Antimicrobial Stewardship in Scotland PAST, PRESENT, FUTURE CLEANLINESS CHAMPION, CONFERENCE, ABERDEEN 2011

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1 Antimicrobial Stewardship in Scotland PAST, PRESENT, FUTURE CLEANLINESS CHAMPION, CONFERENCE, ABERDEEN 2011 DILIP NATHWANI Chair, Scottish Antimicrobial Prescribing Group

2 Acknowledgements Members of Scottish Antimicrobial Prescribing Group NHS Board Antimicrobial Management Teams Association of Scottish Antimicrobial Pharmacists

3 We are interested in improving antibiotic use to reduce harm from infection and preserve an invaluable resource 6 June 2005

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5 Valiquette L et al. CID 2007; 45, S112-S121.

6 How much do we love Q2 What percentage of prescribed antibiotics for humans are inappropriate in hospital? A % B % C. 70% D. 90% antibiotics?

7 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.

8 What is wrong with this statement? Nitrites ++, leukocytes ++: diagnosis UTI Rx with antibiotic

9 Description Probability of asymptomatic bacteriuria? Prevalence of ASB Married woman aged % Married woman aged >65 6.5% Nun aged % Nun aged >65 5.8% Married woman aged with diabetes Female, continent nursing home resident Female, incontinent nursing home resident 8%-18% 25%-57% 80% Patient catheterised for > 4 weeks 100% Probability of bacteriuria if symptomatic? 70 73%

10 Consequences of antibiotic? 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. None B. 1.5 fold increase C. 2 fold increase D. 2.5 fold increase E. 4 fold increase Resistance

11 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 [ ] 12 months

12 Price of an antibiotic Risk of resistance to the individual ~ 2 fold for 2 months and up to 12 months 1 ~8-10 fold risk of CDAD up to 3 months 2 AGE Co-morbidity Type of antibiotic (~8 fold with cephalsporins and 30 fold with quinolones)

13 OBJECTIVES 1. SAPG INTRODUCTION : PAST & PRESENT 2. UPDATE ON PROGRESS WITH KEY CURRENT WORK FUTURE SAPG LOOK FORWARD TO YOUR SUPPORT AND COMMENTS

14 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)

15 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 frontend 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

16 TRIUMPHS

17 What are our ambitions? 1. Establish national and local organisation structures and leadership around antimicrobial stewardship.

18 Integration of antimicrobial stewardship within HAI agenda NHS Boards Antimicrobial Management Teams Infection Prevention & Control Teams National Scottish Patient Safety Programme HPS Surgical Site Infection Programme Infection Prevention and Clinical specialist groups

19 KEY WORKING AND ACCOUNTABILITY RELATIONSHIPS Medical Director Chief Executive Infection Control Manager Area Drugs & Therapeutics Committee Risk Management Committee ANTIMICROBIAL MANAGEMENT TEAM (AMT) Clinical Governance Committee Dissemination & feedback Antimicrobial Pharmacist Infection Control Committee Ward Based Clinical Pharmacists Prescribing support / feedback Microbiologist / Infectious Diseases Physician PRESCRIBER

20 What do we expect Boards to evidence? An Antimicrobial Team Antimicrobial Pharmacists Antimicrobial Prescribing Policies Staff Awareness of Antimicrobial Policies Data on prescribing and usage which informs practice Structured Education Programmes

21 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.

22 4C Antibiotics (High Risk for C difficile): Cephalosporins, Clarithromycin, Clindamycin, Ciprofloxacin Introduction of Empiric Antibiotic Policy Restricting Use of 4C Antibiotics Sep-08 Jul-08 Aug-08 Jul-08 Aug-08 Jul-08 Apr-09 Feb-09 Apr-09 De c-08 Jan-09 Feb-10 Jan-10 Jan-10 Dec-09 Western Isles Tayside Shetland Orkney Lothian Lanarkshire Highland Greater Glasgow and Clyde Gram pian Golden Jubilee Hospital Forth Valley Fife Dumfries & Galloway Borde rs Ayrshire & Arran Jun-08 Sep-08 Dec-08 Mar-09 Jul-09 Oct-09 Jan-10 May-10

23 What are our ambitions? 4. Education and evaluate our educational interventions

24 Foundation Doctors, Staff Induction, Pharmacist Training Packs

25 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.

26 What are our ambitions? 2. A. Improve the quality and quantity of prescribing in all healthcare sectors through guidance and support: initially frontend hospital empiric prescribing. B. national system to measure antibiotic consumption and surveillance of resistance to support local data

27 Antimicrobial resistance Procurement 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 piloted ALERT system being developed and piloted HPS AMR expert group established Ability to track resistance trends early so as to pre-empt threat Information workstream actions by National Services Scotland Antimicrobial use Publication of national prescribing indicators for primary care use of antimicrobials:prisms National participation in ESAC-3 Development of Hospital Medicine Utilisation Database (HMUD): rolling out in 2011 [first national integrated report of hospital consumption, resistance surveillance and CDI due soon]

28 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

29 ESAC SCOTTISH PPS DATA 2009 Indication in notes Compliance with antibiotic policy

30 Duration of Surgical Prophylaxis

31 Health, Efficiency & Access to Treatment (HEAT) Targets 30% (revised to 50%) reduction in CDI by SUPPORTING PRESCRIBING TARGETS 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.

32 Compliance with hospital prescribing 100 Antibiotics Compliant: National Data 800 % Compliance Sample size 0 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 Sample size % Compliance Median Target Indication Documented: National Data 800 %Compliance Sample size 0 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 Sample size % Compliance Median Target 0

33 Surgical Prophylaxis Data from 7 Health Boards; Median, Min & Max 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Duration <24h Antibiotic compliant General Surgery Obstetrics & Gynaecology Orthopaedics

34 HOSPITAL HEAT TARGET S REVISITED EMPRIC PRESCRIBING STUCK 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

35 SAPG PRIMARY CARE PRESCRIBING 2009 Compared with 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

36 Restricted Drugs New "Antibioticman" Policy No of DDDs 3000 CO- AMOXICLAV,AMOXICILLIN,CL AVULANIC ACID CIPROFLOXACIN CLARITHROMYCIN 0 Financial Month / Financial Year

37 LOCAL AND NATIONAL IMPACT ON CDI C.dif model M M M M M M M M M M M M M M M M M01 C diff cases P <0.001 TAYSIDE NATIONAL

38 Time for a Group Hug?

39 Measures of Antibiotic Policy Impact Process Promoted and restricted antibiotics Outcome C difficile infection Balancing Mortality (30 day) for medical and surgical admissions

40 BALANCING MEASURES: UNINTENDED HARM TAYSIDE 30DAY MEDICAL AND SURGICAL MORTALITY MEDICAL ADMISSION SURGERY Policy change Surgical model Death_rate Surgical M M M M M M M M M M M M M M M M M M12 30D FROM ADMISSION

41 SAPG 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

42 AMT AND IPT COLLABORATION Joint Network Event 1/3/2011 Consider AMT + IPT strategic and operational level management SAB [prevention and effective management] CDI [prevention and management] Point prevalence survey -audit Education Session for ICN on bugs and drugs [Cleanliness champions for AMT's] QI initiative- antibiotic review bundle

43 ISSUES Key issues Front-end empiric prescribing Antibiotic Policies (Antibiotic Man) Continuing care antibiotic prescribing Not subject to adequate review Discharge prescribing

44 The 3 Day Antibiotic Bundle INDICATION : Start Date: Review Date: Action Taken on Review Check Microbiology Results Review Patient & Initial Diagnosis Consider IV to Oral Switch

45 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]

46 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 OPPORTUNITIES YOU ALL HAVE A PIVOTAL ROLE IN THIS

47 THANK YOU