Antimicrobial Resistance Update for Community Health Services Elizabeth Beech Healthcare Acquired Infection and Antimicrobial Resistance Project Lead NHS England October 2015 elizabeth.beech@nhs.net
Superbugs to kill 'more than cancer' by 2050
In the UK If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine" David Cameron, UK Prime Minister
UK 5-year AMR Strategy 2013-18 CMO Annual Report 2011* One Health Strategic aims 1. Improve the knowledge and understanding of AMR 2. Conserve and steward the effectiveness of existing treatments *published: March 2013 3. Stimulate the development of new antibiotics, diagnostics and novel therapies 6
UK 5-year AMR Strategy 2013-18: Seven key areas for action DH High Level Steering Group PHE Human health Defra Animal health DH 1) Better access to and use of surveillance data 2) Optimising prescribing practice 3) Improving infection prevention and control 4) Improving professional education, training and public engagement Presentation title - edit in Header and Footer 5) Improving the evidence base through research 6) Developing new drugs, vaccines and other diagnostics and treatments 7) Strengthening UK and international collaboration
Antimicrobial Prescribing Quality Measures Table 3: ARHAI recommended antimicrobial prescribing quality measures October 2014 Measures to reduce total antibiotic prescribing Measures to encourage narrow spectrum antibiotic prescribing Primary care Total antibiotic prescribing to be reduced to 2010 levels at CCG level as measured by number of antibiotic prescriptions ( items ) per 100 patients per year Proportion of antibiotics from cephalosporin, quinolone or coamoxiclav classes to be reduced to less than the current median for English CCGs as measured by the number of prescriptions ( items ) from target classes in comparison with the total number of antibiotic prescriptions per year. Secondary care Total antibiotic consumption to be reduced by 1% per year 2015-2019 as measured by DDD per 1000 admissions per year. Total carbapenem consumption to be reduced to 2010 consumption levels as measured by DDD per 1000 admissions per year.
ESPAUR 2014 Key element of the 5 year AMR strategy was to introduce surveillance systems for antimicrobial resistance and usage 1 st English data for antimicrobial usage data for hospitals AND community in 2014 report Data from 2010 to 2013 Data down to Area Team level Update on AMS activity in hospitals since 2011/2
ESPAUR 2014 - Antimicrobial consumption Antibiotic prescribing has increased in England year on year Total antibiotic use increased by 6% Primary care use is now decreasing Primary care accounts for 80% of all prescribing Inpatient antibiotic use increased by 12% which includes 12% increase in Co-amoxiclav prescribing 49% increase in Piperacillin/Tazobactam 36% increase in Meropenem
ESPAUR 2014 Top choices with growth rates
Is resistance related to antibiotic use? Fluoroquinolone consumption & resistance in EU
Bacteria always develop resistance MDR bacteria use more energy on resistance mechanisms, so replicate more slowly, so are usually suppressed. 13
6 facts you maybe never knew. 35,000 or 7% of all deaths in the UK are caused by infectious diseases 66 different antibiotics prescribed - top 15 account for 98% in general practice and 88% in hospitals Hospital antibiotic use still increasing 35 million courses of antibiotics are prescribed by GPs in England each year, and at least 50% of this is for Respiratory Infections, many self limiting Without antimicrobials, the rate of post-operative infection for clean surgery could be 0-50% and that about 30% of those with a serious infection will die. No chemotherapy will be available due to untreatable sepsis 20% of all NHS clindamycin prescribing is by dentists
Patient Harm prevent and reduce C. difficile infection rates per 100,000 population by NHS England Area Team*, 2014/15 CDI rates are rising in 2015 for first time - worry E.coli bacteraemia rates are increasing why? Resistance to co-amoxiclav is increasing and it s the main cause of CDI avoid CAUTI remain a concern Carbapenemase-producing Enterobacteriaceae CPE surveillance for all NHS organisations and global increasing resistance avoid Sepsis National CQUIN for 2015/16
Sepsis is a national priority safety programme
New guidance and incentives in 2015 2008 Health & Social Care Act Code of Practice to include AMS criterion 3: ensure antibiotic use optimises outcomes & risk of adverse events and AMR. Applies to dentists and GP practices also NHS-England patient safety alert August 2015 NICE guidelines NG15: Antimicrobial Stewardship NICE guidelines consultation changing risk-related behaviours in the general population Start Smart then Focus and TARGET stewardship toolkits NHS England 2015-16 Quality premium for CCGs NHS England CQUIN on Sepsis for acute care providers
NHSE Antibiotic Quality Premium 2015-16 and what it means for CCGs The Quality Premium is intended to Improve the quality of services commissioned, improving health outcomes and reducing inequalities in health outcomes Reward CCGs for quality improvement, paid in the following financial year, and must be reinvested in quality or health outcome improvement Reduction in the number of antibiotic prescriptions by 1% as measured by the NHS BSA MOKTT antibacterials per STAR-PU Reduction in the proportion of broad spectrum antibiotics cephalosporins, quinolones & co-amoxiclav by 10% or to below England median value = 11.3%
Antibiotic prescribing variability CCG level
Antibiotic prescribing variability by GP practice
National Antibiotic Quality Premium dashboard
PrescQIPP AMS Hub https://www.prescqipp.info/ Antimicrobial Stewardship Hub Launched The Antimicrobial Stewardship (AMS) Hub, hosted as part of a PrescQIPP collaboration with NHS England to support CCG Quality Premium activity. This work has been led by Elizabeth Beech, Healthcare Acquired Infection and Antimicrobial Resistance Project Lead, Patient Safety Domain, NHS England, who is responsible or the range of content available on this AMS Hub. The AMS hub offers a selection of resources and links to help you better understand and navigate this key area of work for commissioners and providers alike. Free access Lots of links to resources Primary care prescribing data use it and contribute
Antimicrobial Stewardship Activity Guidelines NICE, PHE, and local Audit Education HCP and the public Pathway review Implementing No and delayed antibiotic systems Use of TARGET resources Local CQUINs of providers Promoting vaccination Lots of collaboration Champions most effective
TARGET resources http://www.rcgp.org.uk/clinical-andresearch/toolkits/target-antibiotics-toolkit.aspx
What do people think about AMR? Interviews in friendship pairs from London & Manchester. Different age groups & education levels Group interviews from London, Birmingham and Scotland. Mixed ages, education, social grade, & relationship with antibiotics
Looking ahead No new antibiotics so improve how we use the ones we have Behavioural strategies: environment vs person Improve self care and vaccination uptake Educate the next generation - children Use No or delayed (Back-Up) antibiotics Penicillin allergy status Point of care diagnostics Community IV Antibiotic Services (CIVAS)
Why vaccinate these risk groups? Influenza-related population mortality rates and relative risk of death among those aged six months to under 65 years by clinical risk group in England, September 2010 May 2011 Number of fatal flu cases (%) Mortality rate per 100,000 population Age-adjusted relative risk In a risk group 213 (59.8) 4.0 11.3 (9.1-14.0) Not in any risk group 143 (40.2) 0.4 Baseline Chronic renal disease 19 (5.3) 4.8 18.5 Chronic heart disease 32 (9.0) 3.7 10.7 (7.3-15.7) Chronic respiratory disease 59 (16.6) 2.4 7.4 (5.5-10.0) Chronic liver disease 32 (9.0) 15.8 48.2 (32.8-70.6) Diabetes 26 (7.3) 2.2 5.8 (3.8-8.9) 30 Immunosuppression 71 (19.9) 20.0 47.3 (35.5-63.1) Chronic neurological disease (excluding stroke/tia) 42 (11.8) 14.7 40.4 (28.7-56.8) Total 378 0.8 The national flu immunisation programme 2015/16
Maternal deaths from influenza 2009-12, 36 pregnant women died from influenza (43% all deaths from infection) Median 28 years, 63% born in UK 18% BMI >30 & 28% current smokers documented fever (97%), cough (66%) and dyspnoea (38%)
Penicillin allergy NICE Drug Allergy guidance 10-20% claim beta-lactam allergy probably ~1% Test if allergic to 2 AB classes or need for beta-lactam Allergy information on ALL Rx & correspondence Increased incidence of CDI and MRSA in this group Higher mortality, ITU admission, higher costs Macrolide resistance is increasing Who is routinely reversing inappropriate allergy labels?
What are you doing in November?
Key take home AMR messages The Drugs Don t Work - Tough action needed to avoid antibiotic resistance Prevent Infection vaccinate, hand wash, stay home! Tackling AMR is everybody's responsibility Collaboration is essential Behaviour change is key Evidence suggests what works is a bundle of interventions Useful resources and tools are available use them Don t forget Healthcare Acquired Infections Become an AntibioticGuardian.com and a champion