Antimicrobial Stewardship in the UK
Collaborative Working: Antimicrobial StewardshipSIFO Piemonte-VdA & ANDMO Piemonte-VdATorinoJanuary 31st 2014
Paul WadeConsultant Pharmacist - Infectious Diseases
Directorate of Infection, Guy’s & St. Thomas’s NHS Foundation TrustHonorary Clinical Senior Lecturer, King’s College, London
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Disclosures
Honoraria, consultancy fees & speakers’ bureau fees from:AstellasAstraZenecaCubistGileadICNetMerckNovartisPfizerWyeth
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Generalist service
National strategy / drivers for antimicrobial stewardship
Local strategy / drivers for antimicrobial stewardship
Implementation in the UK & at GSTT
Specialist service
Five Year Antimicrobial Resistance
Strategy
Start Smart, Then Focus
CDI targets
CRO outbreaks
What is antimicrobial stewardship?
What is Antimicrobial Stewardship (AMS)
Core strategiesProspective audit with intervention & feedbackFormulary restriction & pre-authorisation
Supplemental strategiesEducationGuidelines/pathwaysOrder formsDe-escalationDose optimisationIV-oral conversion
What makes an antimicrobial stewardship program?
Antimicrobial stewardship is a package of measures designed to:
provide effective, safe and economic use of antibiotics while also preventing resistance development
Who is involved in an AMS Programme?
Antimicrobial Stewardship Team - multidisciplinary
• ID physician/clinical microbiologist
• ID pharmacist
• IT support
• IC/epidemiology support
Antimicrobial Stewardship Committee
• Members of the AMS team
• Director for Infection Prevention & Control for organisation
• Other clinical members– Intensivists, physicians, surgeons, paediatricians
Antimicrobial resistance is increasing
Healthcare advances are leading to increasing antimicrobial use in secondary care settings
Limited return on investment has led to disengagement in new drug development from Pharma
Lack of information on efficacy of strategies to control antimicrobial usage, resistance development & HCAIs
What is the national & international context?
Drivers for Antimicrobial StewardshipNational & Local
Historical MRSA data
My organisation had 171 MRSA bacteraemias in 2003
Clostridium difficile infection: April 2007 to March 2008
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
April to June 2007 July to September 2007 October to December 2007 January to March 2008
Quarter
Num
ber o
f cas
es
Historical Clostridium difficile infection data
My organisation had 192 C. difficile infections in 2007-08
A major driver was also the media pressure…
o Past UK data suggests up to 50% are used inappropriately
o 30% (400) of in-patients are on antimicrobials
o 200 patients per day who may require intervention
o 15 patients per day added to referral & watch list
o 600 patients requiring review in last 2 months
o Robust data is time-consuming to generate & hard to maintain
o IT support is lacking
Extent of antimicrobial usage & associated risks
Other resistance problems on the increase
Antimicrobial pipeline is almost dry
2005-2011
Ertapenem
Doripenem
Tigecycline
Daptomycin
Linezolid
2012
Fidaxomicin
2013
Ceftaroline fosamil
National Guidance
Government directives, guidelines, reports since 1998 – slide 1
Government directives, guidelines, reports since 1998 – slide 2
Government directives, guidelines, reports since 1998 – slide 3
Government directives, guidelines, reports since 1998 – slide 4
Available at: http://www.researchdirectorate.org.uk/uhsm/asat/rac/rac-request.asp?racdid=AT315701
Most recent relevant Government directives, guidelines, reports
• Start Smart, Then Focus• Published 2011
• Chief Medical Officer’s Report 2011– Published 2012
• UK 5 Year Antimicrobial Resistance Strategy • Published 2013
START SMART
THEN FOCUS
• Allergy
• Follow local guidance
• Document (chart & notes)
• clinical indication
• stop/review date
• Take appropriate specimens
Surgical prophylaxisONE DOSE
CLINICAL DECISION AT 48 HOURS
Stop Switch Continue Change OPAT
DOCUMENT DECISION
• Clinical review
• Check microbiology result
IV to oral Review at 72h Narrow spectrum
Adapted from ARHAI Antimicrobial Stewardship GuidanceNovember 2011
Right Drug, Right Time, Right Dose, Right Duration…..
….. Every time
UK Five Year Antimicrobial Resistance Strategy
Actions:
National Implementation & Outcomes
National antimicrobial consumption data
CMO’s report highlights issues facing UK
“Squeezing the balloon”
Aim for heterogeneity
Need to increase E&T
Urgent need for more new antimicrobials
Benchmarking for improvement is in its infancy
Need robust quality measures
Can Pharmacy contribute to stewardship?
Other positive outcomes
Exemplar approach across an area: Scotland
http://www.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribing_Group__SAPG_
Outcomes for HCAI
More recent MRSA bacteraemia data
My organisation had 1 MRSA bacteraemia in 2012-3
More recent Clostridium difficile infection data
My organisation had 48 C. difficile infections in 2012-13
National Progress with CDIQuarterly cases over 2y – 2007 to 2012 - HPA
Local Implementation & Outcomes
Provision of guidance & education
Control measures to limit broad-spectrum agent use
Encouraging routine best practice to improve overall prescribing patterns
Individual patient review to optimise care
GSTT strategy & implementation
Pharmacy role in AMS
Specialist input
o Education of all levels & specialities of staff
o Development of Trust-wide guidance
o Monitoring & surveillance of antimicrobial usage
o Specialist consult & patient review
o Manage introduction of new agents
Generalist input
o Routine patient review & antimicrobial management
o Collection of audit data & significant contribution to performance
o Help to control antimicrobial useo Daily follow-up & referral
Increased resource made available since August
Guidelines
Consistently most used guidance within Trust
Regularly reviewed & updated
Multidisciplinary involvement
Specific guidance available for clinical areas, e.g. ICU, Cancer, Renal, etc.
Smartphone app will be available next month
Our own local antibiotic consumption data
In more detail
Outcomes
0
50
100
150
200
250
300
350
400
0
5000
10000
15000
20000
25000
30000
35000
40000
2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13
Expenditure (£)D
DD
s
Carbapenem Usage 2006-2013
Actual Use Estimated Expected Use Actual Expenditure (£1000s) Estimated Expected Expenditure (£1000s)
Estimated Expected Usage based on average increase in usage over 2007-2010 and extrapolated to future years. Antimicrobial stewardship programme only really began to embed in 2009-10 & was significantly impacted by flu pandemic in this year. Savings from 2010-11 onwards should be seen as indicative of potential performance. Fluctuations in expenditure on carbapenems was heavily affected by contract negotiations in 2007-08 and again (as meropenem became available in generic form) in 2010-11. Subsequent falls in usage will result in reductions in expenditure (as seen between 2011 and 2013).
High-risk agents & CDIGSTT Antibacterial Consumption For High-Risk Agents & CDI Cases [All or Attributable]
2005-2011
0
100
200
300
400
500
600
700
800
900
Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul
Month
DDDs
/100
0 O
BD
0.000
0.200
0.400
0.600
0.800
1.000
1.200
1.400
CDAD Cases/1000 OBD
C. difficile All inc Community C. difficile Attributable Cefuroxime Ciprofloxacin Co-amoxiclav
1st edition of Pocket guidelineslaunched August 2007 Pandemic influenza
period
New CDI test introducedSeptember 2010
Prescribing Process
Using a “Care Bundle”-type approach
Measuring 4 elements of an ideal prescription
• Allergy documentation
• Indication
• Duration/review date
• Missed doses
Results improving
GSTT Antimicrobial Process Monitoring Tool 2011‐2013:Compliance with Individual Elements
0
25
50
75
100
MayJun
eJul
yAu
gust
Sept
embe
rOc
tober
Nove
mber
Dece
mber
Janua
ryFe
brua
ryMa
rch April MayJun
eJul
yAu
gust
Sept
embe
rOc
tober
Nove
mber
Dece
mber
Janua
ryFe
brua
ryMa
rch April MayJun
eJul
yAu
gust
Sept
embe
rOc
tober
Nove
mber
Dece
mber
Month
% Com
pliance
Allergy Indication Duration Missed Doses Total Compliance
Always document a duration or review date
Always document an
indication
Review at Day 2 Decide by Day 5
If there’s no duration or review date, then a Red Highlight will be added to the chart along Day 5. The prescription must be rewritten if it is still required.
Any prescriptions without a duration which have not been rewritten by Day 5 should be queried with the prescribing team, and any that remain active on Day 7 should be escalated for Infection review
Antibacterial prescriptions will have an OrangeHighlight added along Day 2 to prompt review
If the duration is known, then the prescriptionshould be cancelled from the final due day
Antimicrobial StewardshipOptimising Quality, Improving Safety
FIRST DOSE ONLY prescribed in Emergency Department on front of prescription chart
FURTHER DOSES prescribed by admitting team, if necessary, inside of prescription chart
For continuing prescriptions:DOCUMENT indication &duration/review date
On the horizon
Is this all a hospital issue? No…
Some progress has been made…
What more needs to be done?
Improve compliance to guidelines
Improve control of duration of therapy
• Appropriate (early) IV to oral switch• Appropriate de-escalation of therapy• Narrow spectrum or stop
Ensure prescribing process is consistently appropriate
Improve referral process
Help with improving time to first dose – sepsis or otherwise
Need to strengthen liaison with primary care
Need more routine input
Need more information on eligible patients
Need clinicians to buy-in wholeheartedly
Need improved IT / surveillance information
Need more agile control systems
Primary care colleagues need to see importance of resistance
Future developments – next 2-5 years
Electronic prescribing
Automated audit, surveillance & feedback of antimicrobial usage patterns & associated resistance & outcomes
Faster, near-patient diagnostics
Real-time PCR / genomics directly from clinical samples
Conclusions
Antimicrobial stewardship is a multifactorial & multidisciplinary process
• Clearly linked to patient safety & has clinical, quality and financial implications
Introduction of stewardship has shown significant positive outcomes
• Markedly decreased C. difficile infection rates
• Alterations in antimicrobial consumption
• Local linkages between changes in practice & positive outcomes
Substantial risks exist, performance is not optimal, full engagement is slow
• Extensive action list - will not come without cost
• Next steps are out in the community…
Acknowledgements
GSTT colleagues:
Raj Thangarajah, Nick Price, Bill Newsholme,
Carolyn Hemsley & the AMS team
Colleagues throughout UK, in no particular order:
Kieran Hand, Hayley Wickens, Mark Gilchrist,
Laura Whitney, Lilian Li, Phil Howard,
Kelly Alexander, Wendy Lawson, Conor Jamieson,
Tim Hills, Jacqui Sneddon & Jonathan Cooke
Members, past & present of:
United Kingdom Clinical Pharmacy Association
Infection Management Group
Current C. difficile picture in London
NHS London Clostridium difficile Toxin-positive Cases April to November 2013
0
10
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30
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60
70
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Current CDI cases Expected CDI cases Annual Threshold
26 hospitals8 have already failed their target4 are on schedule to fail3 are within 5% of their estimate
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