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The International Convention Centre (ICC), Birmingham11 – 12 September
2017
Antibiotic Review Kit - Hospital (ARK-hospital)
Elizabeth Cross
Brighton and Sussex University Hospitals NHS Trust
Brighton and Sussex Medical School
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Overview
• Background – 10 mins
• Introducing ARK-Hospital – 4 mins
• Findings from feasibility study – 4 mins
• Questions – 2 mins
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WHO Antimicrobial Resistance Global Report on Surveillance 2014
Antimicrobial resistance by 2050 threatens:
• A reduction in the world economy of 0.1-3.1%
Taylor J, et al. Estimating the economic costs of antimicrobial resistance: model and results. 2015. http://www.rand.org/ randeurope/research/projects/antimicrobial-resistance-costs.html
Antimicrobial resistance….Successful surgery
Cancer chemotherapy
Immunotherapies
AMR the end of modern medicine
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‘The English Miracle’1
Introduction of targetsFinancial penalties
Substantial changes in antibiotic useCephalosporins and Quinolones β-lactam/β-lactamase inhibitors
Cooke J, et al. Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008–13): working towards hospital prescribing quality measures JAC 2015
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The challenge of antibiotic resistant GNRs in the UK
• >3x increase in E . coli bacteraemiasince 2004• Currently 36,000 cases / year
Rates of resistance to key agents…
Gentamicin
Ciprofloxacin
Co-amoxiclav
Piperacillin – tazobactam
….climbing alarmingly
46% of E. coli bacteraemia isolates now reported as co-amoxiclav resistant
0
5
10
15
20
25
30
35
40
45
E. coli - Co-amox K. pneumoniae - Pip-tazo%
Iso
late
s re
sist
ant
2010
2011
2012
2013
2014
English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2015
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Some typical local data
• If you don’t believe predictions of a world without antibiotics by 2050
• Imagine working in your hospital without these antibiotics by 2020
E. coli cultured from urine Enterobacteriaceae cultured from blood
Co-amoxiclav 27% 39%
Ciprofloxacin 12% 19%
Piperacillin-tazobactam 14% 16%
Gentamicin 10% 14%
Some key rates of antibiotic resistance at this trust in 2016
At what rate of resistance would these drugs cease to be reliable clinically selected treatments?
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Antibiotics also place individual patients at risk of resistant infection
• Explored relationship between prior antibiotic use and antibiotic resistance
• Reviewed 24 studies– 19 Observational
– 5 RCTs
– >27,000 participants
• Urinary Infections• Respiratory Tract infections
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9
Forest plots of included studies
Urinary Infection Respiratory Tract Infection
Substantial
Lasting
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Option 1 - Don’t start!
10
Always begin broad-spectrum intravenous
antibiotics within the first hour!
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Option 2
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In reality ’focus’ rarely means stop
>95% of ‘Review and Revise’ Decisions are to
continue antibiotic treatment
With thanks to Dr Kieran Hand, Southampton
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A time-line of stewardship in the UK
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Why do we find stopping antibiotics so hard to do?
• Lack of knowledge of risks of prolonging treatment
• ‘Prescriber etiquette’
• Patient beliefs…
• ‘Complete the course’
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Do we know how long a course should be?
There is a lack of evidence that recommended durations are superior to antibiotic-sparing approaches*
*w/exception of otitis media, Hoberman A et al New Eng J Med. 2016;375:2446-2456
Recommended course durations have fallen
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Complete the course to avoid resistance?
1940’s Fear
Professional Pathogens
Transmitted during disease
M. tuberculosisMalariaHIV
Resistance selected during treatment
Resistance selected by inadequate treatment
21st Century Reality
Commensal Opportunist pathogens
Transmitted in carrier state
S. aureus E. coliK. pneumoniae
Resistance selected as bystanders
Resistance selected any antibiotic use.More use = more resistance
Two paradigms of resistance selection
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Introducing ARK-hospital(4 mins)
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The ARK-Hospital Team
Nationally Locally
The antimicrobial stewardship teamSally CurtisSam LippettVikesh Gudka
Martin LlewelynJasmin IslamLizzie CrossWill HamiltonCatherine SargentDan AgranoffNelson Barbon
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What is ARK-hospital?
The overarching aim of ARK is to reduce the incidence of serious infections caused by antibiotic-resistant bacteria in the future, through substantially and safely
reducing antibiotic use in hospitals now
A 5-year applied research programme funded by NIHR
Underlying hypotheses:
• In hospitals, most antibiotics are started appropriately; but there is reluctance to stop them once started
• Short durations of antibiotic treatment are sufficient to treat most genuine bacterial infections in hospitals
• Clinical review will identify those whose condition has not improved who need to continue taking them
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings
1. Online learning tool in form of a website or App
- Info as per slides above- Endorsed by specialist societies- Replacing parts of mandatory training
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings
2. Modification to antibiotic prescription section of the drug chart
- Acknowledges uncertainty around antibiotic prescribing
- Prompts 72-hr r/v of antibiotics
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings
3. In-person education + online tool
- Confirm use of decision aid- Alert doctors to r/v Abxs- Contribute to monitoring and feedback
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings
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4. Information for patientsA patient leaflet
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ARK-hospital provides
1. Information for prescribers about Review and Revise decision making
2. A decision aid applied to antibiotic prescriptions
3. Information for nurses and pharmacists
4. Information for patients
2. A structure for team meetings, monitoring and feedback
5.1 Team meetings to introduce ARK5.2 Monitoring of Abx prescriptions5.3 Feedback to clinical teams- Audit data- Clinical cases
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Results of feasibility study(4 mins)
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ARK-hospital results
• Feasibility: 3 months from April to July 2017
• 588 antibiotic prescriptions
• Point prevalence surveys• Weeks 1, 2, 3, 4, 6, 8 and 12
• Medical specialties:• Acute medicine, respiratory, elderly care, endocrine, gastroenterology
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Prescriptions reviewed within 72 Hours
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12
CQUIN Target
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Prescriptions using ARK-hospital decision aid
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12
ARKTarget
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Prescriptions stopped within 72 hour review
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Week 1 Week 2 Week 3 Week 4 Week 6 Week 8 Week 12
TrustBaseline
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Next steps…
• Feasibility ✔
• Three pilot sites kicking off this month• South Tees
• Oxford
• Wexham Park
• Recruiting 33 further trusts to main trial…
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• Key people• Acute medic
• Pharmacist
• Infection specialist
Recruitment to main trial
Pre
scri
pti
on
s w
ith
72
-hr
revi
ew (
%)
Prescriptions stopped (%)
10
Reducing the impact of serious infections
CQUIN 2017-19
https://fingertips.phe.org.uk/profile/amr-local-indicators