antibiotic guardian london workshop

Welcome to the Antibiotic Guardian London Work Shop

Chairs introduction

Professor Anthony KesselDirector of International Public Health

Public Health England

Antibiotic Resistance Overview

Dr Diane Ashiru-Oredope, Pharmacist Lead, Public Health England & Department of

Health Expert Advisory Committee on AMR & HCAI (ARHAI)

Infection Prevention and Control

in reducing Antimicrobial

Resistance

Karen ShawInfection Prevention and Control LeadPublic Health EnglandAMR Programme

National Priorities for addressing AMR

5 Infection Prevention and Control in reducing AMR Karen Shaw

1. Improve

Infection

Prevention and

Control

practices

Every infection prevented means less

antibiotics used

Lowering the use of antibiotics lowers the

risk of resistance

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=ywvWBTUkX2d2TM&tbnid=nQ-p6ZVcB56nJM:&ved=0CAUQjRw&url=http://www.blogging4jobs.com/work/its-not-my-job/&ei=me18Uvr8EMjT0QX-5YHwDg&psig=AFQjCNFITQd3fyVgDTXz37W9JzYJeL7tvw&ust=1384005295789577

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12

“We need to get to a point where:

good infection prevention and

control measures to help prevent

infections occurring become the

norm in all sectors …..”

Professor Dame Sally C. Davies

Infection Prevention and Control in reducing AMR Karen Shaw

14

Com

pete

nt

sta

ff

Senio

r E

ngagem

ent

Aseptic T

echniq

ue (

AN

TT

)

Legislation

Mic

robio

logy a

nd

Labora

tory

support

Strategic Plan, Vision and Governance

Cle

an S

afe

Enviro

nm

ent

Surv

eill

ance a

nd

audit

Technic

al guid

elin

es a

nd

pro

cedure

s

Antim

icro

bia

l ste

ward

ship

Occupational H

ealth

Infection Prevention and

Control Programme

Health and Social Care: Code of Practice 2015

15Infection Prevention and Control in reducing AMR Karen Shaw

IPC is complex


Stop infections at every

patient contact.

Infection

Control in

Cambodia

Prevention and

http://www.who.int/en/

http://www.who.int/en/

Why didn’t IPC work?

25

1. Lack of legislation

2. Lack of understanding and belief that ‘it’s

not my job!’

3. Lack of compliance with known standards

4. Lack of engagement

OWNERSHIP


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http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=KnlwnNPc6BVgLM&tbnid=F2YMJkTq3r-AFM:&ved=0CAUQjRw&url=http://devblog.springest.com/holacracy-ii-roles-and-responsibilities-in-development&ei=5O18Utj7D_GT0QXS2oHgBw&psig=AFQjCNFITQd3fyVgDTXz37W9JzYJeL7tvw&ust=1384005295789577

Responsibility

31 2013/v1.0

2buttonush-mailn

34

Strengthen IPC

Every infection prevented conserves antibiotics


Protect patients at every intervention

LondonFebruary 24, 2016


AMR Action

WHO/EURO Region

Saskia Nahrgang Programme Control of Antimicrobial ResistanceDivision of Communicable Diseases and Health

Security WHO Regional Office for Europe


WHO European Region

Draft Global Action Plan for AMR

European strategic action plan on

antibiotic resistance

2011–2020


European Commission


Global action plan on

antimicrobial resistance


Global AMR Action Plan - Strategic Objectives

1. Improve awareness and understanding

2. Strengthen knowledge and evidence

base

3. Reduce incidence of infection

4. Optimize use of antimicrobial medicines

5. Develop economic case for sustainable

investment

http://www.who.int/drugresistance/global_action_plan/en/


WHO European Region


UK Strategy 2013-2018

Key area 1: improving infection prevention and control practices Key area 2: optimising prescribing practice Key area 3: improving professional education, training and public engagement Key area 4: developing new drugs, treatments and diagnostics Key area 5: better access to and use of surveillance data Key area 6: better identification and prioritisationof AMR research needs Key area 7: strengthened international collaboration


German strategy (DART 2020)

Six-point plan:

1. Close co-operation between ministries and with international organizations. 2. Monitoring systems should be strengthened (…)3. For human and veterinary medicine, the diagnosis should be improved and the implementation of hygiene measures will be promoted. 4. An optimization of methods in animal husbandry. 5. Education of the public as well as by physicians and veterinarians will be intensified. 6. Emphasis on interdisciplinary projects.


GOOD PRACTICE

Source: http://www.bag.admin.ch/themen/internationales/11287/15615/index.html?la

ng=

• Strengthening the One Health approach

• Combating and preventing infections

• Promote the responsible use of antibiotics

• Strengthening surveillance systems

• Support of research and development


Surveillance in the EU

Antimicrobial Resistance

Antimicrobial Consumption

EARSS1998

2011ESAC

2001

2010EARS-Net

ESAC-Net


Surveillance in European region

Antimicrobial Resistance

Antimicrobial Consumption

CAESAR

AMC2011

2012

http://www.escmid.org/



CAESAR Annual Report 2014

Data of 5 countries (Turkey, The former

Yugoslav Republic of Macedonia, Serbia,

Belarus, Switzerland)

EQA results 2013 (9 countries)

Guidance for data interpretation

Encourage implementation, maintenance and

improvement of national AMR surveillance

programs

2015 and 2016 report will be published this

year (now incl. Russian Federation)


Central Asian and Eastern

European Surveillance of

Antimicrobial Resistance (CAESAR)

World Health Organization Regional Office for Europe

Expanding AMR surveillance

throughout EuropeCountry Level

of eviden

ce

No. of labs in

network

#isolate

s

Belarus B 10 (33% labs)

386

FYROM B 6 (26% labs)

189

Serbia B 14 (50% hosp)

1465

Switzerland A 20 (70% hosp)

7945

Turkey A 77 (?%) 10377

Source: CAESAR Report 2014

Countries submitting data to CAESAR


CAESAR data - Levels of evidence

• Level A

– Data is representative of target population

– Laboratory results reliable

• Level B

– Data is not representative of target population

– Laboratory results reliable

• Level C

– Data is not representative of target population

– Laboratory results not entirely reliable


Sharing good practice


Global Initiatives and

Partnership


Research & Innovation


Awareness

2008 Materials for the general public32 countries participated

2009 Materials for primary care prescribers

2010 Materials for hospital prescribersand hospitals

Matched Get Smart week in the U.S. and the campaign in Canada

2011 Patient stories and Euronews movie37 countries participated

2012 Collaboration with WHO/Europe:43 countries participatedFirst EAAD Twitter chat Australia becomes a partner

2013 Start work on self-medication with antibiotics, with PGEU and CPME

2014 Revised toolkit for the general public on self-medication with antibiotics

New Zealand becomes a partnerGlobal Twitter conversation and European Twitter chat

For more information: Earnshaw S, et al. Euro Surveill 2009 Jul 30;14(30): & 2014 Oct 16;19(41).

European Antibiotic Awareness Day, 2008-2014

Toolkit for primary care prescribers

Toolkit for hospital prescribers andand hospitals

Toolkit for the general public

Revised toolkit for the general publicon self-medication with antibiotics

Images from national campaigns on prudent use of antibiotics


WAAW Baseline Survey: Russian Federation and Serbia

Russian Federation: • 1007 online interviews• 67% think colds and flu can be treated with

antibiotics• > One quarter (26%) think they should stop

taking antibiotics when they feel better rather than taking the full course as directed.

Serbia:• 510 face-to-face interviews• 68% wrongly believe that colds and flu can

be treated with antibiotics.• Only 60% heard of the term antibiotic

resistance’

13.8K+ views

16.9 M impressions

170K engagements

Global Social Channel Performance Regional Media Coverage

Global video

views

Twitter hashtag

mentions

21M+ 75.5K+ 850K+ 8K+

Global social channel

impressions

Campaign website

page views

4.5 M impressions

18K engagements

Global pieces of

coverage

993+

World Antibiotic Awareness Week Global Highlights

122+ 351+

Region of the Americas Eastern Mediterranean

RegionAfrica Region

48+

\

European Region

339+South East Asia Region

50+Western Pacific

Region

83+

Interviews secured

across the globe

28

*Note: These numbers do not encompass all regions/totals

Most Viewed Materials Ever on WHO Social Media

To view click here

To view click here

To view click here

Most Watched Video on Vine

Most Liked Video on Instagram

Most Liked Infographic on Facebook

https://www.facebook.com/WHO/posts/1023295627715820

https://www.instagram.com/p/-GZDmEKM7o/

https://vine.co/v/iueDhBbq9me

European Region

TOTAL ARTICLES: 339

Russia: 95

UK: 54

Estonia: 60

Bulgaria: 50

France: 26

Republic of Moldova: 4

Spain: 11

Uzbekistan: 8

Switzerland:6

Georgia: 4

Lithuania: 4

Germany: 3

Slovakia: 3

Serbia: 3

Italy: 3

Ireland: 2

Belgium: 1

Israel: 1

Czech Republic: 1

117

63

112

36

94

26

13

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7

No.

of

key m

ess

age m

enti

ons

Key message

Key Message Delivery

6

0

1%

1%

1%

1%

2%

2%

2%

3%

19%

47%

0% 10% 20% 30% 40% 50%

Prof Timothy Walsh

Dr Susan Hopkins

Dr. Des Walsh

Jian-Hua Liu

Laura Piddock

Jim O'Neill

Zsuzsanna Jakab

Sergey Khachatryan

Dr Keiji Fukuda

Margaret Chan

Spokesperson Inclusion

UK in the top 5


Awareness Raising: France

• French National Awareness Campaign

(2002-2007) aimed at the general public

and health care professionals

Reduction in the # of unnecessary antibiotic prescriptions

Goosens H, Guillemot D, Ferech M et al. National campaignsTo improve antibiotic use. Eur J Clin Pharmacol 2006; 62: 373-9


Awareness campaigns: Belgium

• Simple repeated messages in Belgium

2006-07

Decreased sale of antibiotics

Goosens H, Coenen S, Costers M, et al. Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC). Euro Surveill 2008; 13: pii 19036


Thank you for your attention


WHO Europe: Partnership



http://www.nivel.nl/en

http://www.nivel.nl/en


WHO Europe:

Acknowledgments • Division of Communicable Disease,

Health Security & Environment

– Nedret Emiroglu

– Cristiana Salvi

– Siff Malue Nielsen

• AMR Coordination

– Danilo Lo Fo Wong

– Nienke van de Sande-Bruinsma

– Saskia Nahrgang

• Food Safety

– Hilde Kruse

• Health Systems and Public Health

– Hans Kluge

• Health Technologies and

Pharmaceuticals

– Hanne Bak Pedersen

– Guillaume Dedet

• Influenza & other Respiratory Pathogens

– Caroline Brown

– Pamela Hepple

• Vaccine Preventable Diseases &

Immunization

– Robb Butler

• Alert and Response Operations

– Ana Paula Coutinho

• WHO Country offices

• National AMR focal points!

The Governments stance

Professor John Watson, Deputy Chief Medical Officer for the Department of

Health

Building laboratory capacity, surveillancenetworks and response capacity

Dr Mike Turner, Head of Infection and Immunobiology, Wellcome Trust

Question and Answers

Lunch and networking

Wellcome back



Healthy Eating: “The Route to

Health and Wellbeing”

Peter Stevenson

Compassion in World Farming

Most antibiotic use is in intensive sector

• Prophylactic use is “particularly prevalent in intensive agriculture,

where animals are kept in confined conditions”: The Review on

Antimicrobial Resistance, December 2015

• Around 90% of UK farm antibiotic use is in pigs & poultry, the two

most intensively farmed species

• WHO: growing demand for meat “especially when met by intensive

farming practices, contributes to the massive use of antibiotics in

livestock production”

• FAO: “the prevalence of resistance in the agricultural sector is

generally higher in animal species reared under intensive production

systems”

Do we need to increase food production to

meet the demands of a growing population?

• Many argue we need to increase food production by

70%

• And so, driven by that imperative, we must further

intensify agriculture including livestock sector

• And that will mean increased antibiotics use – and

increased resistance

Do we really need a major increase in production?

• Worldwide 25% of food calories are lost or wasted post

harvest or at the distribution/retail & consumer levels: High Level Panel of Experts on Food Security and Nutrition, 2014

• 9% is used for biofuels & other industrial purposes: Cassidy et al, 2013

• 36% of global crop calories are used as animal feed: Cassidy et al, 2013

Dairy Eggs Chicken Pork BeefCalorie

conversion

efficiency (%)

40 22 12 10 3

Protein

conversion

efficiency (%)

43 35 40 10 5

What happens to the 36% of the world’s crop calories

used as animal feed?

For every 100 calories of human-edible cereals fed to animals, just 17-

30 calories enter the human food chain as meat or milk: Lundqvist et al,

2008; UNEP, 2009

Some studies indicate the conversion rate is even lower for meat

Source: Cassidy et al, 2013

Of the 36% of the world’s crop

calories used as animal feed

Approx ¼produces

meat & milk

Approx ¾is wasted: it

produces no meat

& milk for human

consumption

27% of global

crop calories

wasted by being

fed to animals

9% of global

crop calories

produce meat

& milk

Waste Fruitful

Many recognise that feeding cereals to animals is wasteful

Chatham House: “staggeringly inefficient”

International Institute for

Environment and Development: “colossally inefficient”

FAO: “potential to threaten food security”

Bajželj et al, 2014

“a very inefficient use of land to produce food”

Feeding the 2.6 billion extra people anticipated by 2050


People (in billions)


People (in billions)

Extra people (in billions) that couldbe fed by reducing over consumption

Based on data from UNEP, 2009; Cassidy et al, 2013;High Level

Panel of Experts of the Committee on World Security, 2014; World

Resources Institute, 2013,

The false premise that we need to hugely increase

production will drive further intensification of livestock

–and with it increased use of antibiotics

Transformation of the role of

livestock

• Research funded by the FAO examines a reduction (possibly to

zero) in use of grain as animal feed as this competes with crop

production for direct human consumption: Schader et al, 2015: two of

the authors work for FAO

• The study argues that the role of livestock “is to use resources that

cannot be otherwise used for food production”

• Pasture

• By- products

• Unavoidable food waste

• Integrated crop-livestock farming - in line with circular economy

principles. The waste products of one component serve as a

resource for the other: animals are fed on crop residues & their

manure, rather than being a pollutant, fertilises the land.

Reduction of use of grain as feed would lead to

reduced production of meat & dairy

• What would happen if we were to move to healthier diets – more

fruit, vegetables, whole grains, legumes, nuts & seeds and less red

& processed meat?

• Animals could be farmed less intensively with an end to routine

preventive use of antibiotics

• Need to “develop health-orientated systems for rearing of animals”:The Lancet Infectious Diseases Commission, 2013

Health-

Orientated

Systems

Avoid

excessive

group size

Reduce

high

production

levels

Avoid

mixing

Avoid

over-

crowding

Reduce

stress

Good air

quality

No early

weaning

of pigs

Enable

natural

behaviours

Reduced consumption of meat & dairy would

bring many benefits

• This would bring health benefits:

• reduced use of antibiotics in livestock sector

• reduced heart disease, certain cancers, obesity, diabetes: European

Commission 2012; Friel et al, 2009; Aston et al, 2012

• consumption of red meat in Europe is on average more than twice

as much as the recommended limit: Westhoek et al, 2015

• average per capita protein intake in the EU is about 70% higher than

required: Westhoek et al, 2015

Well below 2°C

By 2050 our diets alone likely to have taken us

above the ‘well below 2°C’ target: Bajželj et al, 2014

© Chatham House: From Chatham House

presentation by Antony Froggatt “Putting

Meat on the Climate Negotiating Table”,

December 2015

Reduced meat & dairy consumption could bridge over a quarter of the gap

between emissions pledged & emissions needed to meet ‘well below 2°C’ target

Reduced consumption of meat & dairy would bring

environmental benefits

Factor affected by

reduction in meat

consumption

% reduction from current

levels

Soybean use as animal feed

(=reduced deforestation)75%

Use and pollution of surface-

and ground-water *20%

Cropland use 23%

Nitrogen emissions 40%

Greenhouse Gas emissions 19–42%

* In this case the figure in column 2 refers

to a 45% reduction in meat consumption.

Sources: Vanham et al, 2013; Westhoek et al, 2014 & 2015

Reduced meat & dairy consumption would bring

animal welfare benefits. It would allow a move from

industrial to high welfare systems

To this

Or these

From this

From this

To this

France

Portugal

The 50%/50g Diet

50% reduction in

meat & dairy consumption

&

50g per day per person:

max meat consumption

Two Schools of Food Policy: the

Productionist Approach

• Exemplified by Defra

• Defra’s forthcoming 25 year Plan on Food & Farming will focus on

production, competiveness & agri-tech alone and will almost

completely ignore dietary health, the environment & animal welfare

• Suggested strapline for Defra plan:

Integrated Food System: Building for the Future

Good

Healthy &

Nutritious

Food For All

Environmental

Sustainability

No Routine

Preventive

Antibiotic

Good

Animal

Welfare

Culture:

Bonding,

Richness,

Diversity

Antimicrobial stewardship: Changing risk-related

behaviours in the general population

Jacqueline Sneddon

Antimicrobial Pharmacist

Disclaimer

• I am a ‘topic expert member’ for the guideline on

‘Antimicrobial stewardship: Changing risk-

related behaviours in the general population’

• I am not a NICE employee

• NICE has not had prior sight or approval of this

presentation

The background: why NICE was

set up• Established in 1999

• Aim: to reduce variation in the

availability and quality of

treatments and care (the so

called ‘postcode lottery’)

• To resolve uncertainty about

which medicines and

treatments work best and

which represent best value for

money for the NHS

Core principles of NICE’s work

• Based on the best evidence available

• Expert input

• Patient and carer involvement

• Independent advisory committees

• Genuine consultation

• Regular review

• Open and transparent process

• Social values and equity considerations

NICE Guidance by Year

Antimicrobial stewardship:

Changing risk-related

behaviours in the general

population

Guideline due for publication

2016• This is a Public Health Guideline and has

been in development for about 18 months

• Core PH committee members plus 6 topic

experts

• Limited evidence base impact of

interventions

• Public consultation on guidance:

8 September to 20 October 2015

Scope

• Interventions to change public behaviours

to reduce development of AMR and stop

spread of resistant microbes

– Includes measures to raise awareness and

knowledge about antibiotic use and AMR

– Includes measures to prevent and control

infection

Target audience

• Those with responsibility for prescribing and

dispensing antimicrobials

• Those in public health

• Those who give information and advice to the

public

• Those responsible for preventing and controlling

infections

• The public themselves – especially vulnerable

groups

Draft guideline - Seven areas of

recommendation1. National and local information

campaigns

2. Public interventions to prevent

infection

3. Interventions to reduce inappropriate

antimicrobial demand and use

4. Childcare settings

5. Schools

6. Educational and residential settings

for young adults

7. Healthcare settings

Setting-specific

recommendations

1. National and local information

campaigns

• Raise awareness of AMR and appropriate

antimicrobial use

• Give info on preventing and controlling

infections e.g. “Now wash your hands”

• Using range of modes of delivery (verbal

advice, multimedia, written, mass media)

2. Public interventions to

prevent infection

• Advice on hand washing (including when

and how to wash hands; when hand

sanitisers are / are not appropriate)

• Food hygiene advice

• Wider aspects of infection prevention

(such as the need for vaccinations)

3. Reduce inappropriate

antimicrobial demand and use

• Educating patients and the public about the

natural course of self-limiting conditions

(including red-flag symptoms)

• Educating the public about where to seek

help/advice if/when they need it (e.g. use

pharmacies rather than A&E)

• Advising people to use prescribed antimicrobials

appropriately – complete the course, don’t

share, don’t keep

Role of community pharmacy

• Expertise of pharmacists in managing symptoms

and providing advice on medicines often under

utilised

• Accessible to all 7 days a week

• Promote as first port of call for patients with

symptoms of self-limiting infections

• Can refer to GP if required and highlight signs of

serious illness

Personalised symptom advice

4. Childcare settings

• Clean premises and equipment appropriately

• Provide hand washing facilities for staff and

children

• Educate children about hand washing, involving

parents and carers

• Ensure parents and carers are aware of the

importance of preventing spread of infections and

appropriate antimicrobial use to reduce AMR

5. Schools

• Take a ‘whole-school’ approach

• Provide hand washing facilities, and teach hand

washing in an age-appropriate way

• Use teaching resources such as PHE’s “e-bug”

to educate children about microbes and AMR

• Consider integration of wider messages within

curriculum as well as involving parents and

carers

E-bug resources

http://www.e-bug.eu/

6. Educational and residential

settings for young adults

• Awareness raising activities, including about

hand washing (with posters in strategic

locations) and food-safety campaigns

• Raise awareness about other aspects of

infection prevention (e.g. vaccinations)

• Help students to understand about self-care and

where to seek help

7. Healthcare settings

• Give advice about self-limiting conditions,

including natural course and where to seek help

• Consider using decision-support aids to

encourage health professionals not to prescribe

antibiotics for self-limiting conditions

• When not prescribing antibiotics, explain why,

and give written information including safety-

netting advice

• When prescribing antibiotics, explain why, and

give written information on antibiotics

Research recommendations

• Cost-effectiveness

• Multi-component interventions

• High-risk groups

• Workplaces

Overarching implementation

• Consider developing a local area

antimicrobial stewardship strategy linking

public health, local authorities, healthcare,

and social care.

Antimicrobial

stewardship:

systems and

processes for

effective

antimicrobial

medicine use

(NG15)

https://www.nice.org.uk/guidance/ng15

Scope

• Effective use of antimicrobials as part of all

publically funded health and social care

commissioned or provided by NHS

organisations, local authorities (in

England), independent organisations or

independent contractors.

Recommendations for:

• Organisations (commissioners and providers)

– Establish antimicrobial stewardship team

– Establish antimicrobial stewardship programme

– Further specific recommendations around

communication, interventions, and lab testing

• Prescribers and practitioners

– Specific guidelines for prescribing antimicrobials

• Introduction of new antimicrobials

- assessment and approval mechanisms

Keeping up to date with the

latest from NICE

• NICE Pathways - brings together all NICE

guidance, quality standards and support in

easy-to-navigate flowcharts

• Monthly newsletters

• Subscribe to awareness services

– Eyes on evidence, Medicines, Public Health

NICE guidance and BNF apps for your

iPhone or smartphone

Search over 750 pieces of

NICE guidance, including

Public health guidance.

Download it today for free

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and Google Play.

BNF apps available free with

Athens password.

Get involved• Join a NICE Committee- use your expertise to

support development of NICE guidance

• Comment on a Consultation- feedback on

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standards

• Join the Fellows and Scholars programme- a

growing group of professionals benefitting from

NICE sponsorship and mentoring

• www.nice.org.uk/getinvolved

http://www.nice.org.uk/getinvolved

IMPLEMENTING START

SMART AND FOCUS IN

PRACTICE – A CASE

STUDYDanielle Stacey

Lead Pharmacist - Antimicrobials

Dudley Group NHS Foundation Trust

Dudley Group NHS Foundation Trust

• Serves a population of 450,000 across Dudley and areas

of Sandwell, South Staffs and Wyre Forest

• District General

• Provides specialist

services to Black

Country and West

Midlands

Elements of Antimicrobial Stewardship

ExpertiseLeadership

Interventions Monitoring

EducationReporting

First steps

• Start Smart then Focus toolkit first published in November

2011

• Antimicrobial Steering Group established

• Online antibiotic guidelines and credit card published

• Restricted formulary introduced to reduce high-risk broad

spectrum antibiotics

• Antibiotic usage monitoring began

• Quarterly Point prevalence surveys started

Point prevalence surveys

• Quarterly data collection

• PPS benchmarked against rest of region

Issues Identified for Improvement

• Adherence to guidelines

• Elements of Start Smart and Focus

• Documentation of indication

• Documentation of duration/date for review

• High IV antibiotic usage

• Duration of antibiotic course

• Underpinning all of this: Education and Training

Antibiotic guideline adherence

• Microguide App and Webviewer

• April 2014

Reducing duration of IV and overall

course length

• New drug chart – 72 hr review banner

• Drug chart update – duration and micro approved box

added

• Further update – indication box added

Feedback of point prevalence surveys

• After new drug charts introduced, improvements in results

became static

• What will make these improve?

• Educational outreach

• Rolling programme to visit every speciality 6 monthly

• Feedback on C.diff cases and apportionment outcomes


course length

Did it make a difference?

• Documentation of duration still 55-60%

• Indication rose from 60% to 70% after first round of

feedback visits

• Up to 78% after second round of visits

• Highest result in West Midlands Region!

• C.diff cases apportioned due to lapses in Abx prescribing

• 34% cases Trust apportioned in 2014-15

• 18% cases Trust apportioned in 2015-16 so far


course length

• Improved documentation has not reduced usage

Ensuring Start Smart and Focus

• Are antimicrobial prescribing policies and guidelines being

followed?

• Barriers

• Staff time to collect data

• Ownership of results

• Feedback of results

Adherence Audits

• Mandatory audit – Trust audit programme

• Medic led

• 20 patients per speciality annually

• Each speciality produced report with recommendations

• Discussed at speciality meetings and Trust audit meeting

– see others results!!

Adherence audit resultsTrust standard Target Result

Indication documented

in medical notes100% 80%

Name documented in

medical notes100% 77%

Duration documented

on prescription chart100% 63%

Compliance with Trust

guidelines90% 75%

If no: on microbiology

advice?90% 22%

• Identified 75% compliance with guidelines due to no guidelines for some

indications – worked with specialities to produce guidelines

• 2015 re-audit – to include 48hr Review

Actions

• Trust Clinical Audit lead instructed all specialities to

develop a localised action plan including:

• Documentation of indication & stop/review dates

• Documenting conversations with microbiology

• Stewardship team to work with specialities to develop

more guidelines

• Audit “Start Smart then Focus”

Adherence re-audit 2015Trust Standard Target 2014 Result 2015 Result

Indication

documented in

medical notes

100% 80% 92%

Duration or review

date documented100% 63% 66%

Compliance with

Trust guidelines100% 75% 86%

If no: on

microbiology advice?90% 22% 43%

48-72 hour review

documented for IV

antibiotics

100% Not audited 38%

• Improvements in documentation of indication and duration and

compliance with guidelines compared with 2014

• First year of auditing 48-72 hour review

Education and Training

• Every doctor, nurse and pharmacist has antimicrobial

induction

• Mandatory training every 3 years – e-learning package

• Better training, better care – junior doctors

New initiatives

• Attending audit meetings to present results – league tables!

• Junior doctor liaisons – feedback updates to guidelines, problems in practice, errors• Two way feedback

• Start Smart then Focus – peer review

• 48 hour review ward rounds and weekend planning

• Does 48-72 hour review reduce overall usage?

Summary

• Effective leadership and expertise essential

• Monitor – intervene – monitor

• Prescriber ownership is essential

• Competition helps

• Effective feedback mechanisms – two-way

• Continual education – not one-off

Thank you

Any Questions?

How local networks are enabling antimicrobial stewardship activity in the South West

Elizabeth Beech 24th February 2016 Pharmacist - NHS Bath and North East Somerset CCGNational Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS [email protected] @elizbeech

mailto:[email protected]

Five core features of effective networks

1. common purpose

2. cooperative structure

3. critical mass

4. collective intelligence

5. community building

CCG footprints aligned within the West of England Academic Health Science Network

SWAG – South West Antimicrobial Pharmacist

network

• Membership is hospital antimicrobial pharmacists

• Share clinical audit, education & best practice, professional support

• Collaborate on delivery of the 2016-17 AMR CQUIN

• Link with other networks –microbiologist network

• SWAG network provides a reliable communication cascade system

• Example: working together to develop a methodology for 48 hour review as part of SSTF

BGSW Bath and North East Somerset, Gloucestershire, Swindon, Wiltshire

Clostridium difficile Infection Commissioner Group

• Membership is NHS England quality lead, CCG quality leads & pharmacists, and PHE field and epidemiology staff

• Strategic and operational content to support NHS CDI objectives, and 2015-16 AMR Quality Premium

• Share intelligence – IPC, AMR and AMS data and practice

• Enhanced surveillance of Community Attributed CDI led by PHE, to drive improved management of CDI

BGSW Antimicrobial Stewardship Network

• NHS England led (building on CDI network) - membership open to all organizations including councils and PHE, and all healthcare professionals

• Established to support delivery of the 2015-16 AMR Quality Premium

• Shares intelligence and successful practice fast; including sharing educational resources and expertise

• Example: EAAD 2016 planning

Bristol, South Gloucestershire, North Somerset, Bath and North East Somerset Antimicrobial Stewardship Network

• Membership is CCG and provider organization pharmacists, and links to BGSW network by overlap

• Established to support delivery of the 2015-16 AMR Quality Premium

• Shares intelligence – AMS audit data and practice

• Example: sharing community IV antimicrobial service activity

Bath and North East Somerset Health Strategic Healthcare Infection Prevention

and Control Collaborative

• Originally established to support HAI & IPC agenda - now evolved to include AMR and stewardship

• Led by the CCG, multi organizational, multi disciplinary, acute provider hosted 8 weekly

• Operational and strategic, shares intelligence and expertise

• Example: whole health community dataset for all cases of CDI; improving transfer of information across care boundaries; learning from norovirus to improve preparedness

Bath and North East Somerset AMR Group

• Set up under Health and Well Being Board, reporting to Director of Public Health

• Chaired By CCG Clinical Chair• Membership will represent the

whole community, including patient representation

• Strategic role to support delivery of National AMR strategy and PHE local AMR plans

• Example: Public engagement with, and education about, resistant infections – prevention and appropriate use of antimicrobials

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