Models for stewardship in Hospital - UK Models Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds
United Kingdom of England, Scotland, Wales & Northern Ireland 1.8m 5.3m 53m One Kingdom but four variations of a National Health Service 3.1m
Early UK AMR & AMS activities 1994: BSAC Survey of Hospital antibiotic control measures 1998: Standing Medical Advisory Committee (SMAC) report on Antimicrobial Resistance 2000: Dept Health AMR Strategy & Action Plan 2001: WHO Global Strategy for Containment of Antimicrobial Resistance 2001: Standing Advisory Committee on Antimicrobial Resistance (SACAR) established 2003: Hospital Pharmacy Initiative ( 12m over 3 years for AMS) 2008: Health & Social Care Act: HCAI (C.difficile and MRSA) 2011: DH Antimicrobial Stewardship Guidelines Start Smart then Focus
Clostridium difficile reports Large fines for hospitals missing targets The driver in UK since 2008 has been reducing the incidence of CDI and MRSA bacteraemia
Scottish Antimicrobial Prescribing Group Funded as a multidisciplinary national forum in March 2008 by Scottish Government as part of The Scottish Management of Antimicrobial Resistance Action Plan 2008. SAPG co-ordinates & delivers a national AMS framework: antibiotic consumption and prescribing guidance resistance surveillance organisational accountability for antimicrobial stewardship antimicrobial prescribing education for healthcare professionals and infection management Highly successful model with representation from all 13 Health Boards www.scottishmedicines.org.uk/sapg/scottish_antimicrobial_prescribing_group SAPG_
Scottish approach: standardisation Quality improvement programme for: Empiric prescribing & surgical prophylaxis C.difficile and Community acquired-pneumonia Validated dosing tools for vancomycin & aminoglycosides Programme for monitoring for unintended consequences of change NHS Scotland developing an Infection Intelligence Platform (IIP) - a shared resource for Healthcare Associated Infection surveillance and research in development
Primary care targets for reduction 6.5% in total 11.6% Cdiff risk In 2012-3 Target to 50% of GPs in Health Board to lower 25% quartile
High-risk Clostridium difficile antibiotics reduction Driving down the use of broad-spectrum antibiotics in hospitals & community Much better performance than England or Wales
NHS Wales centralised antimicrobial usage and resistance data provided to all hospitals Follow English AMS guidance Amoxicillin-clavulanate (COA) resistance & E.coli resistance identified as major issue as cefalosporin & quinolone use
NHS England (pre 2013): national AMS guidance but no antimicrobials usage or resistance data in hospitals Informal regional networks of: Medical microbiologists and infectious diseases Antimicrobial pharmacists in hospitals National AMS guidelines (Nov-2011) for hospitals: Start Smart then Focus and community: TARGET. No AMR information or usage data available at national level in hospitals, but available in community Local information only for hospitals HCAI performance based around C.difficile and MRSA bacteraemia reduction ASAT (AMS for Acute Trusts) tool to measure performance Commissioners / external assurance agencies (CQC/TDA/Monitor) could request to see AMS programme and results.
2013: UK 5 year AMR Strategy
UK 5year AMRS: 7 key areas for action
UK 5 year AMR strategy 2013-14: detailed implementation plan developing outcome metrics & establishing surveillance systems 2014-15: ESPAUR to report AMR and antimicrobial usage 2015-16: Enough information to assess whether strategy on-course to achieve goals by 2018 Government holding NHS to account to deliver on strategy Devolved countries to lead on own implementation
Progress in year 1 of 5 year AMR strategy English Surveillance Plan for Antimicrobial Usage and Resistance (ESPAUR 2014 report) Programme set up to monitor antimicrobial use and resistance First time reporting for national and regional surveillance of AMR and usage data in hospitals and community. Report on AMS activity in hospitals Prescribing Quality Measures to reduce antibiotic usage to 2010 levels Unified message for European Antibiotics Awareness Day in human & animal health. Antibiotic Guardian campaign. Establishment of 2 NIHR Health Protection Research Units for AMR & HCAI (Imperial & Oxford). Themed NIHR AMR research call. Looked at factors in influencing prescribing in Vets International collaboration: Lead on WHO AMR resolution. Enrofloxacincolistin withdrawn in animals. New drug discovery & diagnostics. PM commissioned a review by Jim O Neill (Economist)
Undergraduate AMS teaching (Imperial 2014)
Antimicrobial Prescribing and Stewardship Competencies 1.Infection prevention and control 2.Antimicrobial resistance and antimicrobials 3.Prescribing antimicrobials 4.Antimicrobial stewardship 5.Monitoring and learning Health Education England: New mandatory framework for education and training on AMR & AMS in 2015-6 for all healthcare staff at undergraduate and post-registration levels
English Surveillance Programme for Antimicrobial Utilisation & Resistance England still has less AMR than Europe ESPAUR 2104
6% in consumption between 2010-13 1.4% last year GPs: 78% of total with 4.1% growth in 2010-3 but 3.5% last year Hospitals: 9.1% IP and 6.2% OP, but 11.9% over 3 years for IP
Significant regional variation in antibiotic use Changes in antibiotic use: 2010 2013 Pressure to reduce cefalosporins and quinolones to C.difficile 48% overall in cefalosporins (GPs 55% and Hospitals 10% ) 5% in quinolones (GPs 6%, Hospital IP 10%, Hospital OP 5%) Big increases in tetracyclines, pencillins & nitrofurantoin Amoxicillin-clavulanate 13% (mainly in hospital), piperacillintazobactam by 46% 31% in carbapenems
Comparisons with Europe General Practice Very low quinolone / cephalosporins High tetracyclines, trimethoprim Hospital Much higher except for cephalosporins & quinolones 2x penicillin, 4x tetracyclines
ESPAUR 2014: 1 st total sector data. We re not as good as we thought!
England AMS Standards Start Smart then Focus after 24 hours
English AMS programme governance (2014) AMS Committee: microbiologist 92%, AMS pharmacist 87%, physician 47%, nursing 43%, surgeons 36%, junior doctors 21%, other pharmacists 7%
AMS policy in hospitals: key elements 2003: 12m 3yr funding to establish AMS National hospital AMS Standards in 2011: Start Smart then Focus
Design systems to do AMS
Models of delivering AMS Proactive follow up of bacteraemic patients Complex patients by specialty or AMR Bacteraemia & ITU daily ward rounds Reactive call taking by micro Comprehensive guidelines Wards ring for patient specific advice to micro or ID Patients on IV AB > 5 days or less Restricted antibiotic follow up Antimicrobial audits Pharmacy referral system Educational ward rounds Usually weekly ward rounds with clinical team Audit meeting presentations
Antimicrobial Pharmacist role Most hospitals had a senior pharmacist for AMS plus 0.5wte of a junior pharmacist or a technician Writing guidelines 97%, formulary 94% (horizon scanning 71%) Referrals by phone or pager 88% Input into hospital IPC group 90% AMS ward rounds where high AB use 65% Publicising local AMR patterns 56% Working with local community AMS lead 37%
Amoxicillin +/- macrolide Amoxicillin + macrolide Amo-clav + macrolide Pip-tazo > amo-clav or Gent+PenG
Trimethoprim or nitrofurantoin Pip-tazo > gentamicin Gentamicin
Amoxicillin-clavulanate Piperacillin-tazobactam Amox + Gent + Metronidazole
2015-6 AMR & AMS drivers Quality Premium Overall aim, return to 2010 prescribing levels in hospitals & community Reduce antibiotic prescribing by 1% next year Hospitals: validate data & following year to carbapenems by 1% Primary care: 10% in quinolones + cefalosporins + amoxicillinclavulanate as % of total ABs NICE Antimicrobial Stewardship guideline Consultation on draft in Feb-15, launch May-15 Quality standards to assess implementation Update hospital AMS guidelines Require assurance that AMS is happening
Summary for AMS Models in UK UK 5 year AMR strategy has been a big lever for making improvements quickly Improve AMR and usage reporting for UK to report into Europe Setting targets (and seeing early reduction) in antimicrobial usage Improved mandatory education strategy for AMR & AMS Giving AMS a higher priority alongside IPC Moving the focus away from Clost.difficile & MRSA Scotland probably have the best model for AMS that demonstrates continual quality improvement
Models for stewardship in Hospital - UK Models Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds