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The Why of Antimicrobial Stewardship

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Title: The Why of Antimicrobial Stewardship


1
SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)
2008
Dilip Nathwani Ninewells Hospital Medical
School Dundee, Scotland DD1 9SY
2
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3
Where are we now and why?
4
Antimicrobial Prescribing Facts
  • 1/3 of all hospitalised inpatients at any given
    time receive antibiotics
  • up to 1/3 to ½ are inappropriate
  • up to 30 of all surgical prophylaxis in
    inappropriate
  • Antimicrobials account for upwards of 30 of
    hospital pharmacy budgets. Stewardship programmes
    can save up to 10 of pharmacy budgets.
  • Inappropriate and excessive use leads to
    resistance, C.difficle other ecological
    consequences , increased morbidity,
    mortality,increased cost, increased litigation
    and reduce quality of life

5
OVERUSE
  • The desire to ingest medicines is one of the
    principal features which distinguish man from the
    animals
  • Osler W.Aecquanimitas,1920

6
Why So Many Mistakes
  • High number and complexity of drugs
  • High number and complexity of syndromes and
    pathogens
  • Poor training in antibiotic use
  • Variability over time and place in- pathogen
    prevalence- antibiotic susceptibilities-
    antibiotic formularies

7
Interventions to improve antibiotic prescribing
practices for hospital inpatients Cochrane
Systematic Review
i.gould courtesy
8
Antibiotic use and resistance in the hospital
MRSA temporal series (Aberdeen, 1996-2000)
Monnet et al. Emerg Infect Dis 2004 101432-41
9
What is Antimicrobial Stewardship?
  • A marriage of infection control and antimicrobial
    management
  • Mandatory infection control compliance
  • Selection of antimicrobials from each class of
    drugs that does the least collateral damage
  • Collateral damage issues include- MRSA- ESBLs-
    C.difficile- stable derepression- MBLs and
    other carbapenemases- VRE
  • Appropriate de-escalation when culture results
    are available

Dellit TH et al Clin Infect Dis 2007 44 159-177
10
How can we reduce consumption, improve quality of
prescribing and reduce resistant transmission?
11
Antibiotic Use
By Patient-staff-patient Patient-patient ?Patient-
environment / equipment patient
12
The Vicious Spiral
  • ? cost
  • Resistance
  • C.difficle
  • ? use of new drugs
  • Use of broad spectrum drugs

Must get right at all cost Inadequate rapid
test Lack of faith in tests Defensive
medicine Patient expectations Poly-pharmacy Increa
sed prescribing empiric Rx
13
Managing risk of empiric therapy
  • Many clinicians regard the right to prescribe
    antibiotics freely (unrestricted) as a basic
    human right
  • However
  • The desire of the clinicians to achieve the most
    optimal outcome for the patient needs to be
    balanced against the risk to the patient, ecology
    and other patients of broad spectrum antibiotic
    use, particularly C.difficle in the most
    vulnerable group
  • The organisation needs to risk manage this
    conflict and help with solutions

14
APPP KEY DOMAINS FOR RECOMMENDATIONS 2006
SMC SLWG Document communicated by CMO to all NHS
Boards 2006
15
KEY ROLE OF AMT
Medical Director
Chief Executive
Infection Control Manager
Drugs Therapeutics Committee
Risk Management Committee
Antimicrobial Management Team (AMT)
Clinical Governance Committee
Dissemination feedback
Infection Control Committee
Speciality-based Pharmacy leads for APPP with
responsibility for antimicrobial prescribing
Microbiologist / Infectious Diseases Physician
Prescribing support / feedback
Ward Based Clinical Pharmacists
PRESCRIBER
http//www.scotland.gov.uk
16
Antimicrobial management team
  • Multi-disciplinary team
  • Resourced
  • Supported
  • Multi-faceted interventions (consistently more
    effective then single interventions)
  • Active team at the coalface
  • Core Interventions
  • Formulary restrictions (expert approval)
  • Audit and feedback (information) of antimicrobial
    use and resistance patterns and unintended
    consequences

17
THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL
RESISTANCE ACTION PLAN
  • ScotMARAP 2007

18
ScotMARAP Output
  • 3 year programme of work launched on the 17th of
    March 2008
  • Total funding of 1.2 million and allocation
    split between key stakeholders
  • SMC asked to convene, host and service national
    clinical forum SAPG

19
SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)
  • The primary role of the SMC is to convene and
    service a group to fulfil the aspirations for a
    national clinical forum as expressed in the
    APPP. This group (SAPG) would include national
    stakeholder organisations and would collate the
    disseminate scientifically rigorous information
    on antimicrobial resistance trends and
    antimicrobial use on an ongoing basis to the NHS
    (primary and secondary care).

20
THE STAKEHOLDERS
Health Protection
NHS Education for
Information Services
Health Protection
NHS Education for
Information Services
Scotland
Scotland
Division
Scotland
Scotland
Division
NHS Quality
NHS Quality
Improvement Scotland
Improvement Scotland
Scottish Medicines Consortium
Scottish Medicines Consortium
Scottish Antimicrobial
rescribing
Group
Scottish Antimicrobial
rescribing
Group
Scottish Patient
Scottish Patient
Safety Alliance
Safety Alliance
Reference
Local
Reference
Local
NHS Boards Area Drug and
NHS Boards Antimicrobial Management
NHS Boards Area Drug and
NHS Boards Antimicrobial Management
Diagnostic
Diagnostic
Diagnostic
Diagnostic
Therapeutics Committees
Team Sub
-
Group of Scottish
Therapeutics Committees
Team Sub
-
Group of Scottish
Services
Services
Services
Services
Antimicrobial Prescribing Group
Antimicrobial Prescribing Group
Clinical Governance
Clinical Governance
Risk Management
Risk Management
NHS Boards Antimicrobial
NHS Boards Antimicrobial
Infection Control Team /
Infection Control Team /
Management Teams
Management Teams
Manager
Manager
Prescribers
Prescribers
21
4 WORKSTREAMS
  • 1. INFORMATION MANAGEMENT (HPS AND ISD)
  • 2. EDUCATION (NES)
  • 3.ORGANISATION AND ACCOUNTABILITY (NQIS)
  • 4.INFECTION MANAGEMENT (SPA,NQIS,NES,HPS-ISD,Profe
    ssional Organisations)
  • All the work-streams work in parallel but with
    vertical integration
  • Workstream work underpinned by an AMT Clinical
    Network

22
1. INFORMATION MANAGEMENT SURVEILLANCE AND
CONSUMPTION DATA Overview of Information from
NHS Boards Reporting antimicrobial use in DDDs
  • 3 NHS Boards routine reporting in primary
    secondary care
  • 2 NHS Boards routine reporting in primary care
  • 3 NHS Boards ad hoc reporting
  • 6 NHS Boards no reporting

23
2 ORGANISATION ACCOUTABILITY Overview of
Information from NHS Boards Antimicrobial
Management Teams (AMTs)
  • 7 out of 14 NHS Boards have established AMTs
  • 4 - primary secondary care
  • 3 - secondary care only
  • Other NHS Boards either have AMT equivalents or
    seek advice / support from other NHS Boards
  • Where AMTs exist there are links with ADTCs
    (direct or indirect reporting)
  • AMTs MUST BE IN PLACE AND ICTs SHOULD SUPPORT
    THIS
  • OVERALL MANAGEMENT BY ICMs but CEO/Medical
    Director accountability

24
CEL 30(2008)8TH July
  • As an immediate intervention to reduce the risk
    form C.difficle,we accept SAPGs recommendation
    that all boards should immediately establish an
    AMT which covers primary and secondary care
    prescribing.
  • AMTs work closely strategically and
    operationally with ICTs and ICM- SAPG

25
CEL 30(2008)8TH July
  • Recognition of the key role of the antimicrobial
    pharmacist central additional funding for
    40,000 for each mainland board and 20k for
    Island boards for 3 years (2011).
  • SAPG (not in CEL) keen on developing clinical
    networks for AMTs to provide support for smaller
    boards, share good practice and do joint
    planning. Launch of AMT clinical network in
    STIRLING 18TH November 2008.

26
Education
  • DOTS onl line- all foundation doctors mandatory
    training in prescribing
  • PAUSE website for undergraduates- Scottish Deans
    Educational Group
  • Pharmacy and non-medical prescribers programme
    for prescribing
  • Module on antibiotic resistance and C.difficile
    being developed
  • Nurses programme on recognition of infection and
    use of microbiology
  • Dental antibiotic prescribing

27
4 INFECTION MANAGMENT PHILOSOPHY
  • HIGH BURDEN, HIGH IMPACT CONDITIONS
  • EVIDENCE OF BENEFIT FOR INTERVENTION
  • ALSO TARGET SYSTEMS CHANGE TO BRING ABOUT DESIRED
    BENEFIT
  • INTEGRATE, DEVELOP AND IMPLEMENT EXISITING AND
    NEW PROJECTS OVER 3 YEAR TIME FRAME WORK CLOSELY
    WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g
    HPS, SPA)
  • IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP,
    C.difficle and Surgical Prophylaxis
  • Others

28
The First Six Months of SAPG
  • Guidance on CDAD- restrictive policy, CDAD
    management protocol, measures of improvement
    set up extra-net
  • Surgical prophylaxis
  • SNAP-CAP
  • AMT network November 18th launch
  • Appointment of key personnel
  • National generic prescribing template
  • Antimicrobial prescribing and resistance
    education programme.

29
Outbreak
Muto et al CID 2007 45 1266-73.
  • June 2000
  • One university hospital, US
  • Increase C.difficle from 2.7 to 7.2 infections
    per 100 hospital discharges
  • Increase in the frequency of severe outcomes
  • Tiered as opposed to a bundle approach.
    Implemented over time.
  • Education
  • Increase in case finding and rapid initiation of
    appropriate therapy
  • Expanded infection control measures
  • Infection control audits
  • Targeted antimicrobial restriction
  • Measuring and feedback of antibiotic use and
    local surveillance data

30
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31
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32
  • Guidance for Proven or Suspected C. difficile
    associated diarrhoea
  • (CDAD)

Your patient is in a healthcare facility or has
been admitted with new onset of
DIARRHOEA Constipation with overflow diarrhoea
(make sure PR done), laxatives and other common
causes of diarrhoea have been excluded
  • Does patient have risk factors for CDAD?
  • History of use (lt 3m) or current use of an
    antibiotic
  • Prolonged recent hospital stay
  • Use of PPI
  • Increasing age especially gt65y
  • Surgical procedure (in particular bowel
    procedures)

Yes
Inform Infection Control Team
Send stool for C. difficile toxin
  • Stop PPI
  • Stop anti-microbial treatment if possible
  • Stop laxative

Isolate patient in single room Designated toilet
or commode
Hand hygiene with soap and water Wear gloves and
disposable apron
Toxin -ve
Toxin ve
Continue with guidance
Discontinue C. difficile guidance or if index of
suspicion high seek ID referral
  • UNDERTAKE SEVERITY ASSESSMENT
  • Suspicion of Pseudomembranous colitis (PMC) or
    toxic megacolon or ileus
  • OR two or more of the following severity
  • markers
  • Colonic dilatation in CT scan gt6cm(if available)
  • WCC gt15 cells/mm3
  • Creatinine gt1.5 x baseline
  • Albumin lt25 g/l

Yes
No
Patient has severe CDAD
Patient has non-severe CDAD
  • Treat with oral metronidazole 400mg t.d.s. for
    10-14 days
  • Rehydrate patient
  • Treat with oral vancomycin 125mg q.d.s. for 14
    days
  • Rehydrate patient and consider referral to
    hospital or healthcare facility if patient at home

Refer to Infectious Disease
Daily assessment of patient with mild to moderate
disease Observe bowel movement, symptoms (WBC
and hypotension) and fluid balance. If condition
doesnt improve after 3-5 days of treatment with
metronidazole, patient should be switched to
treatment with vancomycin (125mg q.d.s. for a
further 10-14 days)
Daily assessment of patient with severe
disease Observe bowel movement, symptoms
(WBC and hypotension) and fluid balance. Surgery
Consult and AXR and CT scanning consider PMC,
toxic megacolon, ileus or perforation If ileus is
detected add 500mg metronidazole i.v. t.d.s.
until ileus is resolved
  • Contact Details
  • Infection control team via switchboard
  • Public health via NWH switch board if care home
  • On call duty microbiologist 4039 Ninewells or
    via switchboard
    5315 Perth
    Royal
  • On call ID 5075

For recurrent (3 or more episodes) CDAD
seek Specialist ID/Micro advice
Tayside HAI Network September 2008 Review
September 2009
33
REDUCE TRANSMI SSION
34
Day 3 Antibiotic Review Bundle Clinical
Diagnosis, Laboratory Results, Duration, Route
Pulcini et al, JAC, 2008
35
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37
CONCLUSIONS
  • SAPG is a national clinical forum with broad
    multi-disciplinary ownership. A structure for
    clinical and fiscal governance is established.
    SMC is the host organisation.
  • SAPG is now in operation with 4 key proposed
    work-streams. These would be key deliverables
    over specific time frames.
  • Other areas to be developed over time, especially
    around primary care and community/LTCF
    prescribing
  • AMT clinical network will provide national
    cohesion and need to work in close collaboration
    with ICTs and should have a unified vision
  • We need hospital leadership and all healthcare
    professionals to engage with it and own it

38
Your thought of the day To restrict or not
to..?
  • Whether tis nobler in the mind to suffer the
    slings and arrows of outrageous prescribing..
    or take arms against a sea of.. resistance and
    diarrhoea.. and by opposing antibiotics end
    it..

Adapted from Shakespeare W Dilip.nathwani_at_nhs.net
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