Advances in Antimicrobial Stewardship (AMS) at University Hospital Southampton

Dr Julian Sutton Consultant in Infectious Diseases & Medical Microbiology

Federation of Infection Societies

1st December, 2017

Disclosures

IhavebenefitedfromsponsorshiptoattendnationalandinternationalmeetingsfromEumedica,AstellasandMSD.

Whyistacklingantimicrobialresistanceimportant?

Backgroundtohe2016/17AMRCQUIN

•  TotalantibioticconsumptioninEnglishhospitalshasbeenincreasingsteadilywhenadjustedforactivity(admissions);risingby6%between2010and2014

•  Piperacillin-tazobactamandcarbapenems(mainlymeropenem)consumption–rosemuchmoresharply;by62%and42%in5years

•  Theseincreasesinprescribinghavecoincidedwithincreased

antibioticresistance

Piperacillin-tazobactamconsumption(ESPAURreport2015)

0

0.02

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0.08

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0.12

2010 2011 2012 2013 2014

DDDpe

r1,000

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rday

Consumptionofpiperacillin-tazobactaminEngland

10.9%increasefrom2013;62%increasefrom2010

Carbapenemconsumption(ESPAURreport2015)

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2010 2011 2012 2013 2014

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ConsumptionofcarbapenemantibioticsinEngland

8.1%increasefrom2013;42%increasefrom2010

The2020Goal:cutinappropriateprescribingofantibioticsbyhalf

G72016inJapan:PMpressstatement.Availableathttps://www.gov.uk/government/speeches/g7-2016-in-japan-pm-press-statement(accessedAugust2016)

TheUKGovernment5-yearstrategy

PublishedSeptember20137keyareasforfutureaction:1.  Improvinginfectionpreventionand

control2.   Optimisingantibioticprescribing3.   Improvingprofessionaleducation,

trainingandpublicengagement4.  Developingnewdrugs,treatments

anddiagnostics5.   Betteraccesstoanduseof

surveillancedata6.  Betteridentificationand

prioritisationofAMRresearchneeds

7.  Strengthenedinternationalcollaboration

TheNHSresponse

– AQualityPremiumforCCGsfor2015-16and2016-17

– AnAMRCQUINforAcuteHospitalTrustsfor2016-17

PrimaryCare:TheQualityPremium

Expectationsexceededfor2015-16:

•  PositivefinancialincentiveforCCGs

•  2.7millionfewerantibioticswereprescribedcomparedtoprevious12months–7.3%reduction

•  0.6millionfewerbroad-spectrumitems(co-amoxiclav,cephalosporins,ciprofloxacin)–a15%reduction

QualityPremiumimpact:reductioninbroad-spectrumprescriptionsissuedinthecommunity

Thenumberofbroad-spectrumitemsreducedby0.6millionitems(15%)withinthe12monthstoafinalvalueof3,370,606itemsin12monthsApril15–Mar16.

NationalCQUINGoals2016/17(Commissioningforqualityandinnovation)

•  ImprovingthehealthandwellbeingofNHSStaff

•  PhysicalHealthofPeoplewithSeriousMentalillness(PSMI)•  IdentificationandEarlyTreatmentofSepsis•  Antimicrobialresistance(AMR)

HospitalsinEngland-theAMRCQUIN2016/17

5AMRCQUINGoalsbaselineyearis2013-141.  SubmissionofABxconsumptiondatatoPHEforyears:2014/15to

2016/172.  Reductionof1%ormoreintotalantibioticconsumptionagainstthe

baseline*(5%reductionfromlastyearrequiredforUHS)3.  Reductionof1%ormoreincarbapenem(mainlymeropenem)against

thebaseline(11%reductionfromlastyearrequiredforUHS)4.  Reductionof1%ormoreinpiperacillin-tazobactamagainstthebaseline

(12%reductionfromlastyearrequiredforUHS)

5.  Documentedreviewwithin72hoursin>90%ABxprescriptions

DefineddailydosesofantibioticsdispensedbyacuteTruststoinpatientsandoutpatients,per1000admissions,2013-14

UHS2013/14totalantibioticconsumption(treatmentdaysper1000admissions)

Source:http://fingertips.phe.org.uk/Accessed:17May2016

DDD’s/100admissionsofpiperacillintazobactamdispensedbyacuteTruststoinpatientsandoutpatients2013-14

Source:http://fingertips.phe.org.uk/Accessed:17May2016

UHS2013/14piperacillin/tazobactamconsumption(treatmentdaysper1000admissions)

TheUHSAMRCQUINGroup

•  Face-to-faceteaching–JuniorDrs•  PresentationsatConsultantmeetings•  OngoingantibioticstewardshipWRs•  RevisionofTrustSepsisguidelines•  EmailtoallUHSConsultants•  e-prescribingcourselengths(e.g.“trimethoprimfor3days”)•  Pre-72hourABxreviewpromptonDoctors’Worklist•  Pharmacist-ledauditsofpre-72hourABxreviews•  Lobbiedseniortrustleadersfornursing/pharmacy/data

analystsupport

TheUHSAMRCQUINGroup–furtherinterventions

•  AppointedaBand6nursetoanewantimicrobialstewardshipspecialistroletoleadonnursingengagementwithAMS

•  AppointedaparttimedataanalysttosupportpharmacistsindatasurveillanceandABxconsumptiondatasubmissiontoPHE

•  MicroGuideappupdatedtoreflectrevisedUHSsepsisguideline

•  RevisedMaternityservicessepsisguidelines•  RevisedCAPguidelines•  Publicity–WAAW,InfotoCQCetc

Doctors’Worklistalerticontopromptreviewwithin72hoursofstartingantibiotics

Usinge-prescribingtosupportappropriatedurations

•  Newdefaultoptionsfororalantibioticstoencourageshortercourselengthsandpromptpatientreview

ResistanceinGram-negativebacilliatUHS–allspecimentypes2011-2015

Thereisresistanceinlessthan5%ofGram-negativebacillispecimenstopip-tazandasimilarlevelofresistancetoacombinationofco-amoxiclavplusgentamicin

• Emphasisesprescribingbyanatomicalsite

• Foruncertainsourceofinfection:!stlineregimenisacombinationofco-amoxiclav+gentamicin

2016:RevisedUHSguidelinefortreatmentof‘sepsis’

Theresults

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4455 44124197

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FY2011/12 FY2012/13 FY2013/14 FY2014/15 FY2015/16 FY2016/17*

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UHStotalantibacterialsper1000admissionsperyear*admissionsdatapendingconfirmationforMarch&April2017

TotalUHSAbxconsumptionreducedby9%c/w2013/14(target1%reduction)

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FY2011/12 FY2012/13 FY2013/14 FY2014/15 FY2015/16 FY2016/17*

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sUHSpiperacillin-tazobactamper1000admissionsperyear

*admissionsdatapendingconfirmationforMarch&April2017

UHSPip-tazobactamconsumptionreducedby26%c/w2013/14(target1%reduction)

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sUHScarbapenemsper1000admissionsperyear*admissionsdatapendingconfirmationforMarch&April2017

UHSCarbapenemconsumptionreducedby24%c/w2013/14(target1%reduction)

85.7%90.0%

92.3% 90.3%

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UHSpre-72hourprescriptionreview(2016/17)

90%ofUHSpatientshadadocumentedABxreviewwithin72hoursinQ2,Q3andQ4

PneumoniaatUHS:standardisedmortalitycontinuestofall

RelativeRisk:100%=predictedmortalityforhospitalcase-mix

UTIatUHS:standardisedmortalitycontinuestofall

RelativeRisk:100%=predictedmortalityforhospitalcase-mix

SepticaemiaatUHS:standardisedmortalitycontinuestofall

RelativeRisk:100%=predictedmortalityforhospitalcasemix

PublicHealthEnglandannualESPAURreport,Oct2017

•  “In2016,thecommonestcauseofbloodstreaminfectionswasEscherichiacoli;ofthese,41%wereresistanttothecommonestantibioticusedtotreatinfectionsinhospitals(co-amoxiclav)andalmostoneinfiveofthesebacteriawereresistanttoatleastoneofotherkeyantibiotics,thoughmulti-drugresistance(resistancetothreeantibiotics)remaineduncommon(<5%).

•  Thissuggeststhatpatientswithsevereinfections,includingsepsis,whohaveriskfactorsforresistantbacteria,mayrequireacombinationofantibiotics,suchasaβ-lactamantibioticandanaminoglycoside,forthefirst24hoursoftreatmentwhilewaitingforlaboratoryresultstoguidethechoiceofoptimaltherapy.”

PublicHealthEngland,ESPAURReport2017

UHSAbxconsumption2016/17asAMRCQUINinterventionswereintroduced

TheAbxescalation‘escalator’

PercentageofUHSpatientswhoreceiveadoseofABxonanygivenday?

10%,20%,30%,40%,50%,60%,70%

‘YPOIs’YoungOldPregnantImmunocpmpromised(e.g.malignancy,immunosupressants,biologics,etc)Co-morbidities

“AntimicrobialStewardshipiseveryone’sbusiness”

Canwepredictthefuture?

Simpsons“BarttotheFuture”episodein2000,predictsUSpresidencyforTrump

Simpsons“BarttotheFuture”episodein2000,predictsUSpresidencyforTrump

ProportionofCarbapenemsResistant(R+I)Klebsiella

pneumoniaeIsolatesin2010and2014

2010 2014

Multi-resistantpathogensinUHS(carbapenemase-producers)

ToConclude–UHS20167/17AMRCQUINoutcomes

AcombinationofnovelAMSinterventionsfromacommittedmultidisciplinaryteam,whilstcontinuingtodothebasicswell,ledtoverysignificantreductionsininappropriateprescribingofultra-broadspectrumantibacterials,whilstmaintainingsafepatientcare.

CQUINitself-£668KSavingsonAbxinFY2016/17c/wpreviousFY-£240KOverall≈£0.9M

Thankyou:UHSAMRCQUINGroupKieranHand&HayleyWickensGraemeJones,TatshingYam,SarahGlover,SanjayPatel,SaulFaust,PatrickLillie,MikeVickers,IanJolliffe,EmilyBennett,manyothersandallprescribersofABxatUHS

Acknowledgments