Guests: Observers: Frances Kerr, Antimicrobial Pharmacist, NHS Lanarkshire. Action. 1. Welcome and Apologies

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1 Unconfirmed Minutes of the Scottish Antimicrobial Prescribing Group Meeting Held on Friday 28 th June 2013 Healthcare Improvement Scotland, Delta House, Glasgow Present: Professor Dilip Nathwani (Chairman), NHS Tayside Dr AnneMaree Wallace, Director of Public Health, NHS Forth Valley Mrs Alison Wilson, Director of Pharmacy, NHS Borders Professor Marion Bennie, Chief Pharmaceutical Advisor, National Medicines Utilisation Unit, Information Services Division Mr William Malcolm, Pharmaceutical Advisor, Health Protection Scotland Professor Alistair Leanord, Consultant Microbiologist, Health Protection Scotland Ms Julie Wilson, AMR Manager, Health Protection Scotland Mrs Arlene Brailey, Assistant Director of Pharmacy, NHS Education for Scotland Dr Gill Walker, Programme Director for HAI, NHS Education for Scotland Dr Stephanie Dundas, Consultant in Infectious Diseases, NHS Lanarkshire Professor Craig Williams, Consultant Microbiologist, Infection Control Doctors Network Ms Ysobel Gourlay, Lead Antimicrobial Pharmacist, NHS Greater Glasgow and Clyde Mrs Alison Macdonald, Lead Antimicrobial Pharmacist, NHS Highland Mr Willie McGregor, Senior Charge Nurse, NHS Lothian Mr Graeme Bryson, Prescribing Advisor, NHS Ayrshire and Arran Dr Sara Jamdar, Consultant Microbiologist, NHS Forth Valley Mr Colin Redmond, Infection Control Manager, NHS Borders Dr Susan Smith, Consultant Microbiologist, NHS Fife Dr Martin Connor, Consultant Microbiologist, NHS Dumfries and Galloway Ms Carol Philip, Antimicrobial Pharmacist, NHS Lothian In attendance: Dr Jacqueline Sneddon, Project Lead Scottish Antimicrobial Prescribing Group Ms Susan Paton, Project Officer, Scottish Antimicrobial Prescribing Group Apologies: Mrs Anne Lee, Chief Pharmacist, Scottish Medicines Consortium Ms Andrea Patton, Information Analyst, Scottish Antimicrobial Prescribing Group Mr Andrew Wilkinson, Head of Healthcare Associated Infection and Regulation Team, Scottish Government Dr Stuart Rodger, Associate Medical Director, NHS Greater Glasgow and Clyde Dr Michelle Watts, Associate Medical Director, NHS Tayside Professor Ian Gould, Consultant Microbiologist, NHS Grampian and Scottish Microbiology and Virology Network Dr Andrew Seaton, NHS Greater Glasgow and Clyde, Antimicrobial Management Team Professor Peter Davey, NHS Tayside, International Liaison Mrs Liz McClurg, Infection Control Manager, NHS Highland Dr Abhijit Bal, Consultant Microbiologist, NHS Ayrshire and Arran Dr Alexander Mackenzie, Consultant in Infectious Diseases, NHS Grampian Dr Alexander Crighton, Consultant in Oral Medicine, NHS Greater Glasgow & Clyde Ms Catriona Innes, Antimicrobial Pharmacist, NHS Orkney Professor Kevin Rooney, Lead Clinician for Critical Care, NHS Greater Glasgow 1

2 Dr Grant Archibald, Director, Emergency Care and Medical Services, NHS Greater Glasgow and Clyde Ms Vicky Elliott, Information Analyst, Information Services Division Mrs Helen Cadden, Public Partner Ms Deidre Harris, Nurse Consultant Infection Control, NHS Fife and Infection Prevention Society Dr Camilla Wiuff, AMR Lead, Health Protection Scotland Dr David Wilks, Consultant Physician, NHS Lothian Dr Gail Haddock, General Practitioner, NHS Highland Dr Simon Hurding, Medicines Management Adviser, NHS Lothian Dr Emma Watson, Director of Medical Education, NHS Highland Guests: Jane McNeish, Senior Nurse Epidemiologist, Health Protection Scotland Alison Thomson, Senior Lecturer, Strathclyde Institute of Pharmacy and Biomedical Sciences Ken Monaghan, Project Manager, NSS Selma Lai, Pharmacist, Hong Kong Sheila Noble, Project Manager, Antimicrobial Pharmacy Stage 3 Training Observers: Frances Kerr, Antimicrobial Pharmacist, NHS Lanarkshire 1. Welcome and Apologies Action The Chair welcomed all present and requested that any member declarations of interest should be advised in advance of relevant items. The Chair advised of apologies and guests as noted above. The Chair welcomed Dr Gill Walker who will be taking up the post of Programme Director for HAI from 3rd July 2013 replacing Helen Maitland who is on secondment to the Scottish Government. Formal invitation will follow once Gill takes up post. The Chair advised that Dr Annemaree Wallace is retiring from NHS employment in September and thanked Annemaree for her contribution to SAPG as Vice Chair, lead for the Quality Improvement Workstream and previously as member representing NHS Forth Valley Antimicrobial Management Team. The Chair advised that Liz McClurg, Infection Control Manager, NHS Highland will be retiring in September. Bob Wilson, Chair of the Infection Control Managers group will advise on their new representative on SAPG. The Chair advised that Gillian Stevenson, Nurse Consultant (HAI) who currently deputises for Deirdre Harris on behalf of the Infection Prevention Society is retiring this week and Deirdre will seek a volunteer to act as deputy. The Chair introduced guests and observers as noted above. 2

3 2. Minutes of the previous meeting held on 22 nd April 2013 The minutes of the meeting held on 22 nd April 2013 were agreed. 3. Matters Arising SIGN 104: Antibiotic prophylaxis in surgery JS advised that the publication date for the revision of SIGN 104 has still not been confirmed but that sign-off is expected in the next few weeks. SAPG Community Space JS advised the SAPG community space has now been developed and some testing has been completed. Details of how the space can be accessed will be sent to SAPG, AMT Leads and Antimicrobial Pharmacists. JS advised that the community space will only be as good as members make it and encouraged members to join. Action: Details of the community space to be sent to SAPG members, AMT Leads and Antimicrobial Pharmacists. SP UK Antimicrobial Resistance (AMR) Strategy JS updated on behalf of AW that publication of the new UK five-year AMR Strategy and Action Plan is expected in September. The Department of Health will undertake some engagement work with stakeholders/delivery partners to secure their commitment to actions to maximise the impact of the Strategy. The current Scottish action plan (ScotMARAP) will be refreshed following publication of the UK Strategy. Urinary tract infection update on national work UTI Surveillance Pilot. JM advised that the protocol and data collection forms have been finalised and will be tested in a care home and a community hospital in July. Feedback will inform staff training requirements for the pilot study in 10 care homes and 10 community hospitals across several health board areas. Training for staff will be delivered during August followed by surveillance from September to November 2013 and analysis of the data during December 2013 to March JM advised that the SAPG UTI decision aid is being promoted during the pilot work and that the aim of the pilot is to provide information about the prevalence of UTI and to generate ideas for improvement initiatives in care homes and community hospitals. JM confirmed that although data will be collected by non-clinical staff it will be checked by HPS staff. CW suggested collecting information on staff time required for the surveillance and JM agreed that this could be done. Scottish Patient Safety Indicator (SPSI) JS updated that the Scottish Patient Safety Programme (SPSP) is planning to develop a safety indicator for preventable harm in acute care which will be monitored using the Datix incident reporting system. The indicator will include measures for falls, pressure 3

4 ulcers and catheter associated UTI (CAUTI). JS has attended the first meeting of the SPSI CAUTI short life working group which is developing measures and a driver diagram for prevention of CAUTI. One of the key aspects to be agreed is the definition of CAUTI to ensure it is consistent with other surveillance and improvement work. JS has suggested that the UTI decision aid is included as an improvement tool and that measures incorporate treatment of CAUTI compliant with local antibiotic policy for choice of therapy and duration and whether catheter is changed. JS will report back progress to SAPG. It was agreed that all national work on UTI would benefit from integration under a strategic group encompassing SAPG, HPS, HIS and clinicians from elderly care and old age psychiatry. AL suggested the first step should be a proposal for such a group to be prepared for consideration at the next meeting of the National Advisory Group (NAG). Action: Paper for NAG to be prepared and discussed at September meeting of SAPG. AL Additional work on UTI management UTI Prophylaxis JS updated on work in Tayside to develop guidance for GPs on stopping long term UTI prophylaxis and there have been several requests from colleagues in other boards for national guidance to support review of UTI prophylaxis. CP advised that Lothian has also undertaken some work in this area which could be shared. It was agreed it would be beneficial to develop national guidance working with Urology colleagues and building on Tayside and Lothian work. JS advised that volunteers would be sought to contribute. Action: Canvass for volunteers to be involved in UTI Prophylaxis work. SP/JS UTI Antibiotic use in women JS spoke on behalf of IG on evidence highlighting that many UTI in women are self limiting and this may be a target area to reduce antibiotic use. It was agreed that this was worth exploring but patient acceptability could be a problem and there may be risks involved. As an initial step JS agreed to discuss further with IG and organise a literature review to establish the evidence base. Action: Systematic review of literature on need for antibiotics in female UTI. JS Update on Gentamicin and Vancomycin education resources AT provided a short demonstration of the contents of the package which has been developed in collaboration with NES, the GaV QIP team and learnpro. The Chair congratulated the Gentamicin and Vancomycin Team on the successful conclusion of two years of work including guidance, calculators, documentation and multi-professional education to support safe and effective use. It was agreed that it was a priority to ensure that all foundation year doctors accessed the new resource and that this would require implementation at local level and AMTs should actively promote it via training and governance routes. SS suggested that undergraduate medical schools should also be able to access the learnpro resource and it was agreed that this would be useful. AB agreed to progress 4

5 with the Undergraduate Deans via NES Medical colleagues. Action: Liaise with NES colleagues to contact medical schools through the Deans group. AB Items for Discussion and Agreement 4. Antibiotic review HEAT Target new antibiotic review measure testing. (Paper 2) The Chair asked members for their views on Paper 2 which details testing of a proposed measure for review of antibiotic prescriptions in downstream wards. The expectation is that data collected will be entered on the SAPG Extranet system to generate reports for local feedback and improvement work and to facilitate evaluation of trends at local and national level. Following broad discussion of the proposed measure the majority of members agreed that a measure is required to review antibiotic use. However, the actual measure and how the data would be collected was discussed at length. There was agreement that the primary aim of the measure/review was to try to reduce antibiotic duration use, a key driver of resistance and CDI. Therefore, it was agreed members and SAPG would reconsider how a metric for this could be developed and tested. The Chair thanked members for helpful discussion. A revised paper will be prepared for the September meeting of SAPG addressing the issues raised. Action: Paper on Antibiotic Review for September meeting of SAPG JS/AP 5. Using HMUD reports to measure IV to oral switch. WM advised that he has been working with the Association of Scottish Antimicrobial Pharmacists (ASAP) to develop a series of standard reports within HMUD to measure the proportion of IV and oral antibiotics used in hospitals as proxy measures for antibiotic review and IV to oral switch. Members agreed this work will be useful and it was agreed an update will come back to SAPG once work progresses further. Action: Paper on new HMUD reports to be prepared for future SAPG meeting WM/VE 6. Re-dosing in surgical prophylaxis. (Paper 3) The Chair advised that Paper 3 included feedback from clinicians on a proposal for national guidance on re-dosing of antimicrobials during surgical procedures. Draft recommendations for re-dosing of surgical prophylaxis were developed based on current practice in NHS boards, international guidance and information on antibiotic half-lives. Members agreed the suggested re-dosing intervals and doses of antibiotics noted in the paper. Action: Re-dosing guidance to be communicated to AMTs for local implementation and uploaded to SAPG website JS/SP 5

6 7. Unintended Consequences of surgical prophylaxis. Antibiotic prophylaxis and relative risks of acute kidney injury (AKI) and Clostridum difficile infection (CDI). (Paper 4) JS updated on behalf of PD on the final analysis of the study in orthopaedic surgery from NHS Tayside. It was agreed that the proposed advice on choice of antibiotics for prophylaxis in orthopaedic implant surgery based on this new evidence would be issued to AMTs and the Scottish Orthopaedics and Trauma (SCOT) group and that medical directors should be included in the communication. AMT's should action this with local orthopaedic and anaesthesia teams. Action: Circulate advice to AMTs, SCOT Group and Medical Directors JS/SP Other surgical specialties. JS advised that some initial results are now available for urology in Tayside and PD will present the full results for all surgical specialties using gentamicin-based regimens at the September meeting of SAPG. Action: Presentation of full study results at September SAPG. PD Feasibility study MB advised that the feasibility study to investigate if the Tayside analysis can be repeated in other boards using national data is progressing well utilising NHS Lanarkshire data. Infection Intelligence Platform. (Paper 5) MB updated that Ken Monaghan, Project Manager, has been working for the last three months with stakeholders and the Project Initiation Document (PID) is progressing well, scoping out of the three year programme which will link six key datasets to support 16 individual studies. The PID will be signed off and submitted for funding to the HAI National Advisory Group in July. The Chair thanked MB and KM for all their hard work and advised that outcomes would be fed back to SAPG after the NAG meeting. The programme outputs should become business as usual for key stakeholders and DN will work to ensure this is included in the future e-health strategy. Items for Update 8. Primary care quality indicator 6

7 Information for NHS boards on reduction of total antibiotic use. (Paper 6) WM advised that Paper 6 provided details sent to AMTS about the new primary care antimicrobial indicator which was announced in a CNO/CMO letter sent to NHS boards on 1 st May. The baseline period for the new total use of antibiotics indicator will be January-March 2013 therefore the first data to allow monitoring of progress will be available in June A standard report is available in PRISMS and primary care teams can highlight practices at board level which require to improve prescribing rates. Development of an integrative education resource for Primary Care. (Paper 6a) GB updated that the new resource has now been piloted in 9 GP Practices with learning sessions facilitated by local prescribing advisers and feedback from both prescribers and facilitators will inform the final version which will be available by October. GB has secured a session to promote the resource at the Scottish Prescribing Advisers Association conference at the end of October. AB advised an external evaluation of the pilot is currently being conducted and prescribing data will be available later in 2013 to evaluate the impact on prescribing rates. AB is working with PD and MB to finalise details of how to measure national implementation of the programme and the impact on prescribing practice. Repeat of primary care event. JS advised that the primary care event held in March had been repeated on 11 th June in a condensed half day format with 50 delegates attending. The event has evaluated very well with lots of ideas for future events. 9. HEAT target hospital indicator Reports Empirical Prescribing (Paper 7) and Surgical Prophylaxis (Paper 8) The Chair advised papers 7 and 8 are the latest reports on the current hospital indicators and show continued progress. 10. Blood Culture Validation. (Paper 9) JS advised on behalf of PD that paper 9 provides details of work to validate the use of blood cultures as a proxy measure for sepsis. 11. Nurses role in antimicrobial stewardship. (Paper 10) JS advised Paper 10 is a proposal to develop the role of nursing staff as part of the multiprofessional team approach to antimicrobial management. SAPG has been promoting the contribution that nursing staff can make to antimicrobial stewardship through education initiatives and quality improvement work. It was agreed at the April SAPG meeting that support from the HAI National Advisory Group (NAG) and the Scottish Executive Nurse Directors (SENDs) group is essential to progress further and that a paper should be prepared for their consideration. Paper agreed by SAPG and will be 7

8 submitted to the NAG meeting initially. Action: Contact chair of NAG to request paper is added to agenda for next meeting. JS 12. Multi-drug resistant gram negative bacteria short life working group The Chair advised that the short life working group have been working on two guidance documents; reducing multi drug resistance in gram negative bacteria and neutropenic sepsis and both are with group members for comments by 19 th July. Comments received will be incorporated followed by wider consultation and the final guidance will be available for the September SAPG meeting. Action: Papers for September SAPG. DN/JS 13. HAI Collaborative symposium 21 st May The Chair fed back on the HAL collaborative symposium which had taken place on 21 st May. The event was well attended but there was a lack of front-line clinical staff in attendance. It is planned that this integrative symposium will take place annually. Items for Information NICE Draft quality standard for surgical site infection JS updated that the NICE draft quality standard for SSI which sets out measures has been out for consultation and the final version will be published in a few months. AMT event 19 th November 2013 The Chair advised that the next AMT event will take place on 19 th November and will focus on the new MDRGNB guidance. Invitations will be extended to critical care colleagues, cancer networks and hepato-biliary surgeons to facilitate clinical engagement in implementation of the guidance. Details of the venue and programme will be available at the next SAPG meeting. SAPG Dates Paper tabled with two date changes. The next meeting of SAPG will take place on Friday 13 th September 2013 (changed from Monday 26 th August 2013) and the next event date has been changed to Tuesday 19 th November 2013 (from Tuesday 12 th November 2013). SAPG dates for 2014 The Chair advised that SAPG dates for 2014 would be circulated to members shortly for diary input. 17. AOCB AM advised on behalf of colleagues in Grampian that they are having frequent supply problems with co trimoxazole for IV use and wondered if SAPG influence to help resolve this. It was agreed National Procurement would be contacted for advice. Action: Contact procurement to discuss supply problems with IV co trimoxazole. JS 8

9 18. Date of next meeting Date of next meeting is Friday 13 th September 2013 at 12:30 in Delta House, Glasgow, with buffet lunch available from 12:00. The following meeting will take place on Monday 28 th October