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

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April to June 2007 July to September 2007 October to December 2007 January to March 2008

Quarter

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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

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Expenditure (£)D

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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

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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

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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

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Any questions?

Email: paul.wade@gstt.nhs.uk

Current C. difficile picture in London

NHS London Clostridium difficile Toxin-positive Cases April to November 2013

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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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