The Why of Antimicrobial Stewardship

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SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)
2008
Dilip Nathwani Ninewells Hospital Medical
School Dundee, Scotland DD1 9SY
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Where are we now and why?
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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

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OVERUSE

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

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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

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Interventions to improve antibiotic prescribing
practices for hospital inpatients Cochrane
Systematic Review
i.gould courtesy
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Antibiotic use and resistance in the hospital
MRSA temporal series (Aberdeen, 1996-2000)
Monnet et al. Emerg Infect Dis 2004 101432-41
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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
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How can we reduce consumption, improve quality of
prescribing and reduce resistant transmission?
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Antibiotic Use
By Patient-staff-patient Patient-patient ?Patient-
environment / equipment patient
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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
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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

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APPP KEY DOMAINS FOR RECOMMENDATIONS 2006
SMC SLWG Document communicated by CMO to all NHS
Boards 2006
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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
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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

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THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL
RESISTANCE ACTION PLAN

• ScotMARAP 2007

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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

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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).

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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
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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

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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

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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

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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

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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.

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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

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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

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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.

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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

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• 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
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REDUCE TRANSMI SSION
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Day 3 Antibiotic Review Bundle Clinical
Diagnosis, Laboratory Results, Duration, Route
Pulcini et al, JAC, 2008
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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

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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