Antimicrobial Stewardship and AMR update BGSW Practice Nurse - - PowerPoint PPT Presentation

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Antimicrobial Stewardship and AMR update BGSW Practice Nurse meeting #antibioticguardian

@elizbeech Elizabeth Beech Healthcare Acquired Infection and Antimicrobial Resistance Project Lead NHS England November 2015 elizabeth.beech@nhs.net

www.england.nhs.uk Implementation of national AMS toolkits in England Dr Diane Ashiru-Oredope

You are invited to become an Antibiotic Guardian today (available via mobiles)

2 AMR: Strategic Overview Dr Diane Ashiru-Oredope

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Superbugs to kill 'more than cancer' by 2050

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In the UK

If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine– David Cameron, UK Prime Minister Fears grow over increased antibiotic resistance

BBC 16 October 2015

UK experts said the study confirmed their fears that antibiotic resistance would affect routine surgery. England's chief medical officer has called the issue a ticking time bomb

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G7 Health Ministers meeting Oct 2015 Antibiotic consumption links to AMR

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AMR: individual risk

Risk of resistance persists for at least 12 months in individuals after each intake of an antibiotic

Increased risk of resistant organism Antibiotic in past 2 months Antibiotic in past 12 months UTI 5 studies: n = 14,348 2.5 times 1.33 times RTI 7 studies: n = 2,605 2.4 times 2.4 times

A meta analysis of English Primary Care

Costello et al. BMJ. (2010) 340:c2096.

11 AMR: Strategic Overview Dr Diane Ashiru-Oredope

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CMO Annual Report 2011*

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*published: March 2013

UK 5-year AMR Strategy 2013 -18

1. Improve the knowledge and understanding of AMR 2. Conserve and steward the effectiveness of existing treatments 3. Stimulate the development of new antibiotics, diagnostics and novel therapies

Strategic aims ‘One Health’

UK 5-year AMR Strategy 2013-18: Seven key areas for action

Presentation title - edit in Header and Footer

PHE

Human health

DH – High Level Steering Group Defra

Animal health

DH

• 1) Better access to and use of

surveillance data

• 2) Optimising prescribing practice
• 3) Improving infection prevention and

control

• 4) Improving professional education,

training and public engagement

• 5) Improving the evidence

base through research

• 6) Developing new drugs,

vaccines and other diagnostics and treatments

• 7) Strengthening UK and

international collaboration

Antimicrobial Prescribing Quality Measures

Primary care Secondary care Measures to reduce total antibiotic prescribing Total antibiotic prescribing to be reduced to 2010 levels at CCG level as measured by number of antibiotic prescriptions (“items”) per 100 patients per year Total antibiotic consumption to be reduced by 1% per year 2015- 2019 as measured by DDD per 1000 admissions per year. Measures to encourage narrow spectrum antibiotic prescribing Proportion of antibiotics from cephalosporin, quinolone or co- amoxiclav classes to be reduced to less than the current median for English CCGs as measured by the number of prescriptions (“items”) from target classes in comparison with the total number

• f antibiotic prescriptions per year.

Total carbapenem consumption to be reduced to 2010 consumption levels as measured by DDD per 1000 admissions per year.

Table 3: ARHAI recommended antimicrobial prescribing quality measures October 2014

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ESPAUR 2014 and 2015

• Key element of the 5 year

AMR strategy was to introduce surveillance systems for antimicrobial resistance and usage

• 1st English data for

antimicrobial usage data for hospitals AND community in 2014 report

• 2015 report out now – read

it

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ESPAUR 2015 - Antimicrobial consumption

• Antibiotic prescribing has increased in England

2014 on 2013 but more slowly, by 2.4%

• Primary care items per STAR-PU ↓
• but DDD per1000 inhabitants per day ↑
• Broad spectrum antibiotic use is ↓ to 8.5%
• Primary care accounts for 75% of all prescribing
• Inpatient and OP antibiotic use continues to

increase

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Patient Harm – prevent and reduce

• Patients with AMR have 2-3 times higher

mortality and risk of complications

• CDI rates are rising in 2015
• Co-amoxiclav use ↑ resistance ↑

association with CDI ↑

• E.coli bacteraemia rates are increasing
• CAUTI remain a concern
• Carbapenemase-producing

Enterobacteriaceae CPE surveillance for all NHS organisations and global increasing resistance – avoid use

• Sepsis – National CQUIN for 2015/16

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New guidance and incentives in 2015

• 2008 Health & Social Care Act Code of Practice now includes

AMS – criterion 3: ensure antibiotic use optimises outcomes & ↓ risk of adverse events and AMR. Applies to dentists and GP practices also

• NHS England patient safety alert August 2015
• NICE guidelines NG15: Antimicrobial Stewardship
• NICE guidelines consultation changing risk-related behaviours in the

general population

• Start Smart then Focus and TARGET stewardship toolkits
• NHS England 2015-16 Quality premium for CCGs
• NHS England CQUIN on Sepsis for acute care providers

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NHSE Antibiotic Quality Premium 2015-16

and what it means for CCGs

The Antibiotic element has 3 parts, 2 relate to primary care prescribing (80% of payment)

• Reduction in the number of antibiotic prescriptions by 1% as measured by

population – antibacterial items per STAR-PU

• Reduction in the proportion of broad spectrum antibiotics (cephalosporins,

quinolones & co-amoxiclav) by 10% from 2013-14 baseline or to stay below England 2013-14 median value of 11.3%

• Validation of acute provider antibacterial consumption data for PHE
• CCGs have individual targets published on NHSE Quality Premium

webpage

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Antibiotic prescribing variability – CCG level

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Antibiotic prescribing variability – by GP practice

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Antibiotic prescribing variability – by GP practice

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Antibiotic prescribing variability – by GP practice

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Antibiotic prescribing variability – by GP practice

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Antibiotic prescribing variability – by NMP

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Antibiotic prescribing variability – by NMP

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Antibiotic prescribing variability – by NMP

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NHSE Antibiotic Quality Premium dashboard

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National Antibiotic Quality Premium dashboard

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NHS England Area Antibiotic Quality Premium dashboard

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NHS England Area Antibiotic Quality Premium dashboard

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NHSE Antibiotic Quality Premium dashboard

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CCG performance versus target and all England

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CCG performance versus target and all England

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PrescQIPP AMS Hub https://www.prescqipp.info/

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Free access Lots of links to resources Primary care prescribing data – use it and contribute

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Antimicrobial Stewardship Activity

• Guidelines – Newly updated for BSW; NICE NG 15
• Audit – really useful to collect evidence CQC and CPD
• Education – HCP and the public
• Pathway review – cellulitis, COPD
• Implementing No and Back Up antibiotic systems
• Use of TARGET resources – on PrescQIPP AMS Hub
• Local CQUINs of providers
• Promoting vaccination – particularly flu
• Lots of collaboration - development of AMS networks
• Champions – most effective intervention

Urinary tract infection: PHE guidance 2015

Treat women if severe/or ≥ 3 symptoms & no vag. discharge Women mild/or ≤ 2 symptoms AND Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% PPV; nitrite, leucocytes, blood all negative 76% NPV: Consider back-up / delayed antibiotic Use nitrofurantoin first line (if GFR over 45ml/min; GFR 30-45:only use if resistance & no alternative) as resistance & community multi-resistant ESBL increasing Trimethoprim (if low risk of resistance) and Pivmecillinam are alternative first line agents. In treatment failure: always perform culture Always safety net.

PHE guidance also at www.rcgp.org.uk/TARGETantibiotics

TARGET : Self Assessment Checklist

www.rcgp.org.uk/TARGETantibiotics

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www.rcgp.org.uk/TARGETantibiotics

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TARGET resources – http://www.rcgp.org.uk/clinical-and-

research/toolkits/target-antibiotics-toolkit.aspx

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TYI leaflet built into TPP and EMIS in NHS BaNES CCG

The Patient Perspective:

Back-up/delayed Prescribing: What patients do

IPSOS Mori Surveys: 2014

McNulty,Hawking, Lecky, Butler. FIS 2014

60% collected and took the antibiotic

Back-up antibiotics can reduce antibiotics by 30- 40%

4% Offered back-up / delayed prescribing in past year

Random samples 1625 > 15 yrs, England

Percentage of public in favour of delayed antibiotic prescriptions

McNulty, Butler, et al Ipsos Mori 2014

So a thorough explanation of rationale and how to collect the prescription may be needed for some patients

TARGET acute sore throat: PHE Antibiotic Management Guidance

Acute sore throat CKS Avoid antibiotics as 90% resolve in 7 days without, & pain only reduced by 16hrs If Centor score 3 or 4: Lymphadenopathy; No Cough; Fever; Tonsillar Exudate)3A- consider 2 or 3-day delayed or immediate antibiotics1,A+ or rapid antigen test.10B+ Antibiotics to prevent Quinsy NNT >4000 Antibiotics to prevent Otitis media NNT 200 10d penicillin lower relapse vs 7d in RCT in <18yrs8 phenoxy methylpe nicillin5B- Penicillin Allergy: Clarithro mycin 500mg QDS 1G BD6A+ (QDS if severe7D) 250-500 mg BD 10 days 5 days

www.rcgp.org.uk/TARGETantibiotics

ILLNESS COMMENTS

Drug Adult dose

Treatment duration

What is the evidence for Back-up / delayed

prescribing?

10 20 30 40 50 60 70 80 90 100 Better by day 3 Satisfied patients Think antibiotics are effective Would visit GP again for similar symptoms

%

Given 10 days antibiotic treatment Given NO antibiotics Given DELAYED antibiotics

Little, Williamson, Warner et al. BMJ . (1997) 314:722 - 727

English RCT comparing three treatment strategies for sore throat (n=582)

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What do people think about AMR?

Interviews in friendship pairs from London &

• Manchester. Different age

groups & education levels

Group interviews from

London, Birmingham and

• Scotland. Mixed ages,

education, social grade, & relationship with antibiotics

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Looking ahead

• No new antibiotics – so improve how we use the ones we

have

• Use of No or delayed (Back-Up) antibiotics – the norm?
• Behavioural strategies: environment vs person
• PHE behavioural interventions – coming to a practice near you?
• Improve self care and vaccination uptake
• Educate the next generation – children; use e-bug
• Penicillin allergy status – 10% or 1%?
• Point of care diagnostics – game changer
• Community IV Antibiotic Services (CIVAS)
• All of these require collaboration within clinical networks

and health economies

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Maternal deaths from influenza

• 2009 -12, 36 pregnant women died from

influenza (43% all deaths from infection)

• Median 28 years, 63% born in UK
• 18% BMI >30 & 28% current smokers
• documented fever (97%), cough (66%) and

dyspnoea (38%)

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Key take home AMR messages

• The Drugs Don’t Work - Tough action needed to slow

antibiotic resistance (Kindle for 99p for World Antibiotic Awareness Week)

• Prevent Infection – vaccinate, hand wash, stay home!
• Tackling AMR is everybody's (professional) responsibility
• Collaboration is essential – across health economies and

pathways

• Behaviour change is key – patients and professionals
• Evidence suggests what works is a bundle of interventions
• Useful resources and tools are available – use & share them
• Don’t forget Healthcare Associated Infections
• Become an AntibioticGuardian.com and
• a champion – practice nurses Yes Please

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www.england.nhs.uk Implementation of national AMS toolkits in England Dr Diane Ashiru-Oredope

You are invited to become an Antibiotic Guardian today (available via mobiles)

57 AMR: Strategic Overview Dr Diane Ashiru-Oredope

www.england.nhs.uk

• Stay up to date with the evolving field of antibiotic

resistance! The award winning I’m a Scientist Antibiotic Zone will allow primary healthcare professionals (including GPs, nurses, dentists) to put questions directly to leading experts, between 16th and 27th November. Questions can be submitted through the website at any time, and for an hour each evening there will also be 'live chats', where healthcare professionals can hold real time discussions with the experts. Find out more and take part at http://antibiotic15.imascientist.org.uk/

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Why is Antimicrobial Stewardship Important?

• Click here to view a short cartoon video

explaining why Antimicrobial Stewardship matters and may be useful for use in presentations or clinical networking events. This video is part of the Mount Sinai Hospital- University Health Network Antimicrobial Stewardship Program with support from CAHO.