
aged >75 years – use a lower threshold of > 20 mg/L
- Duration of symptoms is not predicative as deterioration was found to occur at any stage of the illness
Read the full article here:
Goyal D, Inada-Kim M, Mansab F, et al. Improving the early identification of COVID-19 pneumonia: a narrative review.
BMJ Open Respiratory Research 2021;8:e000911. doi: 10.1136/bmjresp-2021-000911
This Bulletin is supported by the South Link Education Trust
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