e96 Abstracts

2) Determine whether to replace or supplement ourcurrent in-house toxin detection method (Pre-miere toxin A/B- Meridian).

Method260 liquid stool samples prospectively tested using the

current in-house method, a 96 well ELISA for the detectionof C. difficile toxin (Premiere Tox A/B-Meridian).

Samples also underwent testing with the followingcommercially available assays.

2X Glutamate dehydrogenase (GDH 96 well ELISA)(Meridian and Techlab).

Positive GDH samples underwent testing with the fol-lowing 2 toxin detection assays.

�Illumipro-10 a novel isothermal LOOP-mediated ampli-fication and detection system for target nucleic acidsequence, for the detection of C. difficile toxin (Meridian).

�Tox A/B QUIK CHEK- Rapid immunoassay for the de-tection of C. difficile toxins A/B (Techlab).

Assays were carried out according to the manufacturer’sinstructions, with culture followed by toxin detection usedas the Gold standard.

Results and Conclusions

The Illumipro-10 (Meridian) assay had 3 false positives andzero false negatives. The Tox A/B QUIK CHEK (Tech lab) had1false negative and 2 false positives. Finally the Premiere EIA(Meridian) had 2 false positives and 1 false negatives.

Premiere GDH Sensitivity 94.4%, Specificity 99.11%, PPV94.4%, NPV 99.6%

Tech lab GDH Sensitivity 97.2%, Specificity 99.5%, PPV97.2%, NPV 99.5%

The toxin assays had the following Sensitivity, Specific-ity, PPV, & NPV.

Toxin assay Sensitivity(%)

Specificity(%)

PPV(%)

NPV(%)

Illumipro-10 100 98.8 84.2 100Tox A/B QUIKCHEK

93.8 99.2 88.2 99.6

Premiere ELISA 87.5 99.2 87.5 99.2

INTRODUCTION OF AN EDUCATION, AUDIT ANDFEEDBACK PROGRAMME TO IMPROVE THERECORDING OF CLINICAL INDICATION ANDDURATION ON ANTIMICROBIALPRESCRIPTIONSCATEGORY: LESSON INMICROBIOLOGY & INFECTION CONTROL

Philip Howard, Helen Smith, Rob Child, Jason Dunne,Jonathan Sandoe, Abimbola Olusoga, Katy WarburtonLeeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Introduction

Our provincial tertiary teaching hospital trust was iden-tified by the Department of Health as under performing

on healthcare associated infections in 2008. Part of theresponse was to expand the antimicrobial stewardshipprogramme. It’s estimated that 50% of antimicrobialsprescribed in hospitals are unnecessary. In order toimprove this, a comprehensive programme to developand maintain infection diagnosis and treatment guidelineswas produced. In addition, the Trust’s Medicines Policywas amended to state that all antimicrobial prescriptionsmust include duration or review date and the indicationin the patient’s notes. An update in December 2009required inclusion of the indication on the prescription aswell.

All staff were educated about the new standard throughbriefings and screensavers. Ward pharmacists undertook anaudit of all patients on all wards in the Trust on any singleday each month. They measured compliance to the Anti-microbial Medicines Code for duration, indication andprescriber identity. The point prevalence audit also re-corded the number of patients on IV or oral antibiotics, andthose potentially suitable for oral switch. Details of pre-scribers who deviated from the code were recorded and fedback to clinical directors.

The results of the audit were entered into a web-baseddatabase that allowed trends by ward, specialty, director-ate, division or trust to be monitored. League tables wereproduced and fed back to users. The results became one ofthe key performance indicators to the Trust board eachmonth. The standard DoH target for High Impact Interven-tions of 95% was set.

Scientific findings

The baseline compliance in November 2008 for durationwas 55%, indication (in notes) 54%. Prescriber identifica-tion was requested in June 2009 was 81%. Performanceslowly improved until July 2010 when both duration andindication were 90%, and prescribed identification was89%. Indication dipped in December 2009 from 92% to 81%when it needed to be recorded in both the patient’smedical notes and the drug chart. The percentage ofpatients on antimicrobials dropped from 35% to routinelyless than 28%. An average of 2.1% drop for the same monthin different years.

Discussion

The DoH recently consulted on a High Impact Interventionfor antimicrobials. This included mandatory recording ofindication and duration on prescription charts. An auditof prescribing standards from 34 UK Trusts showed anaverage of 53% for duration (range 12-99%), and 67% forindication from 11 centres (range 36-86%). The Trust thatscored 99% had electronic prescribing where indicationand duration were built into the prescribing system. Theprevalence of patients on antimicrobials appears lessusing paired months to account for the seasonal variationin infections. Whilst the Trust has never reached thetarget overall, many specialties have achieved >95%compliance.

Abstracts e97

Conclusions

Setting the standard of recording the indication andduration on all antimicrobials on the patients prescriptionchart with monthly audit and feedback of all patientsappears to improve prescribing quality. Reporting thestandards to the Trust board provides strong medicalleadership to ensure standards improve. A range of formatsfor feedback encourages competition and improvement.When the new HII for antimicrobials is introduced, thisapproach could help trusts reach the target.

DEVELOPMENT OF A WEB-BASED ANTIMICROBIALRESOURCE TO IMPROVE ANTIMICROBIALPRESCRIBING - A TWO YEAR REVIEWCATEGORY:LESSON IN MICROBIOLOGY & INFECTIONCONTROL

Jonathan Sandoe, Philip Howard, Abimbola Olusoga,Katy WarburtonLeeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Introduction

The Trust was the poorest performing Teaching Hospital fortwo monitored healthcare associated infections (HCAI) inthe UK: Clostridium difficile infection (CDI) and meticillinresistant Staphylococcus aureus (MRSA) bacteraemia. Thiswas despite ‘CDI friendly’ antimicrobial use in elderlycare (>80 years).

The aim of the project was to build a web-based infectionmanagement resource. The website aimed to provide:

� evidence-based, peer reviewed, infection treat-ment and prophylaxis guidelines

� an educational resource for prescribers� an audit resource incorporating plans, tools andresults

� links to the British National Formulary and Elec-tronic Medicines Compendium

Templates were developed for the guideline develop-ment. Each guideline team had a clinician, microbiologistandpharmacist. They undertook a literature reviewand usedlocal antimicrobial resistance patterns. Each guideline in-cluded a summary, algorithm, aims and objectives, back-ground, diagnosis, investigations, treatment (antimicrobialand non-antimicrobial), choice of agents for empiric anddirected therapy (in routine, penicillin allergic and specialpopulations e.g. over 65 years), IV to oral switch, duration oftherapy, criteria for specialist referral, provenance, refer-ences and review dates. Recommendations stated theevidence level.

Draft guidelines were put on Citywide Health Pathwayspeer reviewsite for fourweeks.Reviewershad three choices,plus encouraged to leave feedback: Endorse the guidelinewithout changes; minor revision ,or major revision needed

The development team responded to the comments andupdated the guideline, repeating the peer review if

necessary. Once guidelines were ratified, they would beuploaded onto the Antimicrobial Guidelines website. This issearchable by specialty or body system.

Scientific findings

� 96 guidelines developed; average of 92 views and6 comments per draft guideline (3 went for sec-ond review)

� >7000 hits per month� Prevalence of antimicrobials decreased fromw35% to w25% of patients

� CDI has decreased from w80 cases per month tow20

The number of hits to each guideline is monitored, anda modification has allowed comments to be made to theauthors once the guideline was in use. All antimicrobials inthe guidelines link to the eBNF and eMC, drug dosing tools(gentamicin and vancomycin) or restrictive supply pro-cesses where appropriate.

Discussion

Many Trusts have used pocket sized or credit card sizedguides. These can often go out of date. Our approach hasbeen to develop pathways that focus on accurate diagnosisand appropriate investigations, with antimicrobials recom-mended only if necessary. The development process pro-motes stakeholder ownership, and therefore subsequentusage. The feedback mechanism ensures they are contin-ually updated through use. The monthly point prevalencehas shown a drop in patients on antimicrobials. Themonthly CDI rate is only 25% of the monthly rate for thesame time last year. Changes in antimicrobial prescribingmay have contributed towards this.

Conclusions

Web-based, evidenced-based, peer-reviewed antimicrobialguidelines are an effective method to support prescribers intheir diagnosis and treatment of infection. Links to externalinternal information resources such as eBNF, eMC and dosecalculators further improves patient safety. Processes thatallow feedback and rapid update to guidelines ensure thatguidelines are up to date. Guidelines designed and de-livered in this manner promote usage, and when combinedwith other elements of antimicrobial stewardship, is asso-ciated with a decrease in the prevalence of antimicrobialusage and reductions in some HCAIs.

INTRODUCTION OF A COMPREHENSIVEANTIMICROBIAL STEWARDSHIP PROCESS TODECREASE BROAD SPECTRUM ANTIMICROBIALUSAGE AND HCAISCATEGORY: LESSON INMICROBIOLOGY & INFECTION CONTROL