Dilip NathwaniNinewells Hospital & Medical School
Dundee, Scotland DD1 9SY
SCOTTISH ANTIMICROBIAL PRESCRIBING
GROUP (SAPG) 2008
Where are we now and why?
Antimicrobial Prescribing Facts
~ 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 Antimicrobials account for upwards of 30% of
hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.
Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life
“The desire to ingest medicines is one of the principal features which distinguish man from the animals”
Osler W.Aecquanimitas,1920
OVERUSE
Why So Many Mistakes
High number and complexity of drugsHigh number and complexity of
syndromes and pathogensPoor training in antibiotic useVariability over time and place in
- pathogen prevalence- antibiotic susceptibilities- antibiotic formularies
Interventions to improve antibiotic prescribing practices for hospital inpatients Cochrane Systematic Review
Interventions to improve antibiotic prescribing practices for hospital inpatients Cochrane Systematic Review
Intervention Outcome Good
evidence
Weak evidence
No evidence
Restriction of third generation cephalosporins
Resistant gram –ve bacteria
Carling
de Man
Calil
Landman
Meyer
Leverstein van Hall
CDAD Carling McNulty
Khan
MRSACarling
Landman
VRE Bradley
Restriction of aminoglycosides
Resistant gram –ve bacteria
De Champs
Gerdingi.gould courtesy
Antibiotic use and resistance in the hospital MRSA: temporal series (Aberdeen, 1996-2000)
Monnet et al. Emerg Infect Dis 2004; 10:1432-41
What is Antimicrobial Stewardship?A marriage of infection control and antimicrobial
managementMandatory infection control complianceSelection of antimicrobials from each class of drugs that
does the least collateral damageCollateral damage issues include
- MRSA- ESBLs- C.difficile- stable derepression- MBLs and other carbapenemases- VRE
Appropriate de-escalation when culture results are availableDellit TH et al Clin Infect Dis 2007; 44: 159-177
How can we reduce consumption, improve
quality of prescribing and reduce resistant transmission?
Maintains ResistanceMaintains ResistanceMaintains ResistanceMaintains Resistance
Spreads ResistanceSpreads ResistanceSpreads ResistanceSpreads Resistance
Causes ResistanceCauses ResistanceCauses ResistanceCauses Resistance
Antibiotic UseAntibiotic Use
Cross InfectionCross Infection
Don’t forget antibiotic use to modulate
resistance and control outbreaks eg. patient
decontamination regimens
Antibiotic UseAntibiotic Use
By Patient-staff-patient
Patient-patient
?Patient-environment / equipment – patient
By Patient-staff-patient
Patient-patient
?Patient-environment / equipment – patient
The Vicious Spiral
Must get right at all cost Must get right at all cost
Inadequate rapid testInadequate rapid test
Lack of faith in testsLack of faith in tests
Defensive medicineDefensive medicine
Patient expectationsPatient expectations
Poly-pharmacyPoly-pharmacy
Increased prescribingIncreased prescribing & & empiric Rxempiric Rx
costcostResistanceResistance
C.difficleC.difficle
use of new use of new drugsdrugs
Use of broad Use of broad spectrum spectrum
drugsdrugs
Managing risk of empiric therapy
“Many clinicians regard the right to prescribe antibiotics freely (unrestricted) as a basic human right”
However
“The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk to the patient, ecology and other patients of broad spectrum antibiotic use, particularly C.difficle in the most vulnerable group
“The organisation needs to risk manage this conflict and help with solutions “
APP&P KEY DOMAINS FOR RECOMMENDATIONS 2006
Recommendations in the following key areas:Key Area
1. Establish standard structures and lines of responsibility &accountability in NHS Boards across Scotland.
2. Define structures and responsibility for multi-disciplinaryand generic undergraduate and post-graduate trainingrelated to antimicrobial prescribing.
3. Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial resistance patterns.
4 Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial consumption and quality of prescribing at anorganisational level and/or ward specific level.
5. Define the key areas for acute hospital policy andrecommendations for audit.
6. Develop and define performance indicators that could beused to assess or gauge performance related toantimicrobial prescribing in hospitals
SMC SLWG Document communicated by CMO to all NHS Boards 2006
Medical DirectorMedical Director Chief ExecutiveChief Executive Infection Control Infection Control ManagerManager
Drugs & Drugs & Therapeutics Therapeutics CommitteeCommittee
Antimicrobial Antimicrobial Management Team (AMT)Management Team (AMT)
Speciality-based Pharmacy leads for Speciality-based Pharmacy leads for APP&P with responsibility for APP&P with responsibility for antimicrobial prescribingantimicrobial prescribing
Ward Based Clinical Ward Based Clinical PharmacistsPharmacists
Risk Management Risk Management CommitteeCommittee
Clinical Governance Clinical Governance CommitteeCommittee
Infection Control Infection Control CommitteeCommittee
Microbiologist / Microbiologist / Infectious Diseases Infectious Diseases PhysicianPhysician
PRESCRIBERPRESCRIBER
Prescribing support / feedback
Dissemination & feedback
http://www.scotland.gov.uk
KEY ROLE OF AMT
Antimicrobial management team
Multi-disciplinary team ResourcedSupported Multi-faceted
interventions (consistently more effective then single interventions)
Active team at the coalface
Core InterventionsFormulary +
restrictions (expert approval)
Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences
THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL
RESISTANCE ACTION PLAN[ScotMARAP 2007]
ScotMARAP Output
3 year programme of work launched on the 17th of March 2008
Total funding of £1.2 million and allocation split between key stakeholders
SMC asked to convene, host and service national clinical forum – SAPG
SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)
The primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum” as expressed in the APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).
Scottish Medicines Consortium Scottish Antimicrobial rescribing Group
Health ProtectionScotland
NHS Education forScotland
NHS Boards Area Drug and Therapeutics Committees
NHS Quality Improvement Scotland
NHS Boards Antimicrobial Management Teams
Clinical GovernanceRisk ManagementInfection Control Team /
ManagerPrescribers
Reference DiagnosticServices
NHS Boards Antimicrobial Management Team Sub- Group of Scottish
Antimicrobial Prescribing Group
Scottish Patient Safety Alliance
Information ServicesDivision
Local DiagnosticServices
Scottish Medicines Consortium Scottish Antimicrobial rescribing Group
Health ProtectionScotland
NHS Education forScotland
NHS Boards Area Drug and Therapeutics Committees
NHS Quality Improvement Scotland
NHS Boards Antimicrobial Management Teams
Clinical GovernanceRisk ManagementInfection Control Team /
ManagerPrescribers
Reference DiagnosticServices
NHS Boards Antimicrobial Management Team Sub- Group of Scottish
Antimicrobial Prescribing Group
Scottish Patient Safety Alliance
Information ServicesDivision
Local DiagnosticServices
THE STAKEHOLDERS
4 WORKSTREAMS
1. INFORMATION MANAGEMENT (HPS AND ISD)
2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY
(NQIS)4.INFECTION MANAGEMENT
(SPA,NQIS,NES,HPS-ISD,Professional Organisations)All the work-streams work in parallel but with vertical
integration Workstream work underpinned by an AMT Clinical
Network
1. INFORMATION MANAGEMENT: SURVEILLANCE AND CONSUMPTION DATA
Overview of Information from NHS Boards Reporting antimicrobial use in DDDs
• 3 NHS Boards – routine reporting in primary & secondary care
• 2 NHS Boards – routine reporting in primary care
• 3 NHS Boards – ad hoc reporting
• 6 NHS Boards – no reporting
2: ORGANISATION & ACCOUTABILITY Overview of Information from NHS Boards Antimicrobial Management
Teams (AMTs)
• 7 out of 14 NHS Boards have established AMTs
4 - primary & secondary care
3 - secondary care only
• Other NHS Boards either have AMT equivalents or seek advice / support from other NHS Boards
• Where AMTs exist there are links with ADTCs (direct or indirect reporting)
• AMTs MUST BE IN PLACE AND ICTs SHOULD SUPPORT THIS
• OVERALL MANAGEMENT BY ICM’s but CEO/Medical Director accountability
CEL 30(2008)8TH July
As an immediate intervention to reduce the risk form C.difficle,we accept SAPG’s recommendation that all boards should immediately establish an AMT which covers primary and secondary care prescribing.
“AMT’s work closely strategically and operationally with ICT’s and ICM”- SAPG
CEL 30(2008)8TH July
Recognition of the key role of the antimicrobial pharmacist: central additional funding for £40,000 for each mainland board and £20k for Island boards for 3 years (2011).
SAPG (not in CEL) keen on developing clinical networks for AMT’s to provide support for smaller boards, share good practice and do joint planning. Launch of AMT clinical network in STIRLING 18TH November 2008.
Education
DOTS onl line- all foundation doctors mandatory training in prescribing
PAUSE website for undergraduates- Scottish Deans Educational Group
Pharmacy and non-medical prescribers programme for prescribing
Module on antibiotic resistance and C.difficile being developed
Nurses programme on recognition of infection and use of microbiology
Dental antibiotic prescribing
4: INFECTION MANAGMENT PHILOSOPHY
HIGH BURDEN, HIGH IMPACT CONDITIONS EVIDENCE OF BENEFIT FOR INTERVENTION ALSO TARGET SYSTEMS CHANGE TO BRING
ABOUT DESIRED BENEFIT INTEGRATE, DEVELOP AND IMPLEMENT
EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA)
IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis
Others
The First Six Months of SAPG
Guidance on CDAD- restrictive policy, CDAD management protocol, measures of improvement & set up extra-net
Surgical prophylaxisSNAP-CAPAMT network –November 18th launchAppointment of key personnel National generic prescribing templateAntimicrobial prescribing and resistance
education programme.
Outbreak
June 2000One university
hospital, USIncrease C.difficle
from 2.7 to 7.2 infections per 100 hospital discharges
Increase in the frequency of severe outcomes
“Tiered” as opposed to a “bundle” approach. Implemented over time. Education ¶ Increase in case finding and
rapid initiation of appropriate therapy ¶
Expanded infection control measures
Infection control auditsTargeted antimicrobial
restriction ¶Measuring and feedback of
antibiotic use and local surveillance data
Muto et al CID 2007; 45: 1266-73.
SPCC RWHT C.difficile Toxin
Guidance for Proven or Suspected C. difficile associated diarrhoea
(CDAD)Your patient is in a healthcare facility or has been admitted with new onset of DIARRHOEA
Constipation with overflow diarrhoea (make sure PR done), laxatives and other common causes of diarrhoea have been excluded
Does patient have risk factors for CDAD?History of use (< 3m) or current use of an antibioticProlonged recent hospital stayUse of PPIIncreasing age especially >65ySurgical procedure (in particular bowel procedures)
Send stool for C. difficiletoxin
Inform InfectionControl Team
Isolate patientin single room
Designated toilet or commode
Stop PPIStop anti-microbial
treatment if possibleStop laxative
Hand hygienewith soap and
waterWear gloves
and disposable apron
Toxin -ve Toxin +ve
Continue with guidance
Discontinue C. difficileguidance or if indexof suspicion high seek ID referral
Patient has non-severe CDAD
Treat with oral metronidazole 400mg t.d.s. for 10-14 days Rehydrate patient
Daily assessment of patient with mild to moderate disease:
Observe bowel movement, symptoms (WBC and hypotension) and fluid balance.
If condition doesn’t improve after 3-5 days of treatment with metronidazole, patient should be switched to treatment with vancomycin (125mg q.d.s. for a further 10-14 days)
Treat with oral vancomycin 125mg q.d.s. for 14 days
Rehydrate patient and consider referral to hospital or healthcare facility if patient at home
Daily assessment of patient with severe disease:
Observe bowel movement, symptoms (WBCand hypotension) and fluid balance.
Surgery – Consult and AXR and CT scanning; consider PMC, toxic megacolon, ileus orperforation
If ileus is detected add 500mg metronidazole i.v. t.d.s. until ileus is resolved
Patient has severe CDAD
Contact Details
Infection control team via switchboard
Public health via NWH switch board if care home
“On call” duty microbiologist: 4039 Ninewells or via switchboard 5315 Perth Royal
“On call” ID: 5075
Refer to Infectious Disease
Yes
UNDERTAKE SEVERITY ASSESSMENTSuspicion of Pseudomembranous colitis (PMC) or toxic
megacolon or ileus OR two or more of the following severitymarkersColonic dilatation in CT scan >6cm(if available)WCC >15 cells/mm3
Creatinine >1.5 x baselineAlbumin <25 g/l
For recurrent (3 or moreepisodes) CDAD seekSpecialist ID/Micro advice
Tayside HAI NetworkSeptember 2008
Review September 2009
YesNo
REDUCE TRANSMI SSION
Day 3 Antibiotic Review Bundle : Clinical Diagnosis, Laboratory Results, Duration, Route
Pulcini et al, JAC, 2008
0
5
10
15
20
25
30
35
40
Jan-
05
Apr
Jul
Oct
Jan-
06
Apr
Jul
Oct
Jan-
07
Apr
Jul
Oct
Jan-
08
No.
of C. Diff
Cas
es
c-chart for Cases of c. difficile Acquired in Ninewells Hospital: Jan 2005 – Mar 2008
Upper Control Limit
Lower Control Limit
Upper Warning Limit
Lower Warning Limit
CONCLUSIONSSAPG is a national clinical forum with broad multi-
disciplinary ownership. A structure for clinical and fiscal governance is established. SMC is the host organisation.
SAPG is now in operation with 4 key proposed work-streams. These would be key deliverables over specific time frames.
Other areas to be developed over time, especially around primary care and community/LTCF prescribing
AMT clinical network will provide national cohesion and need to work in close collaboration with ICTs and should have a unified vision
We need hospital leadership and all healthcare professionals to engage with it and own it
Your thought of the day : To restrict or not to..?
“Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous… [prescribing].. or take arms against a sea of.. [resistance and diarrhoea].. and by opposing [antibiotics] end it..”
Adapted from Shakespeare [email protected]
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