Questions and Answers from the chat on the Antimicrobial Stewardship Webinar 10th April 2017

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1 Questions and Answers from the chat on the Antimicrobial Stewardship Webinar 10th April 2017 Would be useful to get advice on how to tackle the e Blood stream infection target and how CCGs can work with acute trusts. Clinical networks are a good way to work together across organisations and professional groups. Consider existing IPC and HCAI and Antimicrobial stewardship groups are they already whole health economy wide? If not could they move towards that? Pharmacy is in a good place to lead this. Some health economies have such networks in place: Cornwall, Leeds and Bath and North East Somerset are examples Can you tell us any more re what Leeds West have done? There will be nervousness amongst clinicians to use nitrofurantoin due to CKD status, particularly elderly. Not all patients have recent blood test results. Nitrofurantoin is a good empirical choice to treat a lower UTI due to its very low E.coli resistance (see PHE AMR Portal for resistance data). It can be used in patients with an egfr as low as 30ml/min but 45ml/min is usual cut off point at which it is known to be effective. E.coli resistance to trimethoprim is far more likely to deliver a treatment failure in elderly people due to the high rates of E.coli resistance. I have found elderly patients are more likely to have a recent renal function test result than a recent urine culture result. However pivmecillinam and fosfomycin are alternative choices for these elderly patients and have been placed in the updated PHE guidelines: Managing common infections: guidance for primary care All elderly patients should have had an annual CKD check which can guide therapy. Unlikely to unexpected CKD. If in doubt, pivmecillinam. Nitrofurantoin also has some long term effects especially if used prophylaxis. What are people doing regarding this? I.e. pulmonary issues. The MHRA are surveying nitrofurantoin following the changes to its licenced use in people with reduced renal function, and this may identify any unintended consequences of increased nitrofurantoin use (acute and chronic); they are aware of the drive to increase nitrofurantoin use in primary care. This recent publication may be of interest 1

2 Why is the DCS dataset different to the recommended data to be recorded by CCGs regards to Ecoli bateraemia cases?? CCGs currently have no write permissions to the DCS, and at the time the GNBSI QP was submitted to NHS England there was no funding in place to allow this to happen in time. Many of the DCS fields were not mandatory. The CCG pre BSI data fields have been developed with PHE and it is hoped will align when DCS fields are updated. Ideally there would be a single DCS case record all organisations could populate and view. Are local authorities aware of this important area or it is remit of CCGs to cascade info (think this related to the Dip or not to Dip in Carte Homes) The NHS ambition to reduce gram negative blood stream infections forms one of the priority areas in the recent NHS Next Steps in the Five Year Forward View Report. However it would be sensible to ensure local authority Directors of Public Health and care home commissioners are aware of the CCG GNBSI QP and are included in the whole health economy approach Why were broad spectrum Ab removed from QP for as many prescribers in primary care may restart prescribing broas spec ABs This AMR metric was removed from the GNBSI QP due to need to accommodate the reduction in E.coli BSIs. However the CCG Improvement Assessment framework will continue to include both the MOKTT AMR metrics that have been in use in the 2015/16 and 2016/17 AMR QPs, but at a fixed target of at or below both antibacterial items/starpu per 12 months, and at or below 10% broad spectrum antibiotics. So some CCGs will find these new at or below targets a challenge in the short term. The epact2 AMS dashboard will report both these metrics as will the NHSBSA/NHSE antibiotic monitoring dashboard from which NHSE take the CCG IAF metrics. Is there a resource where we can benchmark our antimicrobial consumption based on admisions data against similar trusts? I work for a partnership trust which has in-patient units and community hospitals. Look at RX-info Define (if you have it) and Rx dispensed by hospital and not FP10. If latter, then PRESCQUIPP Elizabeth mentioned a communication sent to all CCGS A cascade mail was sent via the PAG and CPhO on 10 th April Contact if not yet seen Is there hospital data CCGs can access CCGs can access some hospital metrics on the PHE AMR Portal 2

3 Yes - PHE AMR Fingertips is open access forall Are tertiary centres included in the data collection Yes - everybody Why is the baseline for 2017/18 CQUIN set at calendar year rather than financial year 2016/17? Needed to have a target set before the end of the financial year that was validated by the Trust, so 2016 was closest. It probably makes it more achievable. How are other trusts identifying patients with diagnoses sepsis (i.e. those that have a diagnosis of sepsis but are spread far and wide accross the hospital) - incase your stewardship team wanted to see them before day 3. One might say anybody of IV antibiotics needs to be treated in the same way. Flagged by ward pharmacists or nurses How do you identify patients that were treated for sepsis after discharging (as coding is poor for sepsis) Using the same system as per the sepsis CQUIN in the 2 previous years. Many trusts had a database. When will Trusts be informed what our % reduction targets will be for 2017/18 for the serious infection CQUIN? Already published on NHS-Improvement site I would like more information on the data on 10% e col BSIs - how to work with providers to collect and report? The GNBSI QP is a CCG incentive and they (not providers) are responsible for collecting a pre BSI data set, as suggested in the QP annex published on the NHS England QP web site. The idea is that CCGs use this data capture to identify risk and opportunities to reduce this risk if possible. Some CCGs are already doing this using a variety of models: a whole health economy IPC lead; a CCG IPC lead; practice pharmacists. Some CCGs may adopt the systems in place for capturing other HCAI activity in primary care such as CDI. Providers will probably be the ones entering the data onto PHE DCS. Commissioners need to be assured that it is being done. 3

4 Any tips or levers CCGs can use with local Trusts to encourage them to take part in antiimicrobial stewardship work across the interface? Pharmacy is in a good place to lead as they are working in acute, community services and commissioning organisations. Some CCGs have contracted time from the local microbiology service and this joins up activity. IPC networks can be encouraged to expand to include antimicrobial stewardship. CCG pharmacists can join the provider AMS group. Some NHS areas have AMS networks are CCGs included? Directors of Public Health and Health and Well Being Boards may be an effective driver to engage. And AMR is in the STP planning guidance reducing GNBSIs is an excellent priority to implement at an STP level as it requires lots of organisations to work together on similar topics: continence, hand hygiene, safe management of invasive devices, wound care; elective surgery prophylaxis. This was agreed at English Hospitals Chief pharmacists group that collaboration needed to start if not happenng already. AMR needs to be on all Pharmacy meeting agendas at regional level. We are using e-prescribing to identify sepsis patients from the inidcation - these are drop down options. Thanks - no erxing here. Anyone got any other methods? See above - anyone on IV AB will hit sepsis flag Other suggestions from attendees: Critical care outreach team and Sepsis review team Wonder if increased antibiotic use in A&E is related to deterioration in 4 hour target? Possibly Regarding the collection and reporting of core primary care data for all E.coli BSI: 1. Why is COPD listed on the suggested data collection, should we include other long term conditions? 4

5 Current intelligence suggest COPD and diabetic patients seem to be more likely to have HCAIs including GNBSI anecdotal but included as little data available to inform us at the moment. CCGs could collect more categories if they wanted to. 2. Should we also identify care home residents, are they at higher risk of E. coli BSI due to increased risk of antibiotic resistance? Yes, the proposed data capture requires residential classification and your local IPC lead can probably tell you what the data looks like already as its captured in routine DCS. Anecdotally, it varies by CCG I have found. Again a good reason for the QP data capture. 3. How are others intending to capture data from primary care? What are IPC leads? I think it will be difficult to get Practices on board to collect the data without incentivising them. Many CCGs have an Infection & Prevention lead in the Nursing and Quality team. The CCG DoN & Quality will be leading the CCG QP programme so may have already planned a data capture approach, and may already do this for CDI and MRSA (note the data capture for this GNBSI QP is not an RCA). Practice Pharmacists are a great idea as they are very good at retrieving data accurately, as are CCG pharmacy technicians. As the CPhO is the SRO for the reducing inappropriate antibiotic programme, he is very clear antimicrobial stewardship is a key medicines optimisation role, so would expect the NHSE GPPP pilot roles to support antimicrobial stewardship activity. Note the number of cases is not great when captured weekly or even monthly. The other aspect is that this data set needs good analysis to identify areas of risk, so CCGs need to consider how this will happen effectively and sustainably. 4. Can the PHE DCS data set be updated to include the extra data requirements? It currently includes the following risk factors: Urinary catherisation, Vascular device, invasive/indwelling device, surgical/ invasive procedure, Neutropaenia and Wound/ulcer. There are no time scales attached to these can we update these fields to specify in the last 28 days as suggested for the primary care data set. PHE are currently working to amend the DCS and we will try to align as far as possible. The CCG data set is a proposed data set and can be amended by CCGs to suit local requirements. There is a contact mail for the DCS system and it would be helpful to mail them with your comments Responses from Elizabeth Beech in blue and Philip Howard in red. 5