Role of the general physician in the management of sepsis and antibiotic stewardship

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1 Role of the general physician in the management of sepsis and antibiotic stewardship Prof Martin Wiselka Dept of Infection and Tropical Medicine University Hospitals of Leicester

2 Sepsis and antibiotic stewardship Sepsis Illustrative cases Historical perspective New initiatives Antimicrobial Stewardship Rational use of antibiotics NHS Targets / CQUINS

3 Public awareness

4 Public awareness

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6 Case 1 28 year old lady previously well, flu symptoms for 4 days Travelled by coach home to family arrived 8pm Family unhappy about her condition called 999 ambulance at 11pm, diagnosed with flu 2 further 999 calls to ambulance service overnight called GP following morning - telephone advice Next day called GP brought into surgery admitted to hospital Cardiac arrest shortly after arrival in hospital

7 Case 1 28 year old lady previously well, flu symptoms for 4 days Travelled by coach home to family arrived 8pm Family unhappy about her condition called 999 ambulance at 11pm, diagnosed with flu 2 further 999 calls to ambulance service overnight called GP following morning - telephone advice Next day called GP brought into surgery admitted to hospital Cardiac arrest shortly after arrival in hospital PM staphylococcal pneumonia complicating influenza

8 Case 2 43 year old lady previous splenectomy for spherocytosis Went to work at 7am Found unwell in toilet at 10am vomiting + headache declined ambulance Taken home by colleague arrived home at 11am Husband dialled 999 arrived in hospital at 12 mid-day Unrecordable BP, purpura fulminans Survived with antibiotics and supportive care in ITU Bilateral below knee amputations and amputation right hand

9 Case 2 43 year old lady previous splenectomy for spherocytosis Went to work at 7am Found unwell in toilet at 10am vomiting + headache declined ambulance Taken home by colleague arrived home at 11am Husband dialled 999 arrived in hospital at 12am Unrecordable BP, purpura fulminans Survived with antibiotics and supportive care in ITU Bilateral below knee amputations and amputation right hand Diagnosis: Streptococcus pneumoniae septicaemia

10 Sepsis: Lessons to be learnt Sepsis can affect young previously fit people Can be rapidly progressive Observations often unremarkable until impending death Very difficult to recognise in early stages Non-specific flu-like symptoms GI disturbance Toxic rash (like sunburn rash)

11 Sepsis: How big is the problem Organisation Cases Mortality Sepsis Trust 150,000 44,000 Time to Act 100,000 37,000 NHS Choices 100,000 31,000 Avoidable deaths 10,000-13,000

12 Issues in sepsis Definition Pathophysiology Incidence and mortality Recognition Immediate management

13 Definition of sepsis

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16 Old definition of sepsis

17 New definition of sepsis Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection Septic shock is a subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

18 Issues in sepsis Definition Pathophysiology Incidence and mortality Recognition Immediate management

19 Pathophysiology of sepsis

20 Issues in sepsis Definition Pathophysiology Incidence and mortality Recognition Immediate management

21 Sepsis mortality (BMJ 2013)

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24 Sepsis 100,000 admissions and 37,000 deaths/year, (10,000 avoidable) More than doubled in last 10 years Overall mortality 35% 5x higher than MI or stroke Every hour of treatment delay increases mortality by 8% Use of sepsis 6 care bundle improves outcome Number needed to treat to save 1 life = 4.6 Poorly recognised and managed in 2013 only 32% of patients treated within 1 hour Could save NHS 196m per year

25 Failings in care provided

26 Failings in care provided

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28 Issues in sepsis Definition Pathophysiology Incidence and mortality Recognition Immediate management

29 RCP

30 RCP

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34 University Hospitals of Leicester UHL has made Sepsis the new 5th Critical Safety Action. Dr John Parker Consultant Intensivist will be leading on this. He will be working in partnership with key clinicians from all specialties in UHL to improve sepsis recognition and treatment and to reduce the deaths and disabilities caused by sepsis.

35 Sepsis: screening and initial management

36 Sepsis screening The Adult Screening & ImmediateAction Tool must be applied to all adult patients with: a suspected new infection EWS of three (3) or more where staff or relatives have expressed concerns

37 Sepsis box on all wards

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39 Antibiotic resistance

40 Antimicrobial resistance MRSA VRE PRP VISA/GISA VRSA/GRSA MDRTB/XDRTB Falciparum Malaria Multi-resistant Gram -ves Acinetobacter Stenotrophomonas Pseudomonas Salmonella Gonococcus ESBL producers Carbapenamaseresistant organisms (CRO s, CRE s) NDM-1, OXA, KPC

41 Factors contributing to antibiotic resistance Genetic exchange Overuse of antibiotics Veterinary use Travel Asymptomatic carriage Inadequate infection control Poor Drug pipeline

42 Factors contributing to antibiotic resistance

43 Background Antibiotic resistance is a major public health problem. Devt of multidrug-resistant organisms limits choice of therapy Infections with multidrug-resistant bacteria result in higher morbidity and mortality prolonged hospital stay Emergence of C. difficile

44 Over use of antibiotics Goossens et al Lancet 2005; 365:579.

45 Over use of antibiotics Goossens et al Lancet 2005; 365:579.

46 Over use of antibiotics Goossens et al Lancet 2005; 365:579.

47 Antibiotic awareness

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50 The problem

51 The Solution

52 RCP guidance All physicians who prescribe antibiotics have a responsibility to prescribe optimally. Clear structures with direct responsibility at Board level for monitoring and agreeing antimicrobial prescribing in hospitals Establishment of a multidisciplinary antimicrobial management team lead doctor, antibiotic pharmacist, infection specialist and senior manager. Agreed antimicrobial formulary should be implemented and performance audited.

53 RCP guidance

54 Antimicrobial Stewardship Effective antibiotic prescribing Systems to identify patterns of antibiotic usage. A rolling audit of patient outcome, antimicrobial resistance, and antimicrobial prescribing Antibiotic education strategy that involves all staff involved in antibiotic administration Liaison with appropriate community prescribers to harmonise antibiotic prescribing guidelines Specialist antibiotic ward rounds

55 Interventions to limit antibiotic prescribing Intervention Effect Collect and feedback data on antibiotic use +/- Educational meetings +/- Antibiotic policies + Information on prescriptions + Antibiotic rounds ++ Restrictive policies ++++ Antibiotic gatekeepers?

56 Antimicrobial website

57 Importance of early appropriate therapy Weinsten et al Clin Infect Dis 1997; 24:564 Ibrahim et al Chest 2000; 198:146 Luna et al Chest 1997;111:676

58 Paradox of antimicrobial therapy Time to initiation of effective antimicrobial therapy is a strong predictor of mortality. Inappropriate or inadequate initial therapy is associated with increased mortality, morbidity, and length of hospital stay. Therapy with broad spectrum antibiotics must be initiated before the causative pathogen is identified.

59 Paradox of antimicrobial therapy Time to initiation of effective antimicrobial therapy is a strong predictor of mortality. Inappropriate or inadequate initial therapy is associated with increased mortality, morbidity, and length of hospital stay. Therapy with broad spectrum antibiotics must be initiated before the causative pathogen is identified.

60 Paradox of antimicrobial therapy Time to initiation of effective antimicrobial therapy is a strong predictor of mortality. Inappropriate or inadequate initial therapy is associated with increased mortality, morbidity, and length of hospital stay. Therapy with broad spectrum antibiotics must be initiated before the causative pathogen is identified. De-escalation strategy

61 Rational Antibiotic use ~50% of antibiotics unnecessary Overuse of antibiotics Drug resistance Adverse effects Unnecessary cost C.difficile

62 Rational Antibiotic use ~50% of antibiotics unnecessary Overuse of antibiotics Drug resistance Adverse effects Unnecessary cost C.difficile Surgical prophylaxis Surviving sepsis Early antibiotics Public pressure Medicolegal Clinical freedom

63 Rational Antibiotic use ~50% of antibiotics unnecessary Overuse of antibiotics Drug resistance Adverse effects Unnecessary cost C.difficile Surgical prophylaxis Surviving sepsis Early antibiotics Public pressure Medicolegal Clinical freedom

64 CQUIN 2016/17

65 CQUIN 2016/17

66 CQUIN 2016/17

67 Summary and conclusions Awareness of sepsis as a major health issue Recognition and immediate management of severe sepsis red flag sepsis Increasing problems of antimicrobial resistance and healthcare associated infections Antibiotic stewardship Antibiotic policies and infection teams CQUINS for sepsis management and antimicrobial use

68 Outstanding issues for discussion Sepsis difficult to diagnose early Current policy leading to Over-diagnosis of sepsis Escalation of workload Over-use of broad spectrum antibiotics (Meropenem) May exacerbate problems with antimicrobial resistance Tension between antimicrobial stewardship and sepsis management Source control may be neglected