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Antimicrobial Stewardship in Scotland
PAST, PRESENT, FUTURE CLEANLINESS CHAMPION, CONFERENCE, ABERDEEN
2011
DILIP NATHWANI Chair, Scottish Antimicrobial Prescribing Group
Acknowledgements
• Members of Scottish Antimicrobial Prescribing Group
• NHS Board Antimicrobial Management Teams
• Association of Scottish Antimicrobial Pharmacists
We are interested in improving antibiotic use to reduce harm from infection and preserve an invaluable resource
6 June 2005
Valiquette L et al. CID 2007; 45, S112-S121.
How much do we love antibiotics?
Q2 What percentage of prescribed antibiotics for
humans are inappropriate
in hospital ?
A. 10‐20%B. 30‐50%C. 70%D. 90%
Antimicrobial Prescribing Facts: Rule of “1/3”
~ 1/3 of all hospitalised inpatients at any given time receive antibiotics
~ up to 1/3 to ½ are inappropriate
~ up to 30% of all surgical prophylaxis in inappropriate
~ 30% of hospital pharmacy budgets.
Stewardship programmes can save up to 10-30% of pharmacy budgets.
What is wrong with this statement?
Nitrites ++, leukocytes ++: diagnosis UTI
Rx with antibiotic
Probability of asymptomatic bacteriuria?
Description Prevalence of ASBMarried woman aged 24-44 4.6%Married woman aged >65 6.5%Nun aged 24-44 0.7%Nun aged >65 5.8%Married woman aged 24-44 with diabetes
8%-18%
Female, continent nursing home resident
25%-57%
Female, incontinent nursing home resident
80%
Patient catheterised for > 4 weeks 100%
Probability of bacteriuria
if symptomatic? 70‐73%
Consequences of antibiotic ? Resistance
Q3 For an individual patient with urinary tract infection
prescribed an antibiotic within the last 2 months what is the increased level
of risk of resistance ?
A. NoneB. 1.5 fold increase C. 2 fold increaseD. 2.5 fold increaseE. 4 fold increase
Effect of 1ry care prescribing on resistance in individual patients
BMJ 2010
UTI OR 2.5 [2,1-2.9] 2 months
UTI OR 1.33 [1.2-1.5] 12 months
“Price of an antibiotic”Risk of resistance to the individual ~ 2 fold for 2 months and up to 12 months1
~8- 10 fold risk of CDAD up to 3 months2
AGECo-morbidityType of antibiotic (~8 fold with cephalsporins and 30 fold with quinolones)
OBJECTIVES
1. SAPG INTRODUCTION : PAST & PRESENT
2. UPDATE ON PROGRESS WITH KEY CURRENT WORK 2008-2011
3. FUTURE SAPG 2011 -2014
3. LOOK FORWARD TO YOUR SUPPORT AND COMMENTS
SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP[SAPG]
Improve the quality of antimicrobial prescribing and infection management in hospitals and primary care
Reduce amount and reduce broad spectrum Improve quality of prescribing [choice,
route, dose, duration, timeliness]
Reduce harm (mortality, CDAD, resistance) and unintended harm
Measure improvement Measure unintended harm (complications
e.g nephrotoxicity and ototoxicity, readmissions, increased ICU referral, resistance, other)
What are our ambitions? • 1. Establish national and local organisation structures and
leadership around antimicrobial stewardship. • 2. A. Improve the quality and quantity of prescribing in all
healthcare sectors through guidance and support: initially “front- end” hospital empiric prescribing.
B. national system to measure antibiotic consumption and surveillance of resistance to support local data
• 3. Improve prevention and management of specific infections: Surgical prophylaxis, Community acquired pneumonia and febrile neutropenia
• 4. Education and evaluation of our educational interventions
• Measure our progress [AMT Survey's, Network Events, HEI inspection, Clinical teams-AMT collecting data for SAPG- Extra-NET]
• Impact on outcomes [intended and unintended] • Feedback our progress and outcomes
TRIUMPHS
What are our ambitions?
• 1. Establish national and local organisation structures and leadership around antimicrobial stewardship.
Integration of antimicrobial stewardship within HAI
agenda
NHS Boards – Antimicrobial Management TeamsInfection Prevention & Control Teams
National – Scottish Patient Safety ProgrammeHPS Surgical Site Infection ProgrammeInfection Prevention and Clinical
specialist groups
Medical DirectorChief Executive Infection Control Manager
Area Drugs & Therapeutics Committee
ANTIMICROBIAL MANAGEMENT TEAM (AMT)(AMT)
Antimicrobial Pharmacist
Ward Based Clinical Pharmacists
Risk Management Committee
Clinical Governance Committee
Infection Control Committee
Microbiologist / Infectious Diseases Physician
PRESCRIBERPRESCRIBER
Prescribing support / feedback
Dissemination & feedback
KEY WORKING AND ACCOUNTABILITY RELATIONSHIPS
What do we expect Boards to evidence?An Antimicrobial Team Antimicrobial PharmacistsAntimicrobial Prescribing PoliciesStaff Awareness of Antimicrobial Policies Data on prescribing and usage which informs
practiceStructured Education Programmes
Revision of antimicrobial policies to support reduction
of Clostridium difficile infection (CDI)
• Hospital prescribing policies restrict antibiotics associated with CDI for empirical prescribing and surgical prophylaxis
• National policies for gentamicin and vancomycin
• National adoption of Health Protection Agency template for management of infections in primary care.
4C Antibiotics (High Risk for C difficile): Cephalosporins, Clarithromycin, Clindamycin, Ciprofloxacin
Introduction of Empiric Antibiotic Policy Restricting Use of 4C Antibiotics
Jan-09
Dec-09
Jan-10
Jul-08
Aug-08
Dec-08
Apr-09
Jul-08
Aug-08
Jul-08
Jan-10
Feb-09
Apr-09
Sep-08
Feb-10
Jun-08 Sep-08 Dec-08 Mar-09 Jul-09 Oct-09 Jan-10 May-10
Ayrshire & Arran
Borders
Dumfries & Galloway
Fife
Forth Valley
Golden Jubilee Hospital
Grampian
Greater Glasgow and Clyde
Highland
Lanarkshire
Lothian
Orkney
Shetland
Tayside
Western Isles
What are our ambitions?
4. Education and evaluate our educational interventions
Foundation Doctors, Staff Induction, Pharmacist Training Packs
Short Courses
Antibiotic Prescribing for Today’s Prescribers• Foundation Year Doctors in Scotland (Dundee University/NES).
– 4 acute scenarios integration into mandatory training through DOTS
• 3 additional Primary Care Vignettes -Sticky eyes, Earache, UTI• Introduction with additional learning information
– Complete package of a suite of 7 stand alone vignettes – Now rolled out for all learners [introduced Nov 10]
Pharmacist [community and hospital] resource- high uptake
Bacterial Resistance Tutorial– 322 learners have completed the course – 98% stated it would impact on their daily work.
What are our ambitions?
• 2. A. Improve the quality and quantity of prescribing in all healthcare sectors through guidance and support: initially “front- end” hospital empiric prescribing.
– B. national system to measure antibiotic consumption and surveillance of resistance to support local data
Information workstream – actions by National Services Scotland
• Antimicrobial usePublication of ‘national prescribing indicators’ for primary care use of antimicrobials:PRISMSNational participation in ESAC-3Development of Hospital Medicine Utilisation Database (HMUD): rolling out in 2011 [first national integrated report of hospital consumption, resistance surveillance and CDI due soon]
• Antimicrobial resistanceProcurement and installation of OBSERVA software and VITEK 2 sensitivity testing systems [all board must do this] : now in place Electronic link to transfer resistance (VITEK 2) data between diagnostic laboratories and HPS pilotedALERT system being developed and pilotedHPS AMR expert group established
Ability to track resistance trends early so as to pre-empt threat
What are our ambitions? 2. Improve the quality and quantity of
prescribing in all healthcare sectors through guidance and support: initially “front-end” hospital empiric prescribing
• ACUTE CARE EMPIRIC PRESCRIBING “FRONT END PRECRIBING”
• SURGICAL PROPHYLAXIS
ESAC SCOTTISH PPS DATA 2009Indication in notes Compliance with antibiotic policy
Duration of Surgical Prophylaxis
Health, Efficiency & Access to Treatment (HEAT) Targets
30% (revised to 50%) reduction in CDI by 3- 2011
•Hospital-based empirical prescribing: antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in >95% of sampled cases
•Surgical antibiotic prophylaxis: duration of surgical antibiotic prophylaxis is <24 hours and compliant with local antimicrobial prescribing policy in > 95% of sampled cases
•Primary Care empirical prescribing: seasonal variation in quinolone use (summer months vs. winter months) is < 5%, calculated from PRISMS data held by NHS Boards.
SUPPORTING PRESCRIBING TARGETS
Compliance with hospital prescribing Antibiotics Compliant: National Data
0
10
20
30
40
50
60
70
80
90
100
Sep‐09 Oct‐09 Nov‐09 Dec‐09 Jan‐10 Feb‐10 Mar‐10 Apr‐10 May‐10 Jun‐10 Jul‐10 Aug‐10 Sep‐10
% Compliance
0
100
200
300
400
500
600
700
800
Sample size
Sample size % Compliance Median Target
Indication Documented: National Data
0
10
20
30
40
50
60
70
80
90
100
Sep‐09 Oct‐09 Nov‐09 Dec‐09 Jan‐10 Feb‐10 Mar‐10 Apr‐10 May‐10 Jun‐10 Jul‐10 Aug‐10 Sep‐10
% Compliance
0
100
200
300
400
500
600
700
800
Sample size
Sample size % Compliance Median Target
Surgical Prophylaxis Data from 7 Health Boards; Median, Min & Max
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Surgery Obstetrics & Gynaecology Orthopaedics
Duration <24h Antibiotic compliant
HOSPITAL HEAT TARGET’S REVISITED
EMPRIC PRESCRIBINGSTUCK AT ~80% [ = NEAR CHAOS]
*SYSTEMS CHANGE *BETTER DEFINITION
AND CLARITY OF WHAT TO COLLECT [DOCUMENTATION IN CASE NOTES AS 100% STANDARD]
*5 CASES OF POOR COMPLIANCE TO AUDIT, REVIEW, LEARN, SHARE [IMPROVEMENT]
SURGICAL PROPHYAXIS POOR BUY-IN VARIATION IN COLLECTION OF OPERATIONS*COLORECTAL SURGERY *COLLECT <24 H AND <1H OF INCISION NATIONALLY *COMPLIANCE WITH LOCAL POLICY A LOCAL MEASURE
SAPG PRIMARY CARE PRESCRIBING 2009
• Compared with 08 44000 fewer antibacterials prescriptions
• Use of antibacterials associated with a higher risk of CDI reduced by 20%: 3% in quinolones, 11% in co-amoxiclav
• 9/14 boards below target for <5% seasonal variation in quinolones
• 5% increase in use of recommended antibacterials
Restricted Drugs 1
0
1000
2000
3000
4000
5000
6000
7000
No of DDDs
Financial Month / Financial Year
CO-AMOXICLAV,AMOXICILLIN,CLAVULANIC ACID
CIPROFLOXACIN
CLARITHROMYCIN
New "Antibioticman" Policy
LOCAL AND NATIONAL IMPACT ON CDI
0
5
10
15
20
25
30
35
40
45
50
2006
M01
2006
M04
2006
M07
2006
M10
2007
M01
2007
M04
2007
M07
2007
M10
2008
M01
2008
M04
2008
M07
2008
M10
2009
M01
2009
M04
2009
M07
2009
M10
2010
M01
Cdi
ffca
ses C.diff
model
P <0.001
TAYSIDENATIONAL
Time for a Group Hug ?
Measures of Antibiotic Policy Impact
• Process• Promoted and restricted antibiotics
• Outcome• C difficile infection
• Balancing• Mortality (30 day) for medical and surgical
admissions
BALANCING MEASURES: UNINTENDED HARM TAYSIDE 30DAY MEDICAL AND SURGICAL
MORTALITY
SURGERY
0
1
2
3
4
5
6
2004M042004M082004M122005M042005M082005M122006M042006M082006M122007M042007M082007M122008M042008M082008M122009M042009M082009M12
Dea
th_r
ate
Surg
ical
Surgical
model
Policy change
MEDICAL ADMISSION
30D FROM ADMISSION
SAPG 2011-2014 New PID
• Further Integrate into Quality Strategy • Consolidate gains: more work on surgical prophylaxis• Surveillance and consumption [National HMUD
project live for hospital prescribing] • Align with AMTs with IPTs/SPSP/Improvement hub
etc : build on QI expertise & capacity within SAPG • Primary care emphasis [QoF framework, cUTI, quality
audit tool etc] • SAB management and prescribing in hospital
continuing care [antibiotic bundle]• Unintended consequences• Review HEAT supporting prescribing target
AMT AND IPT COLLABORATION
Joint Network Event 1/3/2011Consider AMT + IPT strategic and operational level
managementSAB [prevention and effective management]CDI [prevention and management]Point prevalence survey -auditEducation Session for ICN on “bugs and drugs”
[Cleanliness champions for AMT's] QI initiative- “antibiotic review bundle”
ISSUES
Key issues “Front-end” empiric prescribing Antibiotic Policies (Antibiotic Man)“Continuing care antibiotic prescribing”
Not subject to adequate review
“Discharge prescribing”
INDICATION :
Start Date:
Review Date:
Action Taken on Review
Check Microbiology Results
Review Patient & Initial Diagnosis
Consider IV to Oral Switch
The 3 Day Antibiotic Bundle
WHAT DO I GET OUT OF IT?
Benefits for Doctor & Pharmacist & Nurse & organisation and patient
More streamlined therapy
Better patient management and outcomes
Less IV therapy
Less harm [resistance, CDAD etc]
Less cost
Earlier opportunity for discharge
+ Nurse• Less IV Therapy-more time • Less PVC/CVC infection [Decrease HAI]
CONCLUSION
HAI IS PREVETABLE AND REDUCIBLE INFECTION PREVENTION AND
ANTIMICROBIAL MANAGEMENT TEAMS NEED TO WORK TOGETHER STRATEGICALLY AND OPERATIONALLY
FORTHCOMING HAI PPS SURVEY A GOOD OPPORTUNITY TO SHOW THIS
JOINT EDUCATION OPPORTUNITIESYOU ALL HAVE A PIVOTAL ROLE IN THIS
THANK YOU