The International Convention Centre (ICC), Birmingham11 – 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

WHO Antimicrobial Resistance Global Report on Surveillance 2014

Antimicrobial resistance by 2050 threatens:

• A reduction in the world economy of 0.1-3.1%

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

Antimicrobial resistance….Successful surgery

Cancer chemotherapy

Immunotherapies

AMR the end of modern medicine

‘The English Miracle’1

Introduction of targetsFinancial penalties

Substantial changes in antibiotic useCephalosporins 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

The challenge of antibiotic resistant GNRs in the UK

• >3x increase in E . coli bacteraemiasince 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

0

5

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E. coli - Co-amox K. pneumoniae - Pip-tazo%

Iso

late

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2010

2011

2012

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2014

English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2015

Some typical local data

• If you don’t believe predictions of a world without antibiotics by 2050

• Imagine working in your hospital without these antibiotics by 2020

E. coli cultured from urine Enterobacteriaceae cultured from blood

Co-amoxiclav 27% 39%

Ciprofloxacin 12% 19%

Piperacillin-tazobactam 14% 16%

Gentamicin 10% 14%

Some key rates of antibiotic resistance at this trust in 2016

At what rate of resistance would these drugs cease to be reliable clinically selected treatments?

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

9

Forest plots of included studies

Urinary Infection Respiratory Tract Infection

Substantial

Lasting

Option 1 - Don’t start!

10

Always begin broad-spectrum intravenous

antibiotics within the first hour!

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?

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

Recommended course durations have fallen

Complete the course to avoid resistance?

1940’s Fear

Professional Pathogens

Transmitted during disease

M. tuberculosisMalariaHIV

Resistance selected during treatment

Resistance selected by inadequate treatment

21st Century Reality

Commensal Opportunist pathogens

Transmitted in carrier state

S. aureus E. coliK. pneumoniae

Resistance selected as bystanders

Resistance selected any antibiotic use.More use = more resistance

Two paradigms of resistance selection

Introducing ARK-hospital(4 mins)

The ARK-Hospital Team

Nationally Locally

The antimicrobial stewardship teamSally CurtisSam LippettVikesh Gudka

Martin LlewelynJasmin IslamLizzie CrossWill HamiltonCatherine SargentDan AgranoffNelson Barbon

What is ARK-hospital?

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

A 5-year applied research programme funded by NIHR

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 patientsA 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

2. A structure for team meetings, monitoring and feedback

5.1 Team meetings to introduce ARK5.2 Monitoring of Abx prescriptions5.3 Feedback to clinical teams- Audit data- Clinical cases

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

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100%

Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12

CQUIN Target

Prescriptions using ARK-hospital decision aid

0%

10%

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30%

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50%

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70%

80%

90%

100%

Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12

ARKTarget

Prescriptions stopped within 72 hour review

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12

TrustBaseline

Next steps…

• Feasibility ✔

• Three pilot sites kicking off this month• South Tees

• Oxford

• Wexham Park

• Recruiting 33 further trusts to main trial…

• Key people• Acute medic

• Pharmacist

• Infection specialist

Recruitment to main trial

Pre

scri

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ith

72

-hr

revi

ew (

%)

Prescriptions stopped (%)

10

Reducing the impact of serious infections

CQUIN 2017-19

https://fingertips.phe.org.uk/profile/amr-local-indicators

Interested?

Visit: http://www.arkstudy.ox.ac.uk/

Or contact: Professor Martin LlewelynM.J.Llewelyn@bsms.ac.uk