What are the key challenges in implementing Stewardship the AMS team view

What are the key challenges in implementing Stewardship the AMS team view Philip Howard Consultant Pharmacist Twitter: AntibioticLeeds philip.howard2@nhs.net www.england.nhs.uk/ourwork/patientsafety/amr

Disclosures Speaker or consultancy fees, educational grants for conferences or research from: Astellas, AstraZeneca, BBraun, Danone, Eumedica, Gilead, GSK, MSD, Novartis, Pfizer, Sanofi Royal Pharmaceutical Society spokesman on antimicrobials UKCPA Trustee & Pharmacy Infection Network committee BSAC Council ESCMID Guidelines & Policies Group Committee DH Start Smart then Focus development group RCGP TARGET guidance group WHO AMR Strategy Task Group (for FIP)

New AMS guidance is never ending! Update to the 2008 Health & Social Care Act IPC Code of Practice to include AMS criterion 3: ensure AB use optimises outcomes & risk of adverse events and AMR. NHS-England patient safety alert on AMS NICE guidelines (2) on AMS: systems and processes & changing riskrelated behaviours in the general population (draft) Update of Hospital AMS guidelines Start Smart then Focus Quality premium for general practice to reduce total by 1% and broad spectrum antimicrobial prescribing by 10% or to median of 11.3% NHS-England CQUIN on Sepsis 2015-6 (% red flags and AB within 1 hr) NCEPOD Sepsis report; draft NICE sepsis, new global sepsis definitions BUT AMR keeps increasing, esp Klebsiella to pip-tazo Hospital AB use 6%, carbapenem 36% & pip-tazo 55% from 2011-14 per 100 admissions

UK data from an International Survey of Hospital AMS Howard et al (JAC 2015) Conducted in 2012

Hours per week for AMS Programme 2% funded from savings 23% dedicated funding (extension of 2003 3 year DoH Hospital Pharmacy Initiative) AMS pharmacists posts have grown but not WTE (Wickens 2012) Infection Management Group

Has Sepsis CQUIN ED IV AB use? Overall 4.8% in rolling 12 mth from March to February (info from Rx-Info Define software) CEM audit of IV AB in 60 mins: 2011 = 27% (IQR 17-37%) 2013 = 32% (IQR 20-44%) CQUIN Sepsis 2015-6 Q2 = 49%, Q3 = 58% 61% of red flags required ABs

New 2016/7 CQUINs: Sepsis & AMR Biggest AMS implementation challenge or opportunity? Both 0.25% of tariff income eg 1b turnover = 2.5m Sepsis: ED & In Patients and Day 3 review Expanded to include in-patients this year plus day 3 review. % who met criteria for sepsis screening who were screened (both) % with severe sepsis, Red Flag Sepsis or septic shock and had IV AB within appropriate time period 60 min of arrival at ED, 60 min of recognition for newly admitted or 90 min of existing in-patient to start or change Abs empiric AB review within 3 days (30 pts/mth of ED & IP = 60pts/mth) NHS-England CQUIN on AMR 2016-7 Reduce total antibacterials, piperacillin-tazobactam & carbapenems by 1% per 100 admissions based on 2013-4 baseline. Evidence of day 3 review (and outcome) of 50 patients per month. Thresholds: Q1 = 25%+, Q2 = 50%+, Q3 = 75%+, Q4 = 90%+ Submission of consumption data to PHE for 2014/5, 2015/6 & 2016/7

2016/7 AMR CQUIN: use less or alternatives RR8 = -46 Difference from 2013 to 2014 DDD/100 admissions Total -0.7% Carbapenem +4% Piperacillin-tazo +7% RR8 = -1 RR8 = -1 40% of hospital AB is OP & ED AB. Same AMS principles of checking indication against guidelines still apply & audit of PGDs?

DDDs per 100,000 pop per day NHS Scotland: Use Pip/Taz, carbapenems and carbapenem sparing agents in acute hospitals* (aztreonam, fosfomycin, pivmecillinam, temocillin) but they cost so much more than cheap mero or pip-taz 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 * Excludes NHS Highland Year/Qtr Carbapenems Pip-Tazo Carbapenem Sparing Agents

DDDs per 100,000 pop per day NHS Scotland: Use of carbapenems, carbapenem sparing agents and Pip/Taz in Jul-Sep 2015 in acute hospitals by NHS board* 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 Carbapenems Carbapenem Sparing Pip-Tazo * Excludes NHS Highland

PPS: Compliance With Antibiotic Policy high for meropenem lower for pip-tazo Only 50% have active restricted (protected) AB follow up. (Howard 2015)

Chelsea & Westminster restricted AB follow up (Orla Geoghegan Lead AMS Pharmacist Imperial) Micro unaware 73% of 3048 restricted AB FY20145 14% deemed inappropriate. 56% stopped within 72h 677 interventions - 91 % were actioned. Avg 45min/day UKCPA PIN Award 2015

Reducing total antibiotics Avoid starting or finish earlier NICE diagnostics guidance [DG18] on Procalcitonin testing for diagnosing and monitoring sepsis. high levels can show that a person has a serious bacterial infection. and the results can help doctors to diagnose bacterial infection and decide about starting or stopping antibiotic treatment. not enough evidence to recommend that these tests are used in the NHS... further research and data collection (needed) to show the impact Do potential benefits mean PCT could be used but collect data to show the impact to meet the CQUIN?

Between 2011 and 2014 SSTF surveys: 26% use of separate AB Rx

Do we audit & feedback to improve prescribing? ESPAUR 2014 SSTF: do at least annually. More frequently drives quality improvement LTH audits showed 50% & 81% LTH 59% Only 10% could supply results & outcome (Llewellyn JAC 2015)

Dashboard on AMS performance f antibiotic use & prescribing standards for Feb-16 Antimicrobial ABDO ADULT CARDIO- LEEDS TRAUMA ACUTE NEUROS CHAPEL HEAD & URGENT MED CRITICAL RESPIRA CHILDRE CANCER & WOMEN' Prescribing LTH MEDICIN CIENCES ALLERTO NECK CARE SURG CARE TORY N'S (14) CENTRE RELATED S (12) Standards E (18) (34) N (20) (28) (24) (32) (42) (22) (16) (36) Indication (as per guideline) on chart 96% 97% 97% 96% 99% 100% 100% 86% 100% 98% 98% n/a 92% Duration or review date on chart 94% 94% 97% 100% 100% 67% 100% 84% 100% 98% 92% n/a 75% Follow AB guidelines 99% 97% 100% 99% 100% 100% 100% 100% 100% 98% 98% n/a 100% Day 3 review completed 76% 66% 89% 81% 58% 71% 100% n/a 100% 89% 46% n/a n/a All allergy boxes completed fully 92% 94% 97% 90% 90% 92% 100% 99% 100% 92% 80% n/a 100% Overall performance L L L L L L J L J L L J L Day 3 review outcomes Stop 2% 5% 0% 5% 0% 0% 0% n/a 0% 3% 0% n/a n/a IVOS 6% 11% 0% 14% 0% 0% 50% n/a 0% 3% 0% n/a n/a Oral to IV switch (escalate) 1% 0% 0% 2% 0% 0% 0% n/a 0% 0% 0% n/a n/a IV AB usage to Feb-16 Total IV - short term (3mth vs last yr) Broad spectrum IV - short term (3mth vs last yr) Total IV - long term (12mth vs last yr) Broad spectrum IV - long term (12mth vs last yr) Change AB 2% 0% 0% 7% 0% 0% 0% n/a 0% 0% 0% n/a n/a Continue 89% 84% 100% 72% 100% 100% 50% n/a 100% 95% 100% n/a n/a LTH ABDO MED SURG (32) ADULT CRITICAL CARE (42) ACUTE MEDICINE (18) CARDIO- RESPIRAT ORY (22) NEUROS CIENCES (34) CHAPEL ALLERTO N (20) CHILDRE N'S (14) HEAD & NECK (28) LEEDS CANCER CENTRE (16) TRAUMA & RELATED (36) URGENT WOMEN'S CARE (24) (12) -10% -6% -7% -9% -18% -3% -19% -28% -11% 10% -28% -12% 17% -5% 2% -3% -1% -21% 23% -52% -26% 17% 9% -20% -3% 22% 6% 4% -5% 14% 9% 11% 19% -8% 0% 11% 3% 12% 6% 1% -2% -9% 13% 5% 7% -19% -8% 26% 4% -5% -4% -1% IV AB usage K J J K K L J J K L J J L users like smiley faces easy to understand

Ward health check

Do we actually make a diagnosis? Bodansky 2012 Clin Med (Lond) 100 consecutive MAU admissions started on antibiotics over 3 days Do our guidelines give advice about negative results? Driving D3 review with a sticker put in notes by ward nurse

Electronic systems for AMS Hosp e-rx is poor (9% 17%, but 50% in progress) + ind n + dur n ~34% built in (2012 Global AMS survey UK data) Data warehousing (2% in UK) - links pathology & pharmacy systems to patient admin system Can use data warehousing without e-rxing if issue antibiotics to patients Bug no drug. Drug no bug. Reporting systems of use & resistance Increases productivity by 50% of AMS staff (USA Theradoc) Big savings on antibiotics & improved outcomes (USA) Use CQUIN money to get better AMS tools National specification for e-prescribing to improve AMS (ESPAUR subgroup)

Summary: To improve antibiotic prescribing in hospitals AMR & Sepsis CQUINs are our biggest opportunity Design systems to force better prescribing Consensus based, easy to access guidelines (including diagnosis and investigations) Quality improvement, not annual audit Local antibiotic champions (hierarchy) & multidisciplinary Merge IPC & AMS teams Monitor & benchmark antibiotic usage Regular but varied communication Local education & training at ward level

Thank you to lots of people Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne, Cheryl Mitchell, Mark Wilcox NHS England: Elizabeth Beech, Stuart Brown, Matthew Fogarty, Lauren Mosley, Mike Durkin, Celia Ingham-Clarke PHE: Diane Ashiru-Oredope, Susan Hopkins, Cliodna McNulty, Duncan Selby NHS Scotland: William Malcolm, Jacqui Sneddon, Alison Coburn, Dilip Nathwani, Andrew Seaton, Susan Paton UKCPA PIN: Orla Geoghegan, Mark Gilchrist, Tejal Vegha ESCMID ESGAP: Celine Pulcini, Stephan Harbarth ISC: Gabriel Levy Hara, Ian Gould

Challenges of Antimicrobial Stewardship the AMS team Philip Howard Consultant Pharmacist Twitter: AntibioticLeeds philip.howard2@nhs.net www.england.nhs.uk/ourwork/patientsafety/amr