Dilip NathwaniNinewells Hospital & Medical School

Dundee, Scotland DD1 9SY

SCOTTISH ANTIMICROBIAL PRESCRIBING

GROUP (SAPG) AMT NETWORK

MEETING STIRLING 2008

SAPG AMT CLINICAL NETWORK

Antimicrobial Prescribing Facts

~ 1/3 of all hospitalised inpatients at any given time receive antibiotics

~ up to 1/3 to ½ are inappropriate ~ up to 30% of all surgical prophylaxis is

inappropriate Antimicrobials account for upwards of 30% of

hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.

Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life

Managing risk of empiric or prophylactic therapy & adopting

change“Many clinicians regard the right to prescribe antibiotics

freely (unrestricted) as a basic human right”

“The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk of inappropriate antibiotics to the patient presently & in the future, the ecology and other patients

“The organisation needs to risk manage this conflict and help with solutions “

THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL

RESISTANCE ACTION PLAN[ScotMARAP 2007]

ScotMARAP Output

SAPG: A 3 year programme of work launched on the 17th of March 2008

Total funding of £1.2 million and allocation split between key stakeholders

SMC asked to convene, host and service national clinical forum – SAPG

SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)

The primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum” as expressed in the APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).

Aim

A National Framework for Antimicrobial stewardship

Improve the quality of antimicrobial prescribing and infection management

Scottish Medicines Consortium Scottish Antimicrobial rescribing Group

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team /

ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub- Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

Scottish Medicines Consortium Scottish Antimicrobial rescribing Group

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team /

ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub- Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

THE STAKEHOLDERS

CEL 30(2008)8TH July

As an immediate intervention to reduce the risk form C.difficle,we accept SAPG’s recommendation that all boards should immediately establish an AMT which covers primary and secondary care prescribing.

“AMT’s work closely strategically and operationally with ICT’s and ICM”- SAPG

Antimicrobial management team

Multi-disciplinary team ResourcedSupported Multi-faceted

interventions (consistently more effective then single interventions)

Active team at the coalface

Supported by hospital leadership

Core InterventionsFormulary +

restrictions (expert approval)

Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences

CEL 30(2008)8TH July

Recognition of the key role of the antimicrobial pharmacist: central additional funding for £40,000 for each mainland board and £20k for Island boards for 3 years (2011).

SAPG (not in CEL) keen on developing clinical networks for AMT’s to provide support for smaller boards, share good practice and do joint planning. Launch of AMT clinical network in STIRLING 18TH November 2008.

4 WORKSTREAMS

1. INFORMATION MANAGEMENT (HPS AND ISD)

2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY

(NQIS)4.INFECTION MANAGEMENT

(SPA,NQIS,NES,HPS-ISD,Professional Organisations)All the work-streams work in parallel but with vertical

integration Workstream work underpinned by an AMT Clinical

Network

MEASURES OF IMPROVEMENT: SECONDARY AND PRIMARY

CARE Consumption of antibiotics (total and

class)Surveillance of resistance Quality of prescribing through PPS

(targeted)HEAT indicator/sHAI standards

INDICATOR/S: HOSPITAL AND EMPRIC THERAPY

Indicator: >90% compliance with empiric antibiotic treatment policy in acute medical and surgical receiving/admission units

Measure : 1. the working diagnosis/reason for prescribing the antibiotic was documented in the medical notes

2. The choice (? Route/dose) was consistent with the empiric treatment policy

How ? 5 random charts of patients receiving antibiotic daily

one day a week reviewed by team and compliance charted

EFFECTS OF PERIOPERATIVE PROPHYLAXIS ON NOSOCOMIAL C. DIFFICILE COLONIZATION A Prospective Study

122 patients underlying clean non-GI surgery (herniorraphy, splenectomy, ortho reconstruction…) 3% positive C. difficile culture preoperatively Postoperative positive, by prophylactic regimen:

Cephalosporin 23%

Cefoxitin

1%14%25%

Cefazolin 11441425%14%3%

%

Cefotetan 525% Ceftriaxone 25%

Cefoperazone 44%

Mezlocillin 3%

Privitero et al, AAC 35:208,1991

The Surgical Infection Prevention (SIP) and Surgical Care improvement Project (SCIP): National Initiatives to imporve the

Outcomes of Patients Having SurgeryCID 2006; 42: 322-30.

3 INDICATORS FOR SSI

Antibiotics administered within 60mins

Antibiotic selectionAntibiotic stopped

within 24h

Quality IndicatorsNational Surgical Infection Prevention

ProjectQuality Indicator #3

Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

Numerator statement: no. of patients who prophylactic antibiotics were discontinued within 24h of surgery end time (48h for cardiac surgery)

Denominator statement: All selected surgical patients with no evidence of prior infection

Impact of Prolonged Antibiotic Prophylaxis

2,641 CABG patientsGrp 1 - < 48 hours of antibioticsGrp 2 - > 48 hours of antibiotics

SSI RatesGrp 1 - 8.7% (131/1502)Grp 2 - 8.8 % (100/1139)

Antibiotic resistant pathogen - Grp 2Odds Ratio 1.6 (95% CI: 1.1-2.6)

Harbarth S, et al. Circulation. 2000.

How do we communicate what we would like NHS Boards to do & also hear from them what they would like us to do?

SAPG Communication

Road show about SAPG programme

Developing an SAPG website within SMC website to communicate and share information, recommendations and good practice

Inform the development and monitoring of national antibiotic prescribing indicators

Setting up of extra-nets: SNAP-CAP, CDAD, ? Surgical prophylaxis

Regular AMT network in Stirling: 3/3/09; 2/6/09 & 29/9/09

SAPG

Chair (DN)Project Manager (JS)Project administratorPharmaceutical

advisor (BM)AMR (CW)QIS (PC) Work-stream leads

(AS, MB-AE, LG, JW)

Steering Group (SMC, AMT, Dental, Vet, Medical School, Patient Group Representative, CEO, MD, Industry, ID, Microbiology, SIRN, Pharmacy, General Practice, Nursing, Patient Safety Alliance, SGHD

Co-opted experts in work-streams