The only number you need to know
01872 226703
September 2009
Amoxicillin is not enough!
For a long time the usual treatment for chest
infections has been Amoxicillin 500mg three
times a day for up to 10 days.
The recommended treatment changed
earlier this year with publication of new
antibiotic guidelines in the Joint Formulary.
The recommendations were revised in the
light of local sensitivities and the need to
reduce the incidence of MRSA and
clostridium difficile infections.
We have noticed that patients being
admitted with pneumonia have usually been
treated for a while with amoxicillin but the
patient has not responded.
If we can get it right first time we could avoid
considerable morbidity, hospital admissions
and some mortality.
http://cww.cornwall.nhs.uk/online_formulary/index.asp
Ciprofloxacin is out
The new guidelines also say,
“4-Quinolones eg Ciprofloxacin are NOT
good first choice antibiotics in respiratory
infections as they have poor activity against
pneumococci.
However, they do have use in PROVEN
pseudomonal infections - for example in
patients with cystic fibrosis or
bronchiectasis.”
For all your medical and surgical admissions
For community acquired pneumonia
recommended first line treatment is:
Amoxicillin 500mg 3 times a day
PLUS
Doxycycline 200mg at once then
100mg daily.
For patients sensitive to penicillin the advice
is to use
Clarithromycin 500mg twice a day.
The formulary emphasises that upper
respiratory tract infections are caused by
viruses and do not need antibiotics at all.
Bronchitis in those under 60 without
underlying chest disease is usually viral.
It seems that once the GP has decided to
use an antibiotic for a chest infection then
AMOXICILLIN IS NOT ENOUGH.
What about exacerbations of COPD?
“Many cases are viral - consider whether
antibiotics are needed.
Antibiotics are not indicated in the absence
of purulent or mucopurulent sputum”.
If indicated use for 10 days:
Doxycycline 200mg stat then 100mg daily
Or
Co-amoxiclav 375-625mg three times a day
Or
Clarithromycin 500mg twice a day”
 Troponin T (TnT)
Troponin T starts to rise within 3-4 hours of
symptoms of acute coronary syndrome and
reaches maximum sensitivity at 12-18
hours.
It may remain elevated for up to 8 days.
Therefore blood is not drawn for TnT within
12 hours of the onset of chest pain.
A patient with a history of chest pain who is
cardiovascularly stable and with a normal
ECG just has to wait until the 12 hour mark.
Tell them to bring a book!
Ambulances
South West Ambulance Services Trust will
accept requests for urgent transport to
hospital for five time scales.
They will try to pick up the patient within:
4 hours
3 hours
2 hours
1 hour as requested or
within minutes (999 call).
They will take a patient urgently from a
lower level of care to a higher level of care,
but not the other way.
So a patient who can not get home under
their own steam will get admitted from the
Acute GP Clinic even if they could be
treated in the community.
It would help us if the GP could discuss this
with the patient before they attend our
clinic.
Thanks!
Did you know…because we didn’t?
The dermatology department runs a
same-day out-patient assessment service
for urgent dermatological problems.
Simply call the switchboard at Royal
Cornwall Hospital (01872 250000) and
ask for the dermatology registrar to be
bleeped.
Please don’t abuse this service with
patients who could be processed in the
normal out-patient clinics, otherwise they
will become overwhelmed and may
withdraw the service.
Which way now?
The Acute GP Service was commissioned
by all the practice based commissioning
groups in Cornwall and is a one year pilot
project.
It went live on 5th January 2009 and comes
up for review by the PCT on 28th
September.
Please let your representative know
whether you would like the service to
continue, be extended (e.g. into the out of
hours period; or into screening admissions
from the Emergency Department; or into
screening surgical admissions) or closed
down!
 How are we doing?
The chart below has been adjusted to account for any patients who were admitted in
the seven days after initial triage.

Acute GP Service 2009. Outcomes after 7 days

600

500

400

300

200

100

0
March # April # May # June # July # August #
Total admitted 320 299 317 330 395 361
Total not admitted 122 112 84 139 164 126

20% to 30% of the calls we receive do not result in admission to an acute

adult medical bed.

That’s 4 to 7 patients per working day.

10% to 18% of patients are seen in the Acute GP Clinic most of whom are not
subsequently admitted.

Dr Bina Sardesai The memorial service held at Truro

The sudden death of Dr Bina Sardesai
has had a profound effect on our team
and on the staff on the Medical
Admissions Unit at Treliske, where she
was the lead consultant.
Cathedral was attended by over 600
people on 5th September 2009.
We all miss her wisdom, her gentle
calmness and her very warm and sunny
personality.

Her calm manner and ready smile were
appreciated by all, and her delight in
doing an excellent job rubbed off on all
those who saw her at work.
Her husband Sahrud, who is also a
consultant on MAU, has our deepest
sympathy.
The Acute GP Service team.
 Temporal arteritis feedback 1
“The clinical presentation of temporal
arteritis, giant cell arteritis or polymyalgia
rheumatica and their differentiation from
other conditions is difficult.
We are not the primary carers of these
patients and when temporal artery biopsy is
requested to help make the diagnosis we
should do it (although we have to make a
risk-benefit decision for each patient).
The positive biopsy is about 60% with early
biopsy and does not appear to be reduced
by two or three days of steroid treatment,
falling to about 10% after 1 week of
steroids.
The value of the test at a particular time
may affect the referrer's decision to refer.
Late referrals should be offered biopsy if it
is felt that a small chance of a positive
result will help with management.
Earlier referral and biopsy will increase the
usefulness of the test and increase biopsy
rates but we can absorb this into our
current vascular service.
We will need to carry out temporal artery
biopsy within a few days of starting
steroids.
This means the patient needs to be referred
at presentation to give us time to arrange
biopsy.
There would be no need for weekend
biopsies where patients' treatment may be
delayed by emergencies.
Steroid treatment should not be delayed
while waiting for biopsy.
The route of referral into hospital should be
the Vascular Registrar on call (9-5, Mon-Fri)
who will advise on mode of admission and
arrange for the patient to go on one of our
[day case] lists.”
Graham Riding
Specialty Lead Vascular Surgery
Temporal arteritis feedback 2
“Only refer patients with visual loss to the
ophthalmic unit and not those with just
headaches etc.
These patients will be seen in eye
casualty on the same day and have
ESR/CRP/FBC done plus quantitative
measure of vision.
On call team will decide if need IV pulse
methyl prednisolone and whether TA
biopsy is needed to confirm diagnosis on
dodgy cases - usually possible to get
>2cm and so avoid skip lesions.
I am told the biopsy stays positive for 2
weeks after presentation and some
ophthalmologists will do it themselves -
other may refer to vascular team.
If we establish the diagnosis once patient
is on oral steroids and has stable vision
we discharge to GP/rheumatology.”
Ms Kate Claridge,
Consultant Ophthalmologist
and Speciality Director
Temporal arteritis summary
1. Start high dose steroids if temporal
arteritis is clinically likely.
2. If visual loss refer to eye casualty
urgently.
3. If no visual loss but diagnostic
uncertainty, start steroids and bleep
vascular surgery registrar to arrange
temporal artery biopsy within 48 hours
if possible.
4. These patients do not normally need
an acute medical bed.
The Acute GP Service newsletter is edited
by Dr Simon Barton, clinical lead.
Please give us feedback –
without it we will not get better!
Admin line: 01872 25 3566
acute.gp@cornwall.nhs.uk