Antimicrobial Stewardship in Scotland UKCPA/FIS Scientific Meeting 18 th November 2010 Triumphs and Unintended Consequences Dr Jacqueline Sneddon Project Lead for Scottish Antimicrobial Prescribing Group
Acknowledgements Members of Scottish Antimicrobial Prescribing Group NHS Board Antimicrobial Management Teams Association of Scottish Antimicrobial Pharmacists
Scot MARAP & SAPG Scottish Management of Antimicrobial Resistance Action Plan issued in March 2008. Made recommendations to ensure prudent use of antimicrobials. Scottish Antimicrobial Prescribing Group (SAPG) formed to lead and coordinate national delivery of ScotMARAP hosted by SMC and funded by Scottish Government. SAPG has same collaborative structure as SMC i.e. representatives from key national and local stakeholders
Immediate challenges Raise profile of antimicrobial stewardship across all clinical staff groups in all healthcare settings. Local structures, accountability and leadership. National evidence-based prescribing guidance. Robust information systems for local and national surveillance of antimicrobial use and resistance. Development of measures for judgement (CDI). Measure impact of our interventions.
Local delivery within NHS Boards Medical Director Chief Executive Infection Control Manager Area Drugs & Therapeutics Committee Risk Management Committee ANTIMICROBIAL MANAGEMENT TEAM (AMT) Clinical Governance Committee Antimicrobial Pharmacist Infection Control Committee Ward Based Clinical Pharmacists PRESCRIBER Microbiologist / Infectious Diseases Physician
Antimicrobial Management Team Network
TRIUMPHS
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
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.
Development of training materials on antimicrobial stewardship Antibiotic Prescribing for Foundation Year Doctors Launched 2006, revised June 2009, wider access in 2010. Bacterial Resistance & Clostridium difficile online tutorials. Training on the use of antimicrobials in clinical practice resource pack Framework of learning outcomes for inclusion in undergraduate medical curriculum. Comprehensive education programme for pharmacists
Multiprofessional education
Pharmacist education and training Specialist training Antimicrobial pharmacist intensive training Pharmacokinetics of gentamicin & vancomycin training CPD Resource pack >900 hospital and community pharmacists Learning session delivered in every NHS Board area
Data management systems to support quality improvement National surveillance system for antimicrobial use and resistance Local data on antimicrobial use and resistance in hospitals National participation in ESAC-3 point prevalence study National primary care prescribing indicators Institute for Healthcare improvement Extranet system for evaluation of hospital prescribing and infection management
Hospital Prescribing National Point Prevalence Study 2009 ( ESAC-3 ) Scottish data 31 hospitals (8732 patients) 27.8% patients on antimicrobials 50.5% given intravenously 76.1% reason recorded in case notes 57.9% compliant with local guidelines 30.3% surgical prophylaxis more than one day some room for improvement
ESAC-3 Scotland and Europe Comparison of total antimicrobials prescribed Amoxicillin Doxycycline Antimicrobial Metronidazole Trimethoprim Flucloxacillin Ciprofloxacin Clindamycin Cephalosporins Scotland Europe 0 5 10 15 20 25 Proportion of total antimicrobials prescribed (%)
Primary Care Prescribing Promoted and Restricted (C. diffogenic) antibiotics PROMOTED RESTRICTED 5% decrease in 2008-9 20% decrease in 2009-10
Trends in resistance 2008-09 Amx Amc Cro Caz Gen Cip Mem Ptz Tmp C/Q C/G E coli 61 27 12 10 7 20 0 3 36 11 5 K pneumoniae 99 14 16 13 8 11 0 7 18 9 10 P. aeruginosa 94 96 94 8 2 12 5 8 95 ESBL producers E. coli 7.2% Carbapenemase producers 0 K. pneumoniae 8.4% 0*
CDI HEAT Target (Health, Efficiency & Access to Treatment) 30% reduction in CDI rate by March 2011 (target to 50%,June 2010). SAPG asked to develop prescribing indicators to support target. Empirical prescribing: compliant with the local antimicrobial policy and indication recorded in case note in 95% of sampled cases Surgical antibiotic prophylaxis: compliant with local antimicrobial prescribing policy and duration <24 hours in 95% of sampled cases Primary Care empirical prescribing: seasonal variation in quinolone use (winter months vs. summer months) is 5%
Empirical prescribing in admission units
Empirical prescribing in admission units
Seasonal variation in quinolones 35 25 15 5-5 -15 2008/09 2009/10 % seasonal variation (DDDs) -25 NHS A & A NHS Borders NHS D & G NHS Fife NHS Forth Valley NHS Grampian NHS GG & C NHS Highland NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside NHS Western Isles NHS Board Target
C. difficile Infection trends Health Protection Scotland 6 th October
Time Series Model of Antibiotic Associated & Residual Cases of C. difficile (Ninewells Hospital) 50 40 30 10 20 5 0 10 0-5 -10-15 I II III IV I II III IV I II III IV I II III IV I 2006 2007 2008 2009 Res idual C.diff M odel
Potential financial impact of restrictive antibiotic policy on CDI Ninewells Hospital, NHS Tayside 12 less cases per month (41% reduction) Cost avoidance of 576K per annum (based on 4K per episode CDI) NHS Lanarkshire, NHS Lothian, NHS Forth Valley 100K saved in antibiotic costs
Summary of outcomes of interventions Antimicrobial stewardship has higher profile and regarded as integral to HAI agenda Reduction in use of cephalosporins, quinolones and co-amoxiclav Increased use of gentamicin Reduction in CDI BUT Unintended consequences of changes in antimicrobial policy?
UNINTENDED CONSEQUENCES
Potential harm from changes in antibiotic policy Renal/ototoxicity due to increased gentamicin use Increased mortality due to less effective therapies Increased resistance rates in common organisms Emerging resistances
Gentamicin toxicity GaV Quality Improvement Programme Share results of local audits and surveillance projects conducted throughout Scotland. Investigate access to current datasets that may provide signal for unintended consequences. Summarise how current guidelines are used in practice identify factors that lead to non-adherence, errors and poor outcomes.
SAPG recommendations Gentamicin management guidelines in place - electronic dose calculator and antibiotic switch guidance at 3 days Hospital prescribers educated in the safe use of gentamicin including recognition of early symptoms of toxicity Local engagement with clinical specialists to monitor VIII nerve toxicity and gentamicin-associated renal toxicity.
Surveillance of resistance Real-time reports on emerging resistance via an electronic Alert system to highlight potential clinical issues. Additional surveillance activities to monitor current and emerging clinical problems e.g. carbapenemases
Mortality early results from time series analysis
We have come a long way but our journey has just begun Dilip Nathwani Chair of SAPG www.scottishmedicines.org.uk/sapg/scottish_antimicrobial_prescribing_group SAPG_