Antimicrobial Stewardship in Scotland

PAST, PRESENT, FUTURE CLEANLINESS CHAMPION, CONFERENCE, ABERDEEN

2011

DILIP NATHWANI Chair, Scottish Antimicrobial Prescribing Group

Acknowledgements

• Members of Scottish Antimicrobial Prescribing Group

• NHS Board Antimicrobial Management Teams

• Association of Scottish Antimicrobial Pharmacists

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

6 June 2005

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

How much do we love antibiotics?

Q2 What percentage of  prescribed antibiotics for 

humans are inappropriate

in  hospital ?

A. 10‐20%B. 30‐50%C. 70%D. 90%  

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.

What is wrong with this statement?

Nitrites ++, leukocytes ++:  diagnosis UTI

Rx with antibiotic

Probability of asymptomatic bacteriuria?

Description Prevalence of ASBMarried woman aged 24-44 4.6%Married woman aged >65 6.5%Nun aged 24-44 0.7%Nun aged >65 5.8%Married woman aged 24-44 with diabetes

8%-18%

Female, continent nursing home resident

25%-57%

Female, incontinent nursing home resident

80%

Patient catheterised for > 4 weeks 100%

Probability of bacteriuria

if symptomatic?  70‐73%

Consequences of antibiotic ? Resistance

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. NoneB. 1.5 fold increase C. 2 fold increaseD. 2.5 fold increaseE. 4 fold increase 

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 [1.2-1.5] 12 months

“Price of an antibiotic”Risk of resistance to the individual ~ 2 fold for 2 months and up to 12 months1

~8- 10 fold risk of CDAD up to 3 months2

AGECo-morbidityType of antibiotic (~8 fold with cephalsporins and 30 fold with quinolones)

OBJECTIVES

1. SAPG INTRODUCTION : PAST & PRESENT

2. UPDATE ON PROGRESS WITH KEY CURRENT WORK 2008-2011

3. FUTURE SAPG 2011 -2014

3. LOOK FORWARD TO YOUR SUPPORT AND COMMENTS

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)

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 “front- end” 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

TRIUMPHS

What are our ambitions?

• 1. Establish national and local organisation structures and leadership around antimicrobial stewardship.

Integration of antimicrobial stewardship within HAI

agenda

NHS Boards – Antimicrobial Management TeamsInfection Prevention & Control Teams

National – Scottish Patient Safety ProgrammeHPS Surgical Site Infection ProgrammeInfection Prevention and Clinical

specialist groups

Medical DirectorChief Executive Infection Control Manager

Area Drugs & Therapeutics Committee

ANTIMICROBIAL MANAGEMENT TEAM (AMT)(AMT)

Antimicrobial Pharmacist

Ward Based Clinical Pharmacists

Risk Management Committee

Clinical Governance Committee

Infection Control Committee

Microbiologist / Infectious Diseases Physician

PRESCRIBERPRESCRIBER

Prescribing support / feedback

Dissemination & feedback

KEY WORKING AND ACCOUNTABILITY RELATIONSHIPS

What do we expect Boards to evidence?An Antimicrobial Team Antimicrobial PharmacistsAntimicrobial Prescribing PoliciesStaff Awareness of Antimicrobial Policies Data on prescribing and usage which informs 

practiceStructured Education Programmes

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.

4C Antibiotics (High Risk for C difficile): Cephalosporins, Clarithromycin, Clindamycin, Ciprofloxacin

Introduction of Empiric Antibiotic Policy Restricting Use of 4C Antibiotics

Jan-09

Dec-09

Jan-10

Jul-08

Aug-08

Dec-08

Apr-09

Jul-08

Aug-08

Jul-08

Jan-10

Feb-09

Apr-09

Sep-08

Feb-10

Jun-08 Sep-08 Dec-08 Mar-09 Jul-09 Oct-09 Jan-10 May-10

Ayrshire & Arran

Borders

Dumfries & Galloway

Fife

Forth Valley

Golden Jubilee Hospital

Grampian

Greater Glasgow and Clyde

Highland

Lanarkshire

Lothian

Orkney

Shetland

Tayside

Western Isles

What are our ambitions?

4. Education and evaluate our educational interventions

Foundation Doctors, Staff Induction, Pharmacist Training Packs

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.

What are our ambitions?

• 2. A. Improve the quality and quantity of prescribing in all healthcare sectors through guidance and support: initially “front- end” hospital empiric prescribing.

– B. national system to measure antibiotic consumption and surveillance of resistance to support local data

Information workstream – actions by National Services Scotland

• Antimicrobial usePublication of ‘national prescribing indicators’ for primary care use of antimicrobials:PRISMSNational participation in ESAC-3Development of Hospital Medicine Utilisation Database (HMUD): rolling out in 2011 [first national integrated report of hospital consumption, resistance surveillance and CDI due soon]

• Antimicrobial resistanceProcurement 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 pilotedALERT system being developed and pilotedHPS AMR expert group established

Ability to track resistance trends early so as to pre-empt threat

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

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

Duration of Surgical Prophylaxis

Health, Efficiency & Access to Treatment (HEAT) Targets

30% (revised to 50%) reduction in CDI by 3- 2011

•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.

SUPPORTING PRESCRIBING TARGETS

Compliance with hospital prescribing Antibiotics Compliant: National Data

0

10

20

30

40

50

60

70

80

90

100

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

% Compliance

0

100

200

300

400

500

600

700

800

Sample size

Sample size % Compliance Median Target

Indication Documented: National Data

0

10

20

30

40

50

60

70

80

90

100

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

% Compliance

0

100

200

300

400

500

600

700

800

Sample size

Sample size % Compliance Median Target

Surgical Prophylaxis Data from 7 Health Boards; Median, Min & Max

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General Surgery Obstetrics & Gynaecology Orthopaedics

Duration <24h Antibiotic compliant

HOSPITAL HEAT TARGET’S REVISITED

EMPRIC PRESCRIBINGSTUCK 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

SAPG PRIMARY CARE PRESCRIBING 2009

• Compared with 08 44000 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

Restricted Drugs 1

0

1000

2000

3000

4000

5000

6000

7000

No of DDDs

Financial Month / Financial Year

CO-AMOXICLAV,AMOXICILLIN,CLAVULANIC ACID

CIPROFLOXACIN

CLARITHROMYCIN

New "Antibioticman" Policy

LOCAL AND NATIONAL IMPACT ON CDI

0

5

10

15

20

25

30

35

40

45

50

2006

M01

2006

M04

2006

M07

2006

M10

2007

M01

2007

M04

2007

M07

2007

M10

2008

M01

2008

M04

2008

M07

2008

M10

2009

M01

2009

M04

2009

M07

2009

M10

2010

M01

Cdi

ffca

ses C.diff

model

P <0.001

TAYSIDENATIONAL

Time for a Group Hug ?

Measures of Antibiotic Policy Impact

• Process• Promoted and restricted antibiotics

• Outcome• C difficile infection

• Balancing• Mortality (30 day) for medical and surgical

admissions

BALANCING MEASURES: UNINTENDED HARM TAYSIDE 30DAY MEDICAL AND SURGICAL

MORTALITY

SURGERY

0

1

2

3

4

5

6

2004M042004M082004M122005M042005M082005M122006M042006M082006M122007M042007M082007M122008M042008M082008M122009M042009M082009M12

Dea

th_r

ate

Surg

ical

Surgical

model

Policy change

MEDICAL ADMISSION

30D FROM ADMISSION

SAPG 2011-2014 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

AMT AND IPT COLLABORATION

Joint Network Event 1/3/2011Consider AMT + IPT strategic and operational level

managementSAB [prevention and effective management]CDI [prevention and management]Point prevalence survey -auditEducation Session for ICN on “bugs and drugs”

[Cleanliness champions for AMT's] QI initiative- “antibiotic review bundle”

ISSUES

Key issues “Front-end” empiric prescribing Antibiotic Policies (Antibiotic Man)“Continuing care antibiotic prescribing”

Not subject to adequate review

“Discharge prescribing”

INDICATION :

Start Date:

Review Date:

Action Taken on Review

Check Microbiology Results

Review Patient & Initial Diagnosis

Consider IV to Oral Switch

The 3 Day Antibiotic Bundle

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]

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 OPPORTUNITIESYOU ALL HAVE A PIVOTAL ROLE IN THIS

THANK YOU