Dilip Nathwani Ninewells Hospital & Medical School Dundee, Scotland DD1 9SY

1. SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG) 2008 Dilip Nathwani Ninewells Hospital & Medical School Dundee, Scotland DD1 9SY

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; 10:1432-41

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 Increased 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. APP&P 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 APP&P with responsibility for antimicrobial prescribing Microbiologist / Infectious Diseases Physician Prescribing support / feedback Ward Based Clinical Pharmacists PRESCRIBER http://www.scotland.gov.uk

16. 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 Antimicrobial management team

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 APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous informationon antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).

20. THE STAKEHOLDERS Health Protection Health Protection Information Services Information Services NHS Education for NHS Education for Scotland Scotland Division Division Scotland Scotland NHS Quality NHS Quality Improvement Scotland Improvement Scotland Scottish Medicines Consortium Scottish Medicines Consortium Scottish Antimicrobial Scottish Antimicrobial rescribing rescribing Group Group Scottish Patient Scottish Patient Safety Alliance Safety Alliance Reference Reference Local Local NHS Boards Area Drug and NHS Boards Area Drug and NHS Boards Antimicrobial Management NHS Boards Antimicrobial Management Diagnostic Diagnostic Diagnostic Diagnostic Therapeutics Committees Therapeutics Committees Team Sub Team Sub - - Group of Scottish 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,Professional 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 ICM’s but CEO/Medical Director accountability

24. CEL 30(2008)8TH July • As an immediate intervention to reduce the risk form C.difficle,we accept SAPG’s recommendation that all boards should immediately establish an AMT which covers primary and secondary care prescribing. • “AMT’s work closely strategically and operationally with ICT’s 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 AMT’s 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. 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 Outbreak Muto et al CID 2007; 45: 1266-73.

30. SPCC RWHT C.difficile Toxin

32. 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 (< 3m) or current use of an antibiotic • Prolonged recent hospital stay • Use of PPI • Increasing age especially >65y • 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 Hand hygiene with soap and water Wear gloves and disposable apron Isolate patient in single room Designated toilet or commode 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 ORtwo or more of the following severity markers • Colonic dilatation in CT scan >6cm(if available) • WCC >15 cells/mm3 • Creatinine >1.5 x baseline • Albumin <25 g/l No Yes Patient has severe CDAD Patient has non-severe CDAD Guidance for Proven or Suspected C. difficile associated diarrhoea (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 doesn’t 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

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@nhs.net