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

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

2. SAPG AMT CLINICAL NETWORK

3. 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 is 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

4. Managing risk of empiric or prophylactic therapy & adopting change “Many clinicians regard the right to prescribe antibiotics freely (unrestricted) as a basic human right” “The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk of inappropriate antibiotics to the patient presently & in the future, the ecology and other patients “The organisation needs to risk manage this conflict and help with solutions “

5. THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL RESISTANCE ACTION PLAN [ScotMARAP 2007]

6. ScotMARAP Output • SAPG: A 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

7. 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).

8. Aim • A National Framework for Antimicrobial stewardship Improve the quality of antimicrobial prescribing and infection management

9. 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

10. 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

11. Multi-disciplinary team Resourced Supported Multi-faceted interventions (consistently more effective then single interventions) Active team at the coalface Supported by hospital leadership Core Interventions Formulary + restrictions (expert approval) Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences Antimicrobial management team

12. 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.

13. 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

14. MEASURES OF IMPROVEMENT: SECONDARY AND PRIMARY CARE • Consumption of antibiotics (total and class) • Surveillance of resistance • Quality of prescribing through PPS (targeted) • HEAT indicator/s • HAI standards

15. INDICATOR/S: HOSPITAL AND EMPRIC THERAPY • Indicator: >90% compliance with empiric antibiotic treatment policy in acute medical and surgical receiving/admission units • Measure : 1. the working diagnosis/reason for prescribing the antibiotic was documented in the medical notes 2. The choice (? Route/dose) was consistent with the empiric treatment policy How ? 5 random charts of patients receiving antibiotic daily one day a week reviewed by team and compliance charted

16. EFFECTS OF PERIOPERATIVE PROPHYLAXIS ON NOSOCOMIAL C. DIFFICILE COLONIZATION A Prospective Study 122 patients underlying clean non-GI surgery (herniorraphy, splenectomy, ortho reconstruction…) 3% positive C. difficile culture preoperatively Postoperative positive, by prophylactic regimen: Cephalosporin 23% Cefoxitin 1% 14% 25% 11441425% 14% 3% % Cefazolin Cefotetan 5 25% 25% Ceftriaxone Cefoperazone 44% Mezlocillin 3% Privitero et al, AAC 35:208,1991

17. The Surgical Infection Prevention (SIP) and Surgical Care improvement Project (SCIP): National Initiatives to imporve the Outcomes of Patients Having SurgeryCID 2006; 42: 322-30. 3 INDICATORS FOR SSI • Antibiotics administered within 60mins • Antibiotic selection • Antibiotic stopped within 24h

18. Quality IndicatorsNational Surgical Infection Prevention Project • Quality Indicator #3 • Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time • Numerator statement: no. of patients who prophylactic antibiotics were discontinued within 24h of surgery end time (48h for cardiac surgery) • Denominator statement: All selected surgical patients with no evidence of prior infection

19. Impact of Prolonged Antibiotic Prophylaxis • 2,641 CABG patients • Grp 1 - < 48 hours of antibiotics • Grp 2 - > 48 hours of antibiotics • SSI Rates • Grp 1 - 8.7% (131/1502) • Grp 2 - 8.8 % (100/1139) • Antibiotic resistant pathogen - Grp 2 • Odds Ratio 1.6 (95% CI: 1.1-2.6) Harbarth S, et al. Circulation. 2000.

20. How do we communicate what we would like NHS Boards to do & also hear from them what they would like us to do?

21. SAPG Communication • Road show about SAPG programme • Developing an SAPG website within SMC website to communicate and share information, recommendations and good practice • Inform the development and monitoring of national antibiotic prescribing indicators • Setting up of extra-nets: SNAP-CAP, CDAD, ? Surgical prophylaxis • Regular AMT network in Stirling: 3/3/09; 2/6/09 & 29/9/09

22. SAPG • Chair (DN) • Project Manager (JS) • Project administrator • Pharmaceutical advisor (BM) • AMR (CW) • QIS (PC) • Work-stream leads (AS, MB-AE, LG, JW) • Steering Group (SMC, AMT, Dental, Vet, Medical School, Patient Group Representative, CEO, MD, Industry, ID, Microbiology, SIRN, Pharmacy, General Practice, Nursing, Patient Safety Alliance, SGHD • Co-opted experts in work-streams