FIS 2014 Abstracts Antibiotics and Resistance Issues. Poster No 0101

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1 Poster No 0101 Impact of a pharmacy to microbiology paper based referral system as an antimicrobial stewardship strategy Lasantha Ratnayake, Charles Waweru James Paget University Hospitals NHS Foundation Trust, Gorleston, UK Prudent antimicrobial prescribing is important to preserve the activity of antimicrobial agents we currently have, to reduce health care associated infection such as C. difficile and minimise toxicity associated with antibiotics. Pharmacists are integral to effective antimicrobial stewardship. A paper based referral form was introduced in pharmacy in October 2013 to facilitate greater interaction between pharmacists and microbiologists as a strategy to promote prudent antimicrobial prescribing by identifying patients who are likely to be on inappropriate antibiotics. Patients were considered to be on inappropriate antibiotics if they were on antibiotics defined as restricted' by the trust, on 3 or more antibiotics or on antibiotics for longer than 5 days. Pharmacists could also refer patients if they had other concerns. Once completed, forms were reviewed by a Consultant Microbiologist and divided into a) those that needed a discussion with the prescriber to optimise antibiotic prescription and b) those that did not need a further review either because prescription was appropriate or had been discussed with Microbiologist previously. All those reviewed were given one of the following recommendations to streamline antibiotics. 1) Discontinue all antibiotics 2) Narrow or broaden antibiotics based on culture results 3) Narrow or broaden antibiotics empirically 4) Convert from parenteral to oral route 5) Increase or decrease dose 6) Consolidate to fewer antibiotics 7) Review the need for further antibiotics 8) Remain as prescribed One hundred and forty forms were received between 7/10/2013 and 31/01/2014. Eighty seven (62%) were discussed with a clinician. Advice was given in 66 patients (76%) to streamline antibiotics (recommendations 1-7). Almost one third of patients (32.1%) who were referred were on restricted antibiotics. Of these, 17 were prescribed without prior microbiology approval. Following discussion, 8 patients (47%) had their restricted antibiotics stopped or changed to a narrow spectrum antibiotic. Of the 19 patients in whom documentation of microbiology discussion and compliance were assessed this had been documented in 14 (73.7%) and microbiology advice followed in 18 patients (94.7%). Results show that this intervention is useful for reducing inappropriate antibiotic prescribing. The paper based method is useful where there is a lack of ward pharmacists, electronic prescribing or lack of microbiologists to do daily infection ward rounds. The referral process should be streamlined further to reduce unnecessary referrals by education of pharmacists, increasing presence of pharmacists on wards as more than 35% of referrals were not acted upon by the Microbiologist. The paper form has now been replaced by an electronic form and the restricted antibiotic policy has been updated to provide more guidance to prescribers and pharmacists. This is an effective antimicrobial stewardship strategy to minimise inappropriate antimicrobial prescribing. This is a good example of close collaboration between departments with a focus on delivery of a quality improvement programme. In the next stage, we hope to measure outcome indicators such as clinical

2 cure, readmission, mortality to evaluate the impact of this strategy on patients' outcomes. This is an integral measurement of any antimicrobial stewardship programme

3 Poster No 0102 The rapid identification and confirmation of carbepenemase-resistant Enterobacteriaceae (CRE) using Brilliance TM CRE Agar and Sensititre TM Gram negative plates (GN4F) Anne Butler 1, Kate Powell 1, Milena Oleksiuk 2, Jessica Screen 2 1 Thermo Fisher Scientific, East Grinstead, UK 2 Thermo Fisher Scientific, Basingstoke, UK The study aimed to determine whether the minimum inhibitory concentration (MIC) of four carbapenem antimicrobials (doripenem, ertapenem, imipenem and meropenem) for carbapenem-resistant Enterobacteriaceae (CRE) grown on Thermo Scientific TM Brilliance TM CRE Agar (Thermo Fisher Scientific) can be determined directly from the agar plate and whether the susceptibility results for these cultures agree with those from cultures grown on Columbia Blood Agar (CBA). Fifty Enterobacteriaceae comprising 31 strains of Klebsiella pneumoniae, 11 strains of Escherichia coli, 6 strains of Enterobacter cloacae and 2 strains of Enterobacter spp., all previously characterised as CRE, were grown on Brilliance CRE Agar & CBA overnight. Following the manufacturer's instructions, the cultures were tested in parallel on Thermo Scientific TM Sensititre TM Gram-negative plate formats (Thermo Fisher Scientific). After overnight incubation, plates were read automatically and visually using both the Thermo Scientific TM Sensititre TM OptiRead TM and Thermo Scientific TM Vizion TM instruments. Forty eight of the strains tested were recovered on Brilliance CRE Agar. One hundred and ninety-one of the 192 organism/antimicrobic combinations (99.5%) were in essential agreement (EA) for the OptiRead reads and 100.0% were in EA for the Vizion reads. The single discordant strain was an OXA-48-producing E. coli which grew weakly on Brilliance CRE Agar and returned a minor discrepancy (according to CLSI interpretations) or category only (according to EUCAST interpretations) for meropenem. Overall, carbapenem MICs from both Brilliance CRE Agar and CBA were consistent. This study demonstrates that MIC results can be determined directly from isolates cultured on Brilliance CRE Agar plates in the majority (98%) of cases and that for these four carbapenem antimicrobials, MICs are equivalent for strains grown on Brilliance CRE Agar or CBA

4 Poster No 0103 Development of a decision aid for management of Clostridium difficile infection (CDI) in Care Homes Susan Roberts 1, Jacqueline Sneddon 1, Margaret Tannahill 3, Lisa Ritchie 2 1 Scottish Antimicrobial Prescribing Group, Glasgow, UK 2 NHS National Services Scotland, Glasgow, UK 3 The Care Inspectorate, Glasgow, UK Care Home staff are a group who can benefit from provision of advice and education on infection and use of antibiotics as residents in Care Homes are among the most vulnerable to infection and in particular HAI due to frequent hospital admissions and out-patient visits. Care Home staff comprise both nursing and social care professionals therefore education designed for healthcare staff is often not appropriate and guidance for hospitals and health centres may not translate into the Care Home setting. The Health Protection Network (HPN) published updated guidance on CDI for NHS Scotland in January In 2013 the Scottish Antimicrobial Prescribing Group (SAPG) developed a decision aid to support management of urinary tract infection (UTI) in older people which was well received by the care home sector. A short life working group of key stakeholders was established to develop a similar decision aid to support management of CDI. Key information was extracted from the HPN CDI guidance and a draft decision aid was developed for Care Home staff covering diagnosis of CDI in a resident with diarrhoea, infection prevention and control precautions, advice for families and carers and treatment of CDI. The information is presented as a flow chart detailing actions required and supplemented by a series of good practice points. Following several iterations the draft decision aid was agreed by the short life working group and is now undergoing broad consultation with relevant groups for comments prior to finalising the content. This piece of work has allowed healthcare professionals to engage with a variety of stakeholders involved in provision of care home services. The increased understanding of the care home worker perspective has been essential to develop a decision aid for CDI to support safe and effective management of residents with diarrhoea. This initiative will be beneficial for not only Care Home staff but also residents and their families and carers. Translation of relevant clinical guidance into user friendly support for Care Home staff should be considered for all future publications to address their specific education needs. National engagement with key clinical groups and care providers has allowed us to develop a decision aid to improve the management of CDI in Care Home residents. The final version of the CDI decision aid will be printed and distributed to all Care Homes as part of NHS Scotland activities to support European Antibiotic Awareness Day We plan to seek feedback on the usefulness of the decision aid from GPs and Care Home staff and also evaluate the impact on infection control practice via the HPN and antibiotic use through analysis of prescribing data

5 Poster No 0104 Improving empirical prescribing in Medical Admissions Units using an antimicrobial prescribing quality indicator Jacqueline Sneddon 1, Andrea Patton 1, Gwen Bayne 1, Dilip Nathwani 1, R Andrew Seaton 2,1 1 Scottish Antimicrobial Prescribing Group, Glasgow, UK 2 NHS Greater Glasgow and Clyde, Glasgow, UK In 2008, the Scottish Antimicrobial Prescribing Group (SAPG) issued national guidance on restriction of antibiotics associated with high risk of Clostridium difficile infection (CDI) within antimicrobial prescribing policies. SAPG developed quality indicators for antimicrobial prescribing to support achievement of the Scottish Government CDI target based on compliance with restrictive policies. One of these indicators focused on empirical prescribing in Acute Medical Admission Units (AMAU) since this was the area where a large proportion of antibiotic prescriptions were initiated. Indication recorded and empirical antibiotic choice compliant with local policy. Target =95% compliance. Empirical prescribing data were collected on indication for the antibiotic recorded in the patient's medical notes and compliance with the local antibiotic prescribing policy. Indicator data were collected monthly for a sample of 20 patients in each unit, aggregated data collated using a web-based system and national reports produced 3-monthly. Local data were also available for real time feedback of results. The national median compliance achieved for the empirical prescribing indicator for was: Indication documented: 98% (Range %) Policy Compliant: 93% (Range %) Data were collected from over 15,000 patients and entered on the web-based system and showed that 14 out of 14 (100%) boards achieved the target for indication documented and four out of 14 (29%) boards achieved the target for compliance with policy. Although the target level for compliance with policy was not reached in all boards it was agreed by SAPG that sustained improvement had been accomplished in the majority of boards. During the period the measure of indication documented' achieved the median target of 95% and all individual boards also met the target. The measure antibiotic choice compliant with local policy' did not reach the median 95% target but all boards showed increased compliance in the majority of AMAU during compared with Following sustained improvement in the national median a final report on the AMAU quality indicator was produced in 2014 and SAPG made the decision to conclude formal reporting of the empirical prescribing indicator in AMAU and move focus to downstream medical wards from April The quality indicator will be re-visited in AMAU at least twice per year to confirm ongoing compliance with antimicrobial policy. Quality indicators are an effective tool to drive improvements in antimicrobial prescribing across hospital and primary care settings. The combination of measures for scrutiny with improvement methodology can lead to reliable and sustainable improvements in prescribing practice. Our experience of using quality

6 indicators to measure prescribing practice in AMAU combined with regular feedback of the data collected to clinical teams has increased compliance with local antimicrobial prescribing policy and provided national assurance that changes in antimicrobial use have been implemented. This has been an important factor in achieving the sustained reduction in CDI rates seen across Scotland from 2009 onwards

7 Poster No 0105 Improving patient outcomes through development of an innovative informatics programme Charis Marwick 2,3, Marion Bennie 1,3, Dilip Nathwani 1,3, William Malcolm 2,3, Jacqueline Sneddon 3 1 NHS National Services Scotland, Edinburgh, UK 2 NHS Tayside, Dundee, UK 3 Scottish Antimicrobial Prescribing Group, Glasgow, UK NHS National Services Scotland (NSS) currently hosts a wide range of infection related data on behalf of NHS Scotland. The NHS Scotland Infection Intelligence Platform (IIP) is being developed to improve patient outcomes and reduce harm from infection through an innovative, integrated database to support clinicians throughout NHS Scotland. The IIP will provide integrated information on infection (for example by combining risk factors, demographics, healthcare activity, medicines use and clinical data) through linking of national and local infection information collected across NHS Scotland. NSS has been tasked with development and implementation of IIP and is supported by a broad coalition of clinicians and national stakeholders. This work builds on previous studies which demonstrated how data linkage could provide valuable information about positive and negative consequences of changes in antibiotic policy. A series of exemplar studies will be used to develop and test data linkages across a broad range of infectionrelated areas. Better use of our national and local data through a collect once and use often approach will enable better, faster and more efficient use of information. Funding and information governance requirements have been secured and existing national datasets are being used and combined to improve our understanding of the epidemiology of antimicrobial resistance, identify populations at high risk of adverse outcomes. These data will be made increasingly available to users in NHS boards via electronic systems to support local infection prevention and control teams and antimicrobial management teams and will also be utilised to inform prescribing strategy and policy development. Work in one NHS board demonstrated how linkage of datasets could provide information about CDI rates and acute kidney injury rates at individual patient level following a change from using cephalosporins to a gentamicin-based surgical prophylaxis regime. The aim of replicating this work in other NHS boards led to the development of IIP as a means of doing this more efficiently. Similar studies are underway to measure the impact of the Sepsis 6 intervention as one of 16 exemplar infection-related studies covering risk, treatment and outcome. The creation of the first Infection Intelligence Platform in the UK is an exciting innovation in the prevention and treatment of infection and confirms Scotland's position as a world leader in healthcare informatics. Following this 3 year project IIP will become embedded in practice to provide ongoing data to drive quality improvement in prevention and treatment of infection. Benefits of IIP include reduction in clinical incidents/ adverse effects associated with HAIs, reduction in time and cost spent gathering and reporting data, more effective bed management, discharge planning and demand planning and an enhanced evidence base to inform policy

8 Poster No 0106 Development of a national quality indicator to support reduction of total use of antimicrobials William Malcolm 1,2, Victoria Elliott 1,2, Jacqueline Sneddon 2, Dilip Nathwani 2, Simon Hurding 3,2 1 NHS National Services Scotland, Edinburgh, UK 2 Scottish Antimicrobial Prescribing Group, Glasgow, UK 3 Scottish Government, Edinburgh, UK In May 2013 a national quality indicator on total antibiotic use in primary care was introduced by the Scottish Government to provide an additional stimulus to reduce unnecessary prescribing for self-limiting infections. The national quality indicator was built on the methodology developed for National Therapeutic Indicators which establishes a best in class level, set at the 25th percentile of all GP practices in Scotland. The antimicrobial national quality indicator is antibiotic use, expressed in items/1000/day in at least 50% of practices in each NHS board will be at or below the 25th percentile of Scottish practices or will have made the minimum acceptable reduction toward that level (using January-March 2013 as the baseline). The indicator will be assessed annually over a 3 year period. The median rate of prescribing has reduced by 5.1% from the baseline period to quarter At GP Practice level, 30.4% of practices in Scotland were at or below the level of the 25 th percentile at baseline and a further 27.1% of practices achieved the target through making an acceptable reduction so overall, 57.5% of practices in Scotland achieved the target. Nine out of 14 NHS boards met the target level. However 29.5% of practices had an increased prescribing rate in Jan- Mar 2014 compared with the baseline and these practices were spread across all NHS boards. During the past year SAPG has engaged with primary care teams via the Scottish Prescribing Advisers Association to reduce unnecessary use of antimicrobials, particularly for self-limiting upper respiratory tract infections. A new education resource was launched in 2013 to support the target but this has only been utilised in two board areas to date therefore is unlikely to have been a factor in the current reductions seen. Additional impetus for reducing unnecessary use may be due to increased coverage of the risks of AMR in national media with the Chief Medical Officer and Prime Minister calling for action. of a national quality indicator for antimicrobials with a target level shows a temporal association with a downward trajectory of total antibiotic use following two years of increasing use. Although some progress has been made during the first year following introduction of the national quality indicator, a reduction in antibiotic prescribing rate was also observed in other UK countries for the same time period. Therefore the impact of the national quality indicator and associated educational support on antibiotic use in Scotland cannot be confirmed until we have prescribing data for year

9 Poster No 0107 Development of a national education programme for Antimicrobial Pharmacists Susan Roberts 5,2, Arlene Brailey 1,2, Fiona McMillan 1, Sheila Noble 1, Jacqueline Sneddon 2, Alison Wilson 2,4, Alison Macdonald 2,3 1 NHS Education for Scotland, Glasgow, UK 2 Scottish Antimicrobial Prescribing Group, Glasgow, UK 3 NHS Highland, Inverness, UK 4 NHS Borders, Melrose, UK 5 NHS Dumfries and Galloway, UK Antimicrobial pharmacists are vital to the success of antimicrobial stewardship programmes in NHS organisations. The Association of Scottish Antimicrobial Pharmacists (ASAP) identified a need to provide advanced level training, based on professional experience for this group of specialist pharmacists. A series of Specialist Vocational Training Frameworks are in development by NHS Education for Scotland (NES) Pharmacy for hospital pharmacists as part of the continuum of training after Generalist Foundation Training (VT2). The development of a specialist competency framework (VT3) enables pharmacists to demonstrate consistency of practice and acquisition of a wider range of knowledge from the application of pharmacy practice through the development of a personal e-portfolio. Funding was secured through the Scottish Antimicrobial Prescribing Group, a project lead was appointed to develop, implement and test the Infection and Antimicrobial Stewardship Competency framework supported by a project steering group over a period of one year. The framework consists of 2 sections, a core section containing 11 elements and an elective section from which the VT3 specialist trainees must complete 4 out of 10 elements. The framework contains defined competencies linked to each element with supporting performance indicators, suggested learning methods, evidence and linked resources. Trainees will take months to complete and collate evidence within an e-portfolio and are supported throughout their training by educational supervisors who have previously been approved by NES Pharmacy. On successful completion of the e-portfolio trainees have an oral assessment by a panel of experts. The programme was completed in April 2014 and three experienced antimicrobial pharmacists commenced an abbreviated training programme to qualify as educational supervisors by early Planned engagement with the national microbiologists group will seek support for pharmacists to gain clinical and laboratory experience. NES Pharmacy and the two Scottish Schools of Pharmacy are working on an impact evaluation of this framework over the next 3-5 years. The supporting literature resource provides a useful reference source for other professions and the content is being utilised to develop education to support nurses and midwives who contribute to stewardship. This framework for providing education on infection and antimicrobial stewardship has been developed in clear alignment with the requirements of NHS e-portfolio, the General Pharmaceutical Council (GPhC) continuing professional development (CPD) and the Royal Pharmaceutical Society faculty structure. It is intended that pharmacists completing this training can use the evidence generated for the RPS Faculty portfolio as well as their GPhC CPD. This work clearly demonstrates excellence in pharmacy education and has delivered a comprehensive competency based educational framework in infection and antimicrobial stewardship for pharmacists in Scotland which will contribute to improved patient safety and outcomes

10 Poster No 0108 Carbapenem prescribing in Scotland: a paradox Ashutosh Deshpande 1, Guy McGivern 3,2, Malcolm William 2, Camilla Wiuff 2, David Henderson 2, Julie Wilson 2, Donald Bunyan 2, Alan Banks 2, Brian Jones 4 1 Southern General Hospital, Glasgow, UK 2 Health Protection Scotland, Glasgow, UK 3 National Services Scotland, Edinburgh, UK 4 Glasgow Royal Infirmary, UK Serious infections caused by extended spectrum beta lactamase (ESBL) producing organisms are conventionally treated with carbapenems, which are often one of the final resorts for treating resistant infections. There is an increasing national push towards stricter antimicrobial stewardship for treating gram negative organisms, due to the risk of development of resistance and the emergence of carbapenem resistance. This poster presents Scottish national data on ESBL resistance rates and carbapenem prescribing rates over the past few years. Scottish antimicrobial resistance data from Health Protection Scotland has shown that the proportion of extended-spectrum beta lactamase producing gram negative organisms such as Escherichia coli and Klebsiella pneumoniae isolates remained stable between 2009 and 2011, since 2011 actually appear to be on a downward trend. However, carbapenem prescribing rose by over 34% between 2008 and 2013 with daily divided doses issued in Scotland in 2008 rising to in Additionally, the number of carbapenemase producing Enterobacteraceaie detected in Scotland has steadily increased since There is a paradoxical relationship between carbapenem prescribing and isolation of ESBLs at a national level. More needs to be done to understand the reasons behind the increased rates of carbapenem prescribing. The Scottish Antimicrobial Prescribing Group (SAPG) has also issued guidance for use of carbapenem sparing agents and hopefully this may curb prescribing rates and the development of resistance. Additionally, a large board-wide audit in Greater Glasgow and Clyde is now underway looking at all instances of carbapenem use and performing a root cause analysis to understand whether this was appropriate or not and the reasons behind carbapenem prescribing. More efforts are required at the grass-root level in all Scottish health boards to understand the barriers to effective gram negative antimicrobial stewardship

11 Poster No 0109 Antimicrobial stewardship in a busy district general hospital: how good are we at getting it right at the front door? John Boyes, Naina Mohan Gloucestershire Hospitals NHS Foundation Trust, UK With an ever increasing importance put on antimicrobial stewardship and appropriate prescribing leading on from the government's Start Smart Then Focus initiative treatment guidelines based on diagnosis are a powerful tool in the struggle to adhere to these ideals. But how good are we at getting the initial diagnose right and grading severity at the time of presentation? Often diagnosing even common infections like pneumonia (CAP) and urinary tract infections (UTI) is difficult and the source of infection is only seen after results of microbiology cultures or other investigations. The number of patient on antibiotics within our trust is consistently above the national average although audits have shown that our compliance with local guidelines is above the national average. We conducted an audit assessing the diagnosis and prescribing accuracy of CAPs and UTIs within our admission units between January and March Data on 50 patients admitted with CAP or UTI was prospectively gathered. 25 patients had a CAP, 19 patients had a UTI and 6 patients had a diagnosis of mixed CAP/UTI. Diagnosis of these infection was compared against national and local guidelines and algorithms. Exclusion were allowed where there was felt to be an exacerbation of an underlying condition or the diagnosis was hospital acquired pneumonia. Of those diagnosed with CAP only 76% of patients fulfilled the diagnostic guidelines criteria; of those diagnosed with UTI 82% fulfilled the local diagnostic criteria and in those diagnosed as mixed CAP/UTI only 50% of patients fulfilled the diagnostic criteria. Of the entire cohort 24% of diagnoses were not compliant with guidelines. With regards to initial antibiotic choice, only 66% of patients were on antibiotics recommended by guidelines or if the antibiotics were off guidelines a documented reason for this was found in the medical records. Although our audit had a very small sample size collected over a limited period of time, our results indicate that there is an alarming lack of adherence to local guidelines when it comes to both diagnosis and prescription of antibiotics. In some cases, doctors were using scoring systems other than the CURB-65 score to grade severity of CAPs, and thereby guide their antibiotic choice. As we know many factors influence the initial prescription of antibiotic but clinical diagnosis and severity of that diagnosis are clearly the mainstay of arriving at the appropriate choice of antibiotic. In our study we saw that almost a quarter of diagnoses were not compliant with Trust guidelines and there was no documented reason as to why this was. In addition approximately one third of patients were prescribed an off guideline antibiotic based on their diagnosis. This obviously has implications affecting antimicrobial stewardship and may propagate the development of resistant organisms in the long-term

12 The results of our audit ask significant questions about the prescribing of antibiotics locally. Why is our adherence to guidelines poor in certain areas and what can be done to improve this? Following presentation at a Medical Grand rounds it was agreed that further work needs done and a re-audit is planned. Furthermore we feel that updated national guidelines taking into account newer assessment algorithms would be invaluable, especially when assessing CAP

13 Poster No 0110 Carbapenemases: How effective is surveillance screening? An observational approach Darryl Braganza Menezes University Hospital North Staffordshire, Stoke-on-Trent, UK Carbapenem-resistant Enterobacteriaceae (CRE) have emerged globally and have become a major threat to public health. Carbapenem resistance can be caused by a variety of mechanisms and have been identified in a variety of Enterobacteriaceae species. As gastrointestinal carriage has been identified as a reservoir for CRE transmission in health care environments, active surveillance among high risk patients has been deemed important for controlling CRE spread in acute health care settings. We review 5 years of CRE detection in a tertiary hospital setting via a widely used screening tool, rectal swabs and assess the detection rate of rectal swabs in confirming CRE when subsequent microbiological specimens have cultured CRE. From a five year period of data collection utilising retrospective identification of CRE specimens via use of the LabCenter audit tool, we identified 24 cases (patient incidents of CRE of which only the first occurrence was recorded) - of these 1 was not a true CRE, as subsequent reference lab confirmation demonstrated AMP-C impermeability and 7 cases were as a result of cross contamination and outbreak in a single renal unit. Thus, 17 cases were identified. CRE was not detected by a rectal swab in 6/17 (35%) of cases. In the missed group of CRE's via rectal swab 3/6 (50%) never grew a CRE despite other specimens recording persistent CRE growth. The most common Enterobacteriaceae demonstrated was Klebsiella pneumoniae 10/17 (59%) with the most common carbapenemase resistance mechanism being Oxa-48 (7/17) gene positivity via reference lab molecular testing. Six of seventeen (35%) cases had a negative rectal swab prior to subsequent CRE confirmation. The median time from negative to positive rectal swab was 16.3 days. 33% of these initially negative rectal swabs demonstrated some level of resistant species prior to detecting a carbapenemase, though the same species was only detected in 6% of cases. Another finding of note was that 1 case demonstrated 2 different mechanisms of carbapenem resistance both NDM and Oxa 48 resistance mechanisms with no history of foreign travel. Our findings demonstrate the potentially high level of missed CRE's utilising rectal swabs as a screening tool. Additionally while 50% of cases did not (inappropriately) have a rectal swab, it is concerning that 50% of cases did not grow a CRE when there was evidence of colonisation elsewhere. The implications of these findings given the increasing number of CRE's both locally and nationally should convince infection prevention and control teams to have a lower threshold for screening and consider a standardised approach, potentially utilising commercial carbapenemase plates. Additionally, this raises the risk of outbreaks in the proportion of patients not appropriately identified and where effective infection prevention and control measures are therefore not instituted. While there should be no missed opportunities, our findings suggest that more work on education at the ward level is essential to ensure that high risk groups are readily identified and screened and that awareness of previous non-cre

14 multidrug resistant species can be harbingers of CRE development prompting increasing frequency of surveillance in these groups. We demonstrate the detection rate of the widely used rectal swab screening procedure for CRE's in a large tertiary health care setting utilising 5 years of retrospective data. In 35% of cases the rectal swab screening missed a CRE and in 50% of these cases despite known CRE colonisation, rectal swabs remained negative. These findings should raise awareness for infection prevention and control and reinforce education at a ward level with lower thresholds for screening and clear criteria for high risk patients to eliminate the number of cases of inappropriately missed opportunities

15 Poster No 0111 Sensitivity of urinary ESBL producing Gram negative isolates to pivmecillinam Jane Cunningham, Paul Beckett, Helena Parsons Sheffield University Teaching Hospital, Sheffield, UK Urinary tract infections are one of the most common infections requiring antibiotic therapy. As resistant Gram negative isolates, such as extended spectrum beta lactamase (ESBL) producers increase, optimal therapeutic options become increasingly challenging. Antimicrobial selection must consider not only the sensitivity of the isolate, but also potential adverse events (including the development of Clostridium difficile associated diarrhoea) and allergy status. Despite a global focus on the urgent need to develop novel anti-microbial compounds, progress remains slow. Reviewing the potential role of existing antimicrobials may provide effective therapeutic options. Pivmecillinam is an oral pro drug of mecillinam which was discovered in the 1970s and is licensed for the treatment of urinary tract infections. Its role in the treatment of ESBLs has been increasingly advocated in the literature. Pivmecillinam has limited impact on both gut and vaginal microflora and the available evidence base is suggestive of low rates of associated C difficile. 170 urine culture isolates were tested by disc methodology for sensitivity to mecillinam. The aim was to establish whether this existing antimicrobial may offer an effective treatment option for urinary tract infection with ESBL producing organisms. Isolates were collected prospectively over a period of three months and tested in accordance with BSAC testing methodology. As per BSAC guidance, zone sizes of <13 were termed resistant and >14 were termed sensitive. Of 170 isolates 20 were resistant and 145 were sensitive. 4 isolates were excluded as they were subsequently identified as Amp C producers or carbapenemase resistant organisms. 1 isolate had intermediate sensitivity. The range of zone sizes was 6-36mm with a mean of Overall 89% of ESBL urinary isolates tested sensitive to mecillinam in vitro. The zone sizes revealed a bimodal distribution. The increasing prevalence of ESBL urinary isolates has resulted in limited oral therapeutic agents for the treatment of urinary tract infections. Novel therapeutic strategies are urgently needed and this data suggests that pivmecillinam may prove an alternative to intravenous therapy with carbapenems in patients who are otherwise well. Pivmecillinam is highly concentrated in the urine, well tolerated with a minimal side effect profile and can be given in renal impairment. The spectrum of activity includes Gram negative Enterobacteriacae, however there is limited Gram positive and anaerobic cover ensuring a targeted approach to treatment. Although the evidence base pertaining to association with C. difficile related diarrhoeal infection is limited, current evidence suggests that pivmecillinam has a minimal impact on existing gut flora and vaginal flora. In vitro models of gut flora exposed to pivmecillinam support this suggestion. Pivmecillinam is an existing licensed gram negative antibiotic which has a potential role in the therapeutic treatment of urinary ESBL isolates. In a sample of 166 ESBL producing urinary isolates, 89% proved sensitive to pivmecillinam by disk. Current evidence suggests a low association with Clostridium difficile and minimal impact on gut microflora. It has been previously used relatively extensively in Scandanavian countries however use in the United Kingdom has been more limited. Further research is needed into clinical outcomes and C. difficile rates in patients on pivmecillinam therapy

16 Poster No 0112 The Antimicrobial Stewardship ward rounds in Edinburgh- an analysis of 12 months of data Rebecca Sutherland 1, Oliver Koch 1, Laura Shaw 2, Alison Cockburn 2, Diane Reekie 2, Carol Philip 2, Eilidh Fletcher 2, Claire Mackintosh 1 1 Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK 2 NHS Lothian Pharmacy Service, Edinburgh, UK Antimicrobial rounds led by an Infectious Diseases Consultant and Antimicrobial Pharmacist were carried out twice weekly on eight general medical and surgical wards in the Royal Infirmary, Edinburgh from May 2013 and April Patients who received IV antibiotics for more than 48 hrs and /or alert antibiotics* / iv metronidazole were identified. Each patient's drug chart, case notes and blood results were then reviewed to ascertain whether continuation of intravenous antibiotics remained appropriate. Where it was judged that continuation of IV antibiotics was not indicated according to predefined criteria, recommendations were made to either stop antibiotics, rationalise antibiotic choice, or change from IV to oral. Furthermore, where continuation of IV therapy was judged to be indicated in patients who who were otherwise well a referral to the OPAT department was suggested. Patients with complex infection problem were highlighted for a formal infection consult review. In 12 months 2,164 antimicrobial prescriptions were reviewed on 1,312 patients. 12% of all those inpatients were on iv antibiotics. 55% of intravenous antibiotics prescriptions were for patients over the age of 70. We suggested stopping antibiotics in 386 cases (17.8%), switching from iv to oral antimicrobials in 498 cases (23%), changing to a narrower spectrum in 51 cases (2.4%), referring to OPAT in 29 cases (1.3%) and continue and review in 54.8% cases. The number of reviews per patient ranged from 1 to 11. Most advice was complete after the first review (1745 times). Most antibiotic prescribing issues centred on the use of broad spectrum agents mainly piperacillin/tazobactam (836 prescriptions -38.6%) and co-amoxiclav (260 prescriptions -12%). A greater number of prescriptions of piperacillin/tazobactam were seen on the surgical wards (54%) than medical wards (27%) although the surgical wards had a higher throughput of patients. In most cases where it was agreed that antibiotics should continue the patients were evaluated as having continuing sepsis (30%). Other common indications included a specific infection (such as a Staphylococcus aureus bacteraemia) in 30% of medical cases, 16% of surgical cases or that the oral route was compromised (17% medical cases, 21% surgical cases). Where advice was to stop antibiotics this was followed in 95% of cases (at subsequent review 3-5 days later). Where advice was to switch to oral antibiotics this was followed in 92% of cases (93% medical, 89% surgical). * meropenem, ceftazidime, linezolid, tigecycline, daptomycin, levofloxacin, fidaxomycin, temocillin, cefazolin, ceftaroline, fosfomycin iv, ertapenem and azithromycin iv The use of antibiotics is high in our hospital but compares to other published studies. The ward round had a significant impact on antimicrobial use and was deemed an acceptable intervention by both medical and surgical units. The high use of broad spectrum antibiotics is in part due to local prescribing policy and this is currently being reviewed. This intervention has provided data to enable specific areas of high IV antibiotic use to be further looked at. This may also in turn enable a move away from broad spectrum agents as first line empirical choices

17 This intervention focussed on specific wards only. Yet several wards, not included in the AMT round, are high antibiotic prescribers (as identified on infection consult rounds and antimicrobial reports). This suggests there is even greater scope for adjustments in antibiotic use in the future. This study did not assess whether a switch to oral antibiotics does decrease the risk of Clostridium difficile diarrhoea and further work is necessary to explore this area. Focusing on whether antibiotics should be started in the first place may be a more effective strategy. The estimated monitory savings from the ward round over 12 months is calculated as 76,000 (comprising cost savings from antibiotics avoided/changed and ancillary costs). Savings were incremental depending on whether or not the advice given was followed on the day of review or later. This does not take account of potential savings in reduced length of stay or releasing nursing time. The antimicrobial ward round is an effective service. The intervention is acceptable to medical and surgical clinical teams. There is considerable use of broad spectrum antibiotics in the Trustour hospital and the study identifies that in many cases these are surplus to requirement for safe patient care. It also identifies specific clinical scenarios where the overuse of these agents can be targeted. Monitory savings can be made in reducing duration of IV therapy. Benefits such as reduced exposure to HAI, release of nursing time and reduced length of stay are likely although not yet quantified

18 Poster No 0113 Lessons learnt from experiences of treating cellulitis in OPAT Jessie Zhang, Rachel Bousfield, Elinor Moore, Anna Mayhew Department of Infectious Diseases, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, UK The introduction of Cambridge University Hospital's Out Patient Antimicrobial Therapy (OPAT) service in 2010 has led to developing experience in managing cellulitis. The patients selected for this service are referred by one of two pathways: by the admission avoidance Ambulatory Care Pathway or by referral of stable in-patients who no longer require hospital admission. National data shows cellulitis causes 1.6% of non-elective hospital admissions (1) and 0.1% of the adult population in Scotland require hospitalisation for cellulitis per year (2). Uncomplicated cellulitis usually requires 3-4 days of intravenous antibiotics before a switch to oral options is made. (3) Our aims were to: Assess the demographics of cellulitis patients using the service Assess the length of treatment with IV antibiotics required by patients with cellulitis Explore the risk factors that predispose to longer courses of OPAT treatment for cellulitis Investigate the inpatient readmission rates and the causes of treatment failures We have a prospective database of 289 episodes of cellulitis that had been treated by the OPAT service, over the course of 3.5 years, contributed to by 267 patients. We collected data using the OPAT electronic database, online medical records and clinic letters. We studied patient demographics, readmission rates and risk factors including previous cellulitis, diabetes, immunosuppression, lymphoedema, peripheral vascular disease, obesity, history of skin conditions, fungal foot infections, blistering cellulitis and peripheral neuropathy. We utilised SPSS version 21 and the Mann-Whitney U test. More service users were males (59%) and the median age was 39. Most cellulitis occurred in the leg (78%). Episodes required 4 days (median) OPAT treatment, most commonly treated with ertapenem (88%). It took significantly more time to treat the cellulitis using IV antibiotics (and utilising OPAT services) if patients had the following risk factors: previous cellulitis, diabetes, immunosuppression, lymphoedema, peripheral vascular disease and were overweight (p-values <0.05.) In contrast no significant differences were found for the following risk factors: concurrent fungal foot infections and peripheral neuropathy (p-values >0.05.) Our data supports previous data that shows risk factors that lead to longer courses of IV antibiotics include previous cellulitis, diabetes, immunosuppression, lymphoedema (4), peripheral vascular disease and being overweight. In the absence of these risk factors IV antibiotic therapy under OPAT was a median of 4 days, similar to published data. (3) Limitations of this study include the small number of patients with certain risk factors that may lead to statistically insignificant results, incomplete data (particularly with relation to BMI) and the retrospective nature of this study

19 The rate of readmissions following our OPAT treatment was low (5.5%) showing it is safe and costeffective. When planning treatment for patients with cellulitis, one must be aware of the risk factors associated with longer courses of IV antibiotic therapy

20 Poster No 0114 BSAC Respiratory Resistance Surveillance Update 2012/13 Rosy Reynolds 1,2, John Murray 3, BSAC Standing Committee on Resistance Surveillance 2 1 North Bristol NHS Trust, UK 2 British Society for Antimicrobial Chemotherapy, Birmingham, UK 3 LGC, Fordham, UK The BSAC Respiratory Resistance Surveillance Programme ( has monitored antimicrobial susceptibility in the UK and Ireland in the major organisms causing community- and hospitalonset (>48 hours) lower respiratory tract infections (LRTIs) since 1999 and 2008, respectively. Between Oct 2012 and Sept 2013, 34 clinical laboratories collected: Streptococcus pneumoniae, 416 Haemophilus influenzae and 223 Moraxella catarrhalis from community LRTIs Staphylococcus aureus, 201 Pseudomonas, 49 Acinetobacter and 744 Enterobacteriaceae comprising 250 E. coli, 197 Klebsiella, 126 Enterobacter, 74 Serratia, 54 Proteeae, 31 Citrobacter and 12 others from hospital LRTIs. Antimicrobial MICs were measured and interpreted by BSAC agar dilution methods ( Community: Resistance in S. pneumoniae has risen markedly over the last four seasons, Oct 2009 to Sept 2013: in 2012/13, 14% were intermediate to penicillin (0.6% resistant), 19% resistant to erythromycin, 16% resistant to tetracycline, and 10% non-susceptible to all three. In the previous 10 seasons (Oct 1999 to Sept 2009) these rates were fairly stable at a mean of 8% for penicillin, 12% for erythromycin, 8% for tetracycline and 4% for all three. As before, 20% of H. influenzae and 99% of M. catarrhalis had beta-lactamase-mediated resistance to penicillins, overcome by clavulanate; they were generally susceptible to tetracycline, ciprofloxacin and, for M. catarrhalis, erythromycin. Hospital: MRSA has been stable at around 25% of S. aureus over the last three seasons, down from 44% in 2008/09 and 37% in 2009/10. MRSA remained generally resistant to ciprofloxacin (86%) and erythromycin (72%) but susceptible to tetracyclines and glycopeptides. MSSA were susceptible to most agents except erythromycin (20% NS). Non-susceptibility among Pseudomonas was similar to previous years at 14-17% for ciprofloxacin and imipenem, 4-7% for gentamicin, ceftazidime and piperacillintazobactam, and 0.3% for colistin. Acinetobacter were non-susceptible to ciprofloxacin, gentamicin, imipenem and piperacillin-tazobactam in 18-31% of cases, but susceptible to colistin. Among E. coli, Klebsiella and Enterobacter, respectively, non-susceptibility was at 10, 8 & 25% for cefotaxime, 26, 10 & 1% for ciprofloxacin, and 8, 8 & 3% for gentamicin - similar to recent years apart from an apparent drop in ciprofloxacin-ns for Enterobacter. Colistin resistance was more common in Enterobacter (8%) than E. coli (0%) or Klebsiella (2%). One isolate each of E. coli, K. pneumoniae, E. aerogenes and Serratia marcescens was resistant to imipenem, a first for E. coli and Enterobacter in this programme. Antimicrobial resistance has increased substantially among S. pneumoniae from community-onset LRTI over the last four years, but remains stable and low for H. influenzae and M. catarrhalis. Resistance in hospital-onset LRTI was largely similar to previous seasons, with MRSA rates having levelled off at around 25% over the last three seasons after earlier large falls. Colistin resistance in LRTI Enterobacter has been found consistently at 5-15% since testing began in 2010/11. Carbapenem resistance remains very rare in Enterobacteriaceae, but its detection in four genera in 2012/13, including E. coli, warns against complacency

21 Poster No 0115 Clinical outcomes and predictors of mortality following bacteraemia with KPC-producing Enterobacteriaceae in a large teaching hospital in the UK: a retrospective case review Louise Sweeney 1,2, Richard Wilson 3, William Welfare 1,3, Andrew Dodgson 1,2 1 Public Health England Laboratory, Manchester, UK 2 Central Manchester University Hospitals Foundation Trust, UK 3 University of Manchester, UK Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPCPE) are a global public health problem with outbreaks reported across the world. Antimicrobials such as colistin and tigecycline have demonstrated in vitro activity against some isolates but resistance has been reported. Treatment of KPCPE infection is a significant challenge with reported mortality rates from 22% to 70%. To date the majority of isolates in the UK confirmed as carbapenemase-producing Enterobacteriaceae (CPE) by the national reference laboratory are referred from the North West. We undertook a retrospective case review of all episodes of CPE bactaeraemia in patients over 16 years of age occurring between May 2010 and February 2014 in a single large teaching hospital in the North West. The primary outcome was death within thirty days of the first positive blood culture. Survivor and non-survivor groups were compared using univariate analysis to identify predictors of mortality and optimum treatment regimens. Sixty episodes of CPE bacteraemia involving 56 patients were reviewed. The overall 30 day mortality rate was 18% (11/60). The mortality rate fell over time from 44.4% (4/9) in 2011 to 8% in 2013 (2/26). Over half of survivors (55%) received dual therapy compared with just 27% of those who died. Temocillin was used alone or in combination to treat 14 patients, all of whom survived. On univariate analysis, the only statistically significant predictor of mortality was escalation of care to HDU/ITU. The overall 30 day mortality rate was 18%, lower than many reported outcomes. Mortality fell over time. It is not known whether this reflects a changing case mix or improved management (earlier use of empirical antibiotics that would cover CPE). The use of combination therapy to treat CPE bacteraemia is associated with improved survival, but the optimum combination is difficult to determine as antibiotic susceptibility varies. This is the first retrospective case series to describe the use of Temocillin. Temocillin should be considered as a treatment option in combination with at least one other agent with activity against KPC-producing Enterobacteriaceae. In this centre, the overall 30 day mortality rate for CPE bacteraemia was 18%. The mortality rate for CPE bacteraemia has fallen, an outcome that has not been demonstrated in any other published case series. This is the first case series to describe the use of Temocillin to treat KPC-producing Enterobacteriaceae. Further studies with larger sample sizes may provide more information as to optimum treatment combinations