The International Convention Centre (ICC), Birmingham 11 12 September 2017 Antibiotic Review Kit - Hospital (ARK-hospital) Elizabeth Cross Brighton and Sussex University Hospitals NHS Trust Brighton and Sussex Medical School
Overview Background 10 mins Introducing ARK-Hospital 4 mins Findings from feasibility study 4 mins Questions 2 mins
Antimicrobial resistance. Successful surgery Cancer chemotherapy Immunotherapies AMR the end of modern medicine Antimicrobial resistance by 2050 threatens: A reduction in the world economy of 0.1-3.1% WHO Antimicrobial Resistance Global Report on Surveillance 2014 Taylor J, et al. Estimating the economic costs of antimicrobial resistance: model and results. 2015. http://www.rand.org/ randeurope/research/projects/antimicrobial-resistance-costs.html
The English Miracle 1 Introduction of targets Financial penalties Substantial changes in antibiotic use Cephalosporins and Quinolones β-lactam/β-lactamase inhibitors Cooke J, et al. Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008 13): working towards hospital prescribing quality measures JAC 2015
% Isolates resistant The challenge of antibiotic resistant GNRs in the UK >3x increase in E. coli bacteraemia since 2004 Currently 36,000 cases / year Rates of resistance to key agents Gentamicin Ciprofloxacin Co-amoxiclav Piperacillin tazobactam.climbing alarmingly 46% of E. coli bacteraemia isolates now reported as co-amoxiclav resistant English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2015 45 40 35 30 25 20 15 10 5 0 2010 2011 2012 2013 2014 E. coli - Co-amox K. pneumoniae - Pip-tazo
Some typical local data Some key rates of antibiotic resistance at this trust in 2016 E. coli cultured from urine Enterobacteriaceae cultured from blood Co-amoxiclav 27% 39% Ciprofloxacin 12% 19% Piperacillin-tazobactam 14% 16% Gentamicin 10% 14% At what rate of resistance would these drugs cease to be reliable clinically selected treatments? If you don t believe predictions of a world without antibiotics by 2050 Imagine working in your hospital without these antibiotics by 2020
Antibiotics also place individual patients at risk of resistant infection Explored relationship between prior antibiotic use and antibiotic resistance Reviewed 24 studies 19 Observational 5 RCTs >27,000 participants Urinary Infections Respiratory Tract infections
Forest plots of included studies Substantial Lasting Urinary Infection Respiratory Tract Infection 9
Option 1 - Don t start! Always begin broadspectrum intravenous antibiotics within the first hour! 10
Option 2
In reality focus rarely means stop >95% of Review and Revise Decisions are to continue antibiotic treatment With thanks to Dr Kieran Hand, Southampton
A time-line of stewardship in the UK
Why do we find stopping antibiotics so hard to do? Lack of knowledge of risks of prolonging treatment Prescriber etiquette Patient beliefs Complete the course
Do we know how long a course should be? Recommended course durations have fallen There is a lack of evidence that recommended durations are superior to antibiotic-sparing approaches* *w/exception of otitis media, Hoberman A et al New Eng J Med. 2016;375:2446-2456
Complete the course to avoid resistance? Two paradigms of resistance selection 1940 s Fear Professional Pathogens Transmitted during disease M. tuberculosis Malaria HIV Resistance selected during treatment Resistance selected by inadequate treatment 21 st Century Reality Commensal Opportunist pathogens Transmitted in carrier state S. aureus E. coli K. pneumoniae Resistance selected as bystanders Resistance selected any antibiotic use. More use = more resistance
Introducing ARK-hospital (4 mins)
The ARK-Hospital Team Nationally Locally The antimicrobial stewardship team Sally Curtis Sam Lippett Vikesh Gudka Martin Llewelyn Jasmin Islam Lizzie Cross Will Hamilton Catherine Sargent Dan Agranoff Nelson Barbon
What is ARK-hospital? A 5-year applied research programme funded by NIHR The overarching aim of ARK is to reduce the incidence of serious infections caused by antibiotic-resistant bacteria in the future, through substantially and safely reducing antibiotic use in hospitals now Underlying hypotheses: In hospitals, most antibiotics are started appropriately; but there is reluctance to stop them once started Short durations of antibiotic treatment are sufficient to treat most genuine bacterial infections in hospitals Clinical review will identify those whose condition has not improved who need to continue taking them
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 2. A structure for team meetings
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 2. A structure for team meetings 1. Online learning tool in form of a website or App - Info as per slides above - Endorsed by specialist societies - Replacing parts of mandatory training
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 2. A structure for team meetings 2. Modification to antibiotic prescription section of the drug chart - Acknowledges uncertainty around antibiotic prescribing - Prompts 72-hr r/v of antibiotics
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 2. A structure for team meetings 3. In-person education + online tool - Confirm use of decision aid - Alert doctors to r/v Abxs - Contribute to monitoring and feedback
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 2. A structure for team meetings
4. Information for patients A patient leaflet
ARK-hospital provides 1. Information for prescribers about Review and Revise decision making 2. A decision aid applied to antibiotic prescriptions 3. Information for nurses and pharmacists 4. Information for patients 5.1 Team meetings to introduce ARK 5.2 Monitoring of Abx prescriptions 5.3 Feedback to clinical teams - Audit data - Clinical cases 2. A structure for team meetings, monitoring and feedback
Results of feasibility study (4 mins)
ARK-hospital results Feasibility: 3 months from April to July 2017 588 antibiotic prescriptions Point prevalence surveys Weeks 1, 2, 3, 4, 6, 8 and 12 Medical specialties: Acute medicine, respiratory, elderly care, endocrine, gastroenterology
Prescriptions reviewed within 72 Hours 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12 CQUIN Target
Prescriptions using ARK-hospital decision aid 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12 ARK Target
Prescriptions stopped within 72 hour review 100% 90% 80% 70% 60% 50% 40% 30% Trust Baseline 20% 10% 0% Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12
Next steps Feasibility Three pilot sites kicking off this month South Tees Oxford Wexham Park Recruiting 33 further trusts to main trial
Prescriptions with 72-hr review (%) Recruitment to main trial Reducing the impact of serious infections CQUIN 2017-19 Key people Acute medic Pharmacist Infection specialist 1 0 Prescriptions stopped (%) https://fingertips.phe.org.uk/profile/amr-local-indicators
Interested? Visit: http://www.arkstudy.ox.ac.uk/ Or contact: Professor Martin Llewelyn M.J.Llewelyn@bsms.ac.uk