Programme & call for abstracts

CPD ACCREDITED

Thursday 19 MarchRoyal College of Physicians, London

One size does not fi t all!

BSAC SPRING MEETING 2015

Dosing and treatment of

bacteria, viruses and fungi in special

populations.

Programme & abstracts

We are grateful for the support we have received from industry and wish to acknowledge the following companies.

Silver sponsors:

Final programme sponsor:

Exhibitors:bioMérieux Cubist EumedicaICNet Launch Diagnostics Leo Pharma Pfizer Thermo Fisher

Cover image courtesy of Dr Conor Jamieson, City Hospital Birmingham

Page

Programme 3 - 4

Free paper abstracts Obesity as a risk factor for complicated antimicrobial therapy: a prospective cross-sectional study 5 Charani E, Gharbi M, Frost G, Drumright L, Holmes A Imperial College London

Informing future surveillance for carriage of multi-resistant gram negative bacteria: problems with recruiting to 5 - 6an English stool sample cross-sectional community prevalence study Presenting author: Mrs Linda Crocker, Co-authors: Dr Deborah Nakiboneka-Ssenabulya, Mrs Rebecca Owens, Dr Donna Lecky, Mr Tom Nichols, Dr Li XuMcCrae, Ms Sahida Shabir, Dr Chung Keun Taik Taik Chung, Dr Lucy Thomas, Dr Mike Thomas, Prof Stephen Smith, Prof Peter Hawkey, Prof Cliodna McNulty

Meropenem Review and De-escalation in a Tertiary Teaching Hospital 6Ni Riain U1 and Tierney M2 1Discipline of Bacteriology, School of Medicine, National University of Ireland, Galway, 2Pharmacy Department, University Hospital Galway, Galway, Ireland.

Development and Evaluation of Bayesian Software for Improving Therapeutic Drug Monitoring of Gentamicin 7in NeonatesEva Germovsek1, Alison Kent2, Nigel Klein1, Mark A Turner3, Mike Sharland2, Elisabet I Nielsen4, Paul T Heath2, Joseph F Standing11Inflammation, Infection and Rheumatology section, UCL Institute of Child Health, London WC1N 1EH, UK; 2Paediatric Infectious Diseases Research Group, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK; 3Liverpool Women’s Hospital, Crown Street, Liverpool, Merseyside L8 7SS, UK; 4Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden

Antimicrobial resistance: Linking future prescribers and patients through near peer education 7 - 8Carwyn Watkins1, Vicki L. Young2 1Royal Devon and Exeter Hospital, EX2 5DW 2Primary Care Unit, Public Health England, Gloucester Royal Hospital, GL1 3NN

Poster abstracts

16S rRNA PCR ASSAY FOR THE EVALUATION OF CSF SAMPLES IN NEUROSURGICAL CENTRAL NERVOUS SYSTEM 9INFECTIONSAjayi A. A, Szendroi A, Eltringham I. JDepartment of Microbiology (Viapath), King’s College Hospital NHS Foundation Trust, London.

Improving antibiotic awareness games for children: Implications from an evaluation of the e-Bug games 10Alexander Hale1, Vicki Louise Young2, Cliodna McNulty2, Ann Grand1.1University of the West of England, Bristol, United Kingdom.2Public Health England, Gloucester, United Kingdom.

Factors influencing Health care associated infection rates at St. John’s Hospital, NHS Lothian 10-11Joshi S, MacSween K, Mackintosh CL, Corretge MSt. John’s Hospital, Livingston, NHS Lothian

Audit of the Management of Neonatal and Paediatric Candidaemia at University Hospital South Manchester 11Lamb, R, Sinha, A, Bakaya, K, Hassan, IPaediatric and Neonatal Department, Wythenshawe Hospital, University Hospital South Manchester

Development of a regional medication chart for use with adult patients in an acute setting with separate 12antimicrobial sectionMallon Caroline1, Gallagher Fiona2. 1Pharmacy Department Belfast City Hospital Belfast Health and Social Care Trust, Lisburn Rd., Belfast BT9 7AB 2Pharmacy Department Antrim Rea Hospital Northern Health and Social Care Trust.

Contents

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Programme

0900 Registration & coffee

0940 Welcome & introductory remarks Dr Nick Brown, BSAC President SESSION ONE: The issues of dosing in obese patients Chair: Dr Nick Brown, Consultant Microbiologist, Addenbrookes Hospital, Cambridge

0945 Antibacterial dosing in obese patients – challenges and pragmatic approaches Dr Alison Thomson, Senior Lecturer, University of Strathclyde 1005 Pharmacological management of viruses in obese patients Dr Dimitar Tonev, Director Medical Affairs UK, Ireland and Nordics, Cubist International Presentation supported by Cubist International

1025 Antifungal PK/PD – the challenges posed by obesity Professor William Hope, Professor of Therapeutics & Infectious Diseases, University of Liverpool

1045 Coffee, exhibition and poster viewing

SESSION TWO: Free Papers Chair: Dr Mike Cooper, Consultant Microbiologist, New Cross Hospital, Wolverhampton

1115 Obesity as a risk factor for complicated antimicrobial therapy: a prospective cross-sectional study Ms Esmita Charani, Health Protection Research Unit, Imperial College London

1125 Development and Evaluation of Bayesian Software for Improving Therapeutic Drug Monitoring of Gentamicin in Neonates Dr Joe Standing, UCL Institute of Child Health/Great Ormond Street Hospital

1135 Informing future surveillance for carriage of multi-resistant gram negative bacteria: problems with recruiting to an English stool sample cross-sectional community prevalence study Mrs Linda Crocker, Public Health England Primary Care Unit, Gloucestershire Royal Hospital

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1145 Meropenem Review and De-escalation in a Tertiary Teaching Hospital Dr. Úna NíRiain, University Hospital Galway, Newcastle Rd, Galway

1155 Antimicrobial resistance: Linking future prescribers and patients through near peer education Dr Carwyn Watkins, Royal Devon and Exeter Hospital

1205 Q&A

1215 AGM / Lunch, exhibition and poster viewing

SESSION THREE: The Garrod Lecture 2015 Chair: Dr Nick Brown, Consultant Microbiologist, Addenbrookes Hospital, Cambridge

1345 Why Is Improvement Difficult? Professor Peter Davey, Lead for Clinical Quality Improvement, University of Dundee

SESSION FOUR: Invited guest lecture Chair: Professor Dilip Nathwani OBE, Consultant Physician, Ninewells Hospital, Dundee

1430 The challenges of antimicrobial prescribing in an ageing population Professor Colin P Bradley, Professor and Head of Department of General Practice, University College Cork

SESSION FIVE: Pregnancy and paediatrics Chair: Professor Dilip Nathwani OBE, Consultant Physician, Ninewells Hospital, Dundee

1500 Antimicrobial prescribing in paediatrics – what collateral damage? Professor Mike Sharland, Paediatric Infectious Diseases Research Group, St Georges University, London

1520 The use and abuse of antibiotics during pregnancy Professor Ronald F Lamont, Emeritus Consultant in Obstetrics & Gynaecology, North West Thames NHS Trust & Hon Reader, Division of Surgery, University College London

1540 Closing remarks

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Free paper abstracts

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Obesity as a risk factor for complicated antimicrobial therapy: a prospective cross-sectional study Charani E, Gharbi M, Frost G, Drumright L, Holmes AImperial College London

Background Obesity is increasing globally and evidence indicates a relationship between obesity and infection. We evaluated the impact of obesity on infection and antimicrobial management in adult medical and surgical patients, and 2) assessed the prevalence of obesity in hospitalised patients.

Methods Three tertiary National Health Service hospitals in London, 2011-2012 were included in a prospective cross-sectional study. Data from all adult admissions units and medical and surgical wards were collected on a single day. Patient demographic data, reason for admission, current medications, infection and obesity status data were collected from the medication charts, nursing and medical notes. The aspects of antimicrobial management assessed were whether or not patients received: 1) second or third line therapy according to local policy; 2) intravenous therapy, where an alternative oral therapy was appropriate; 3) longer than the recommended duration of therapy as per local policy recommendations; 4) repeated courses of therapy to treat the same infection; and, 5) specialist advice into antimicrobial therapy was provided by the medical microbiology or infectious diseases teams. If patients scored yes for two or more of the above criteria the therapy was defined as ‘complicated’.

Findings Of the 1014 patients included in this study, 22% (225) were obese, 9% (93) were underweight and 69% (696) were in the normal and overweight category. Skin and soft tissue infections had a significantly greater prevalence amongst obese patients than the normal/overweight and underweight categories (18% vs. 8% and 7%, p<0.005). Surgical site infections were also more prevalent in the obese compared to normal/overweight categories (7% vs. 3%, p<0.001). Obese patients were significantly more likely to have more ‘complicated’ antimicrobial therapy than normal/overweight and underweight patients (36% versus 19% and 23% respectively, p=0.002). After adjustment for study site, age group, comorbidities (i.e. diabetes and hypertension), and the type of infection, obese patients remained at significantly increased odds of requiring ‘complicated’ antimicrobial therapy compared with normal/overweight patients (OR=2.01, 95% confidence interval [CI], 1.75 to 3.45). Amongst the patients in this study, we found no evidence of any antimicrobial dose adjustments made based on patient weight.

Conclusion One in 5 of hospitalised patients are obese. Compared to the underweight and normal/overweight, obese patients are at significantly greater risk of requiring complicated antimicrobial management.

Informing future surveillance for carriage of multi-resistant gram negative bacteria: problems with recruiting to an English stool sample cross-sectional community prevalence study Presenting author: Mrs Linda Crocker, Co-authors: Dr Deborah Nakiboneka-Ssenabulya, Mrs Rebecca Owens, Dr Donna Lecky, Mr Tom Nichols, Dr Li XuMcCrae, Ms Sahida Shabir, Dr Chung Keun Taik Taik Chung, Dr Lucy Thomas, Dr Mike Thomas, Prof Stephen Smith, Prof Peter Hawkey, Prof Cliodna McNultyPublic Health England Primary Care Unit, Statistics Unit, and Epidemiology; Birmingham University; Southampton University and Bowel Cancer Screening Programme

BackgroundThe rise in infections due to multi-resistant gram negative bacteria is a major public health problem. Monitoring the carriage of such organisms in the asymptomatic population is crucial to informing control efforts. Obtaining stool samples from the asymptomatic population is challenging.

AimsWe set up a cross-sectional community study to determine the prevalence of extended spectrum beta lactamases producing coliforms in the healthy general population, and determined how this could inform the development of future community surveillance of ESBLPCs

MethodsWe purposively selected 15 general practices in four areas of England with different ethnic population structures.After stratification of GP lists by age, ethnicity and antibiotic use, randomly selected patients were sent a postal invitation. Respondents who posted back letters of interest in the study were sent a postal stool kit and questionnaire.

ResultsDifficulties with the study which may affect future community antimicrobial resistance surveillance programmes:1. Data protection issues led to a lot of administration during stratification and selection of patients.2. Obtaining information on patients’ type of antibiotic use in a format to allow easy stratification of patients was difficult in many practices.3. Stool return rates varied greatly by region: Central Urban Birmingham 1.6%, Newham in London 2.4%, Southampton (South England) 3.7% and 8.2% Shropshire (Rural Central England). 4. Stool returns were lower in younger patients (18-39y 1.4%. >60y 9.5% and ethnic minorities (Asian 1.7%, black 4.1%, mixed 3.7%, white 7%).

ImplicationsSurveillance of ESBLPCs in older patients may be undertaken by postal invite, however other recruitment methods will be needed to recruit younger or ethnic minority for routine stool based surveillance studies of antimicrobial resistant organisms.

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Meropenem Review and De-escalation in a Tertiary Teaching Hospital Ni Riain U1 and Tierney M2 1Discipline of Bacteriology, School of Medicine, National University of Ireland, Galway, 2Pharmacy Department, University Hospital Galway, Galway, Ireland. ObjectiveUsage of meropenem in our hospital has doubled over the past seven years from 1.99DDDs in 2008 to 4.35 in 2014. An audit in 2013 showed that although there was appropriate indication for initiating therapy with meropenem in the majority of cases, therapy was rarely subsequently reviewed and de-escalated where appropriate. In response to the audit findings, targeted intervention through focused meropenem de-escalation was undertaken. Heretofore, literature is limited on the impact of meropenem review and de-escalation strategies.

MethodsA local Guideline for review and de-escalation of meropenem was developed and approved by the Antimicrobial Stewardship Team and piloted for a period of four weeks by a consultant microbiologist and antimicrobial pharmacist.Guideline criteria to be met prior to recommendation for meropenem de-escalation were:• A current diagnosis of infection, with a causative organism identified for which there was an appropriate alternative antibiotic or• A current diagnosis of infection suspected , with no causative organism identified and the patient had no organism isolated from any specimen in the previous 12 months for which meropenem therapy was specifically indicated, without suitable alternative.

Implementation of the guideline was piloted over a four week period. Patients on meropenem were reviewed at or after 72 hours of therapy. Patient medical notes, drug charts, laboratory and radiology results were reviewed. Data collected included documentation of indication for meropenem use, documentation of infection specialist input, suspected site of infection, indwelling urinary catheter or central venous catheter, clinical samples collected (blood culture, urine, sputum, wound swab etc) and corresponding results.. A written recommendation was made in patient medical notes to stop meropenem, de-escalate to a specified alternative antibiotic or continue meropenem. Patient drug charts and medical notes were reviewed by the antimicrobial pharmacist 48 hours later to record if the recommendation had been followed.

Results33 patients were reviewed. Advice from infection specialists, microbiology or infectious disease teams, supporting initial meropenem use was documented in 26 (79%) of patients. Meropenem use was empiric in 19 (58%) patients and culture directed in 14(42%).

Overall, recommendation by the review team to de-escalate from meropenem to a specified alternative antibiotic was made for 18 (55%) patients. This advice was followed for 12 (36%) patients.

From the 19 patients where initial meropenem therapy was empiric, a recommendation to de-escalate was made for 16 (84%). From the 14 patients where initial meropenem therapy was culture directed, a recommendation to de-escalate was made for 2 (14%).

ConclusionA daily review of patients on meropenem over 4 weeks resulted in de-escalating meropenem in 36% of patients reviewed. Had the recommendation of the meropenem review team been followed in all cases it would have been possible to de-escalate from meropenem in 55% of patients. Focused meropenem de-escalation in line with locally agreed de-escalation criteria is an effective intervention in reducing unnecessary meropenem use.

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Development and Evaluation of Bayesian Software for Improving Therapeutic Drug Monitoring of Gentamicin in NeonatesEva Germovsek1, Alison Kent2, Nigel Klein1, Mark A Turner3, Mike Sharland2, Elisabet I Nielsen4, Paul T Heath2, Joseph F Standing11Inflammation, Infection and Rheumatology section, UCL Institute of Child Health, London WC1N 1EH, UK; 2Paediatric Infectious Diseases Research Group, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK; 3Liverpool Women’s Hospital, Crown Street, Liverpool, Merseyside L8 7SS, UK; 4Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden

BackgroundGentamicin requires therapeutic drug monitoring (TDM) and samples are currently taken just before the next dose. Using Bayesian methods allows TDM to be performed when samples for other purposes are taken, thus making it less invasive.

AimThis study aimed to develop a Bayesian software (neoGent) for TDM use in neonates. The second objective was to evaluate neoGent on prospectively collected data.

MethodsFirstly, a population pharmacokinetic (PK) model for gentamicin in neonates was developed by pooling data from published studies and performing a PK meta-analysis. The predictive power of the model was then tested with prospectively collected data from five UK hospitals by comparing model predicted trough gentamicin levels with measured levels. To quantify the model’s ability to predict, prediction errors (i.e. the difference between the predicted and the measured level) were calculated.

ResultsA three-compartment model provided the best fit to the data. Allometric scaling and a function describing the maturation of glomerular filtration rate were included a priori. Other significant covariates were postnatal age and serum creatinine standardized for postmenstrual age (PMA). The evaluation dataset included 163 subjects with PMA ranging 23.9-42.3 weeks (median: 34.9 weeks). Median prediction error (95% non-parametric confidence interval) was -0.002 (-0.87, 0.85) mg/L suggesting that the model is able to make predictions of trough levels from opportunistic samples. Additionally, the model was shown to perform best when compared to 11 published models. NeoGent has now been implemented in statistical software R. It was designed to read in demographic features of a neonate, its dosing history and measured gentamicin levels. Real-time Bayesian predictions of the trough levels are then made. The output of the neoGent is a table showing the time when gentamicin concentration will go below a certain pre-specified threshold and a visual presentation of the predictions.

ConclusionThe neoGent software was developed and evaluated with prospective data. The results showed that it can be used for predicting trough levels from opportunistic samples taken at earlier time points, making TDM less invasive. Future work will involve developing a more user-friendly interface.

AcknowledgmentsThis project was funded by Action Medical Research. The authors would also like to thank all patients and collaborators (Dr Mark Anthony, Dr Tim Scorrer, Dr Prakash Satodia, Dr Nasreen Aziz) who participated in this study.

Antimicrobial resistance: Linking future prescribers and patients through near peer education. Carwyn Watkins1, Vicki L. Young2 1Royal Devon and Exeter Hospital, EX2 5DW 2Primary Care Unit, Public Health England, Gloucester Royal Hospital, GL1 3NN

AimsThe Department of Health’s UK 5 Year Antimicrobial Resistance (AMR) Strategy advises that greater education of both medical professionals and the public is a key aspect in promoting appropriate prescribing. One of the great advantages of peer education is the benefit it brings to both ‘educators’ and ‘students’ in terms of knowledge, engagement and motivation. In this context its use has potential to help achieve multiple strategic aims by educating both future prescribers and patients at the same time.

This initiative aims to develop a set of teaching sessions for medical, A-level and Key Stage 3 students using a near-peer model, so that volunteers from each class go on to deliver the material in a simplified format to younger age-groups. The pilot further aimed to assess the feasibility of the on-going implementation of such a project and to evaluate the process from the point of view of students, peer educators and teachers.

MethodsLearning objectives for each age group were defined based on Public Health England (PHE) “antimicrobial and

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stewardship competencies” and school curricula. Teaching sessions on AMR were delivered to medical students in small groups. Volunteers were taken from these groups to be peer educators for A-level students. As well as delivering the sessions, peer educators were actively encouraged to contribute to the development of the activities used in order to maximise the benefits of the near-peer method. Again, volunteers from the A-level classes went on to deliver the same resources in a simplified format to those at Key Stage 3. The process was evaluated through the use of before and after knowledge tests, as well as using a mixture of quantitative and qualitative survey data to gauge student and teacher reactions to the process.

ResultsBoth medical and A-level students demonstrated increased scores on AMR knowledge tests following the intervention (55% to 69% p=0.016 and 54% to 72% p<0.01, respectively). The Key Stage 3 students liked both the interactive nature of the activities and being taught by 6th formers. Peer educators also found the sessions both enjoyable and helpful, with teachers commenting on how they gained in confidence throughout the process. Once the sessions had been developed, the implementation of the school sessions was straightforward, with the activities fitting into a single lesson. Teachers’ feedback was positive, with the school involved in the pilot requesting a repeat cycle the following year.

ConclusionsA cascade approach to near-peer teaching is a feasible, enjoyable and effective process in raising awareness of AMR. The activities developed during this pilot are being taken forward through the development of an antibiotic peer education pack by PHE that has the potential to reach large numbers of future antibiotic prescribers, patients and even students of the allied health professions, most notably pharmacists and nurses.

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16S rRNA PCR ASSAY FOR THE EVALUATION OF CSF SAMPLES IN NEUROSURGICAL CENTRAL NERVOUS SYSTEM INFECTIONSAjayi A. A, Szendroi A, Eltringham I. JDepartment of Microbiology (Viapath), King’s College Hospital NHS Foundation Trust, London.

OBJECTIVESNeurosurgical central nervous system infection is associated with significant morbidity and mortality. Reliance on cerebrospinal fluid (CSF) culture is suboptimal for diagnosis. We report our preliminary results of comparison between culture and real-time 16S rRNA PCR on CSF samples from neurosurgery patients.

METHODSWe selected 31 CSF samples from 133 consecutive CSF samples received in the Microbiology laboratory at King’s College Hospital between 1 May 2014 and 6 June 2014. Inclusion criteria for all samples was neurosurgical CSF sample for microscopy and culture. Exclusion criteria were inappropriate CSF sample collection and insufficient sample for both culture and PCR testing.

RESULTSA total of 31 CSF samples from 19 patients were tested by culture and PCR. The median age was 39 years (range 4 months – 72 years). For 7 of 31 samples, both the PCR and culture results were positive. For 23 of 31 samples, culture was negative and PCR was positive. There was one negative culture, negative PCR sample. There were no positive culture, negative PCR discrepant results. Among the culture negative, PCR positive samples, 18 were taken after prior antibiotic use, and the sample source varied between lumbar puncture (10 samples), extraventricular drain (7 samples) and CSF shunt devices (6 samples). Bacterial species isolated included Klebsiella pneumoniae (3 samples), Staphylococcus epidermidis (2 samples) and mixed infection with Enterococcus faecalis and Streptococcus mitis (2 samples).

CONCLUSIONSBroad range PCR of 16S rRNA gene has potential clinical application in the diagnosis of neurosurgical meningitis. Further work is needed to overcome challenges posed by contamination as well as the selection of discriminatory assays for bacterial PCR products identification.

Poster abstracts

Improving antibiotic awareness games for children: Implications from an evaluation of the e-Bug gamesAlexander Hale1, Vicki Louise Young2, Cliodna McNulty2, Ann Grand1.1University of the West of England, Bristol, United Kingdom.2Public Health England, Gloucester, United Kingdom.

e-Bug is a pan-European educational resource for junior and senior school children that teaches about responsible antibiotic use, the spread, prevention and treatment of infection, as well as vaccinations. The aim of this study was to appraise pupils’ responses to the content and games on the e-Bug student website and suggest methods to which the games can be improved to increase antibiotic awareness. The three games selected for evaluation all contained elements that relate to antibiotics, the correct use of antibiotics, bacteria and viruses, and specific learning outcomes related to these subjects. A mixed methodological approach was undertaken with 153 pupils aged 9-11 in primary schools and summer schools in the Bristol area. The study included questionnaires with multiple choice, open-ended and Likert scale style questions, as well as focus groups and think-aloud session.

The results of the study showed that the Body Busters game was the most popular and Microbe Mania was the least popular. Some of the main suggestions that were made related to the challenge that the game presented, meaning it was either too hard or too easy. This greatly affected the playability and enjoyment of the game for participants. All three of the games demonstrated a need for a wider variety of challenge to suit all player abilities, although the main focus for this comment was directed at Doctor Doctor and Microbe Mania. This can be achieved with adjustments to the game to include an ‘easy, medium, or hard’ selection mode.

Cosmetic improvements to the games can increase the visual appeal and playability of a games. Some suggestions that can be implemented are to give more distinctive characteristics to the bacteria and viruses as the pupils often found it hard to differentiate between the two. This problem can also be solved by increasing the overall size of the game as the games can appear small and difficult to see on increasing larger and high quality monitors. Doctor Doctor had several specific requests to improve the storyline and fantasy elements which would require expensive remodelling of the game and would need to be carefully designed to not detract from the learning objectives.

The Microbe Mania game had the most improvement suggestion comments which were aimed at a general overall expansion of the game. This game provided minimal challenge and became boring very quickly. Improvements to this game would require increasing the number of levels, applying a ‘lives system’ to increase the challenge and creating a more game-like experience over the current quiz-like experience.

The study concluded that the e-Bug games were an excellent tool for increasing awareness of antibiotics in primary school pupils but can still be improved to increase their effectiveness.

Factors influencing Health care associated infection rates at St. John’s Hospital, NHS LothianJoshi S, MacSween K, Mackintosh CL, Corretge MSt. John’s Hospital, Livingston, NHS Lothian

BackgroundPreventing health care associated infections in hospital is a national priority. Local guidelines on antibiotic use, peripheral venous cannula (PVC) and urinary catheter (UC) usage amongst inpatients can play a vital role in reducing health care associated infection rates. We audited our practice at St. John’s hospital against the available guidelines.

MethodsAn audit was performed at St. John’s hospital reviewing antibiotic usage and factors influencing hospital acquired infections from 1st May 2014 to 31st May 2014. The data were collected prospectively from patients on a general medicine ward and included age, gender, co-morbidities, risk factors for aspiration, reasons for admission, antibiotic use and adherence to local guidelines. The indications for a PVC insertion on a medical ward at St. John’s hospital include SEWS =/> 3, cardiac chest pain or for administration of IV fluids or drugs. There is also a PVC proforma that needs to be filled in and maintained with PVC insertion. Indications for UC use include need for acute monitoring of urine output, palliative end of life incontinence that cannot be managed with other methods and urinary retention that cannot be managed with medical therapy and there is no indication for surgical correction.

Results A total of 52 patients (n=26 male) were included in the audit and 38 (76%) patients were > 65 years of age. The most common reason for admission was a respiratory illness in 44%(n=25).Other common causes included gastrointestinal illness and falls. Thirty four (68%) patients received antibiotics during their stay in hospital and in 38%(n=13) the indication for antibiotic use was unclear. Co-amoxiclav was the most commonly prescribed antibiotic and was used in 53% patients. Forty seven patients (92%) had a PVC inserted during their admission of which 76% (n=35) were inadequately documented. 12 patients had a urinary catheter inserted during their admission and the indication was inappropriate in 42%.

Conclusion and future plans We identified high rates of inappropriate antibiotic use locally. In addition, documentation for PVC and catheter

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Audit of the Management of Neonatal and Paediatric Candidaemia at University Hospital South ManchesterLamb, R, Sinha, A, Bakaya, K, Hassan, IPaediatric and Neonatal Department, Wythenshawe Hospital, University Hospital South Manchester

BackgroundInvasive candidiasis (IC) is a relatively common syndrome in neonates and children, associated with substantial morbidity and mortality. Risk factors include prematurity, central vascular catheterization, abdominal surgery, necrotising enterocolitis, exposure to broad-spectrum antibiotics, parenteral nutrition, H2-agonists and endotracheal intubation. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) have produced guidelines providing recommendations for the prevention and treatment of IC.

AimEstablish if neonates and children with IC at UHSM are managed according to standards set by ESCMID and IDSA guidelines.

StandardsAll extremely low birth weight (ELBW) neonates should receive antifungal prophylaxis. Treatment of neonatal IC should include amphotericin or fluconazole, and treatment of older children should include the same or echinocandins. The optimal duration of therapy is 14 days after blood cultures are sterile. Clinical evaluation for deep sites of infection, including ophthalmological examination is required in all cases of IC as well as imaging of the genitourinary tract, liver and spleen. Intravenous catheters should be removed or replaced as soon as possible.

MethodData was collected retrospectively using the Laboratory information and management system (Telepath). A proforma was created to collect data relevant to the standards set. This was analysed using Microsoft Excel.

ResultsFrom 2005-2014, 13 patients were identified for the audit. Only 8 case notes were available for analysis. Of the 8 cases of IC included in this audit, 3 were within the neonatal period and 5 in children. Only 2 patients were treated with prophylactic antifungals; one child and one neonate. The remaining 2 neonates did not receive antifungal prophylaxis despite having lines in situ. The most common infective organism was Candida albicans, which in all cases was sensitive to a range of antifungal agents. Repeat blood cultures were taken in 75% of cases, all of which showed no further growth. All cases received an appropriate antifungal in accordance with guidelines, the most commonly used being amphotericin and fluconazole. Minimum course length was 14 days, although it is unclear from our data if this was after sterile blood cultures. There were no cases of metastatic infection of deep sites; however, clinical evaluation of this was only carried out in 50% of cases.

All patients had been treated prior to infection with antibiotics, 50% of cases had lines in situ, including long lines, umbilical lines and endotracheal tubes and 87% of patients were premature. 50% of patients were receiving TPN and 37% were taking antacids.

ConclusionsOur findings support current evidence regarding risk factors for IC. Cases of IC at UHSM occurred in patients with recognised risk factors. Although the choice of antifungal agent to treat these patients was in concordance with current guidelines, there is scope for improvement in the use of prophylaxis in high risk patients, including neonates with ELBW. Repeat blood cultures are key to informing the length of treatment and clinical evaluation of infection of deep sites should form an integral part of our management of all patients with IC.

insertions did not adhere to local guidelines. Frequent use of Co-amoxiclav was concerning because of its increased capacity to promote C.difficile infection rates and its use should be restricted as per the good practice recommendations by the Scottish Antimicrobial prescribing group. Multidisciplinary meetings are planned to highlight the importance of strict adherence to guidelines as per the Scottish Patient Safety programme. ‘Antibiotic guidelines’ cards and phone applications will be developed for junior doctors to allow easy access to local antibiotic policies and user friendly PVC documentation charts will be introduced to improve documentation. Re-audit will be performed once these recommendations have been implemented.

Development of a regional medication chart for use with adult patients in an acute setting with separate antimicrobial sectionMallon Caroline1, Gallagher Fiona2. 1Pharmacy Department Belfast City Hospital Belfast Health and Social Care Trust, Lisburn Rd., Belfast BT9 7AB 2Pharmacy Department Antrim Rea Hospital Northern Health and Social Care Trust.

BackgroundIn 2014 a regional group was established to consolidate the design and specification of a medicines kardex for adult in-patients across all five Trusts. Infections are one of the leading causes of hospital mortality. One in three in-patients receives antimicrobial therapy at any one time. The prescribing guidance for antimicrobials requires a measured thought process which is different from the regular medication. The group invited representatives from the antimicrobial stewardship team across region to critique the evidence and gather expert opinion of the introduction of a separate antimicrobial section.

MethodA subgroup lead by two antimicrobial pharmacists closely liaised with the wider network of Microbiology & Infectious Diseases medical teams, pharmacists and Infection Prevention & Control teams across the region to design a draft Medication Chart with a separate antimicrobial section. This section is tailored to specifically safeguard the use of antimicrobial agents by leading the prescriber through the decision process of starting an antimicrobial The prescriber must endorse the prescription with indication, asking the prescriber to complete “What Infection Are You Treating?” The Chart asks if cultures are sent; firstly prompting that the cultures, where appropriate, are taken before antimicrobial therapy in initiated and secondly prompting that these results are sought and acted upon. The medication chart incorporated a prompt for antimicrobial review at the point of prescribing and at 48/72 hour review. There is additional space allocated for “special instructions” and “monitoring information”. The design was agreed and the consultation process was disseminated across the region for feedback

Results The Regional group completed the consultation process across the five trusts which included a focus on the antimicrobial section. Results showed overarching support for the inclusion of a separate antimicrobial section across all the professions. There were 305 responses from the consultation process; the majority of responses were from doctor, (47%), pharmacists (27%) and nurses (27%). There were six questions with responses; support, not support, no opinion. The overall response was 70% supportive of the inclusion and design of the antimicrobial section. The breakdown showed the 76% were supportive of the separate section and with 67% of those who replied supportive of the number of entries provided.

The Regional Group accepted the results from the consultation process. There is a separate antimicrobial section to promote antimicrobial stewardship and facilitate audit of antimicrobial prescribing. The roll out of the regional kardex will take place in Spring 2015. There will be an intensive assessment of the safety of the change with pre & post point prevalence study across off areas that use the medication chart to firstly establish that the change was not detrimental to patient care and secondly to assess the level of improvement to antimicrobial stewardship.

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Notes

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