Commonwealth Pharmacists Association (CPA)

Provide a brief overview of your project?

The Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) is a pioneering project run by Tropical Health Education Trust (THET) and Commonwealth Pharmacists Association (CPA).  It is funded by the UK Government Department of Health and Social Care’s Fleming Fund.

CwPAMS aims to build antimicrobial stewardship (AMS) capacity by sharing skills and knowledge, bringing together multidisciplinary teams from the NHS and hospitals in four Commonwealth countries: Ghana, Tanzania, Uganda and Zambia.  These teams will be led by pharmacists as medicines experts within the multidisciplinary team.

CwPAMS focuses on:
• Antimicrobial stewardship, including surveillance
• Infection prevention control
• Antimicrobial pharmacy expertise and capacity

The programme will share knowledge between teams of volunteers including/led by NHS pharmacists through partnerships with local healthcare workers in these countries to support AMS initiatives to tackle AMR.  The partnerships will improve surveillance of antimicrobial consumption; take measures to reduce infection; and put in steps to ensure antimicrobials are used appropriately.  Each team will tailor its approach to the hospital where it is working to ensure that each project responds to the specific local needs.

One crucial aspect across all projects is improving the monitoring of antimicrobial consumption, using Global Point Prevalence Survey (PPS) methodology. Currently only hospitals in two of the four countries have participated in this initiative, highlighting how key the impact of this programme could be through embedding surveillance capabilities. This will ensure that healthcare professionals can make informed decisions on where to focus efforts to reduce unnecessary use of antimicrobials and assess the impacts that initiatives are having.

The programme also encourages bi-directional learning, allowing the volunteers to develop skills including:
• Improved leadership capacity
• Improved understanding of digital technology in health
• Greater understanding and experience of working with limited resources; appreciation of the cost of resources and insights into frugal innovation to bring back to the NHS

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. 12 partnerships selected
   The project has now started and 12 partnerships between the NHS and hospitals in these four LMICs have been chosen to be funded; five of these are completely new partnerships. These new partnerships have developed new international links and discussion of ‘similar but different’ complex challenges around AMR and new links between UK hospital and university departments to co-apply for funding.2. Publicity and engagement
   Launching the scheme has led to greater awareness about AMR and the need for AMS in LMICs. Five launch events were held across the country and we also held webinar.  Other publicity includes:
   • Podcast with Pharmacy in Practice
   • Article in the Guardian Supplement on LMIC AMS
   • RPS blog ‘Putting antimicrobial stewardship in a global context’
   • Article in the Pharmaceutical Journal with quotes from Dame Sally Davies and Keith Ridge, Chief Pharmaceutical Officer for England

   Dame Sally Davies, Chief Medical Officer for England, spoke about this project at the RPS Science and Research Summit, highlighting the importance of building capacity to tackle AMR through AMS initiatives and skills sharing, which are key to this project.

   We have shared press releases with all the partnerships and have already heard that through raising the profile of AMS, the Ugandan government has recently disbanded 15,000 people who were selling antimicrobials door-to-door.

   3.  Enhancing knowledge on AMR in a global context
   CPA shared an international handbook of resources on AMS, antimicrobial prescribing and access to expert documents.

   UK applicants attended a training weekend, which facilitated further networking and knowledge sharing between teams. This covered behaviour change, AMS in LMICs, using data collections tools to assess elements of AMS, international partnership principles, how to conduct Global PPS and case study examples.

   The resources have also been added to a networking platform to allow volunteers to share expertise between the projects.

How is the project to be developed in the future?

The countries in this initiative were chosen due to existing Fleming Fund, THET and CPA ties.  The partners are now going to be deployed to start project work; throughout the 15 month programme these 12 projects will be evaluated to show the impact of these interventions and AMS capacity building using tools provided by the CPA and THET.

Once these projects have shown proof of concept it is envisaged that the programme will be expanded into other Commonwealth countries.  Other countries such as Nigeria have already shown interest in running similar programmes.

East and North Herts CCG

Provide a brief overview of your project?

The need for a dedicated project to reduce antimicrobial prescribing was identified in September 2016 when the total antimicrobial prescribing across East and North Herts CCG was 1.162 items per STAR-PU. This exceeded the limit outlined in the NHSE Quality Premium (QP – defined as equal to or below the England 2013/14 mean performance of 1.161 items per STAR-PU). As of January 2017, 17 (30%) of 58 individual GP practices across the CCG were above the QP threshold. This relative high total antibiotic prescribing rate across the organisation was a consequence of an average 4.3% rise in prescribing in the 12 months since January 2016.

The project involved enhanced antimicrobial stewardship (AMS) in the 20 practices with the highest rate of total antimicrobial prescribing in the CCG. Two behavioural interventions were used support AMS in these practices – an evidenced based ‘nudge’, along with a more traditional prescribing audit.

The ‘nudge’ was based on an American study which showed that displaying a poster-sized commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control1. As in this study, the signed pledge (see appendix) was displayed in each consulting room of the identified practices.

The audit required a named individual (a so called ‘antimicrobial stewardship lead’) from each practice to be responsible for undertaking the audit and it would detail the number of acute antimicrobial items authorised each month by individual prescribers within the practice. The data would be emailed back to the antimicrobial prescribing lead in the CCG as well as disseminated amongst prescribers within the practice to allow for peer comparison of prescribing rates in the practice. Benchmarking in this way has been shown to reduce the rate of inappropriate antibiotic prescribing specifically for acute respiratory tract infections in primary care

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Total antibiotic prescribing in the targeted practices fell 12% in the 12 months following the AMS intervention which started January 2017. This compared to a 4.3.4% rise in prescribing in these same practices prior to the intervention.

Total antibiotic prescribing across the CCG fell 7.7% from Jan 2017 to Jan 2018. This compares to a 5% reduction in total antibiotic prescribing across all CCGs in England over the same time.

A single practice (1%) across the CCG had total antibiotic prescribing above the QP ceiling in March 2018 compared to 17 practices (30%) in January 2017

How is the project to be developed in the future?

Rolling plan to target high prescribing practices by looking at quarterly trends in total antibiotic prescribing at individual practice level.

Kettering General Hospital

Provide a brief overview of your project?

Implementing pharmacy support for code for restricted antibiotics:
At KGH we implemented a code system for meropenem in November 2015 following an audit that showed only 65% of use was authorised by microbiology. Following the introduction of meropenem as first line for sepsis in July 2016, there was a sustained increase in meropenem use. Microbiology expressed a concern due to lack of capacity to continue the code system in October 2018. The antimicrobial pharmacy team volunteered to support microbiology with this workload (antimicrobial pharmacist and antimicrobial specialist technician) and the advice below was communicated to all ward teams.
For meropenem approval:
During working hours Mon-Fri 9-5pm, phone the antibiotic pharmacy team, ext 2577 or bleep 253, with the following information:

•           Is the patient penicillin allergic?
•           What is the source of infection or indication for antibiotic
•           Information on CRP, WCC and temperature trend
•           Blood results eg UEs
•           Differential diagnoses
•           Recent antibiotic history
•           Previous HCAI history including MRSA and C difficile
•           Medication history

The team will either:
•           Recommend an alternative antibiotic from the guidelines/sensitivity information
•           Give a code- for a relevant duration
•           Recommend contacting microbiology for further discussion

Out of hours there is no code system, pharmacy will supply enough meropenem for the patient until working hours.

If you require urgent microbiology advice on a patient out of hours, please contact the on-call microbiologist as per current system.

Data:
From week commencing 26th November 2018 to end of February, the antimicrobial pharmacy team have taken 249 calls, given codes for 145 patients and offered alternatives to 104 patients. The number of patients needing referral to microbiology is minimal (approximately 5 per week). Microbiology have continued to receive calls at a more manageable level. The antimicrobial pharmacist and microbiologists record advice given on telepath ensuring continuity.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Outcomes:
We have seen a reduction in the number of patients prescribed meropenem and a sustained level of meropenem consumption even accounting for winter pressures. The number of patients with documented approval on telepath has risen to >90%, those without approval are followed up by the antimicrobial technician several times a week. We are currently achieving a >2% reduction on carbapenem consumption compared to 2017/2018. There has been improved patient safety through implementation of an approval proforma with the interaction of sodium valproate and renal function being considered as part of standard questioning.

This service has not shown an increase in the use of meropenem and patient safety with regards to interactions and renal function has been improved. .

How is the project to be developed in the future?

Further analysis of outcomes for example mortality rates and re-admissions can be calculated. If these rates are not significantly different, this service could be rolled out to other antibiotics in the WHO reserved category and/or antifungals.

Mid Essex Hospital Services NHS Trust

Provide a brief overview of your project?

An innovative new method of Antimicrobial Stewardship based on behavioural change using psychology graduates. Two antimicrobial stewards perform weekly point prevalence surveys on 20 wards at a 582 bed District General Hospital, collecting data on an average of 500 prescriptions per month. Once data is collected stewards compare prescriptions to local prescribing guidelines and discuss non-compliant regimens with clinical teams. Using a Socratic style of questioning, clinicians are given the opportunity to reach their own conclusions creating cognitive dissonance to encourage compliant prescribing. Data collected also highlights patterns of behaviour, whether within a team or with regards to a specific infection, allowing targeted feedback sessions with clinical teams. Stewards also explore barriers to compliance with guidelines, such as prescribing etiquette, uncertainty avoidance and motivation to use antimicrobial prescribing guidelines app, and take steps to address these.

This project uses minimal resources due to a flexible team and adaptable intervention, allowing the Consultant Microbiologists to have oversight on Antimicrobial Stewardship in a setting with significant Pharmacy vacancies and only two WTE Microbiologists. The Antimicrobial Stewards have been well received and integrated into ward based care, with antimicrobial stewardship embedded into practice being praised in a recent CQC inspection.

The Trust and local CCG have identified the value of this project and shown interest in expanding the model into new areas.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1) We have observed am 11.31% decrease in DDDs/1000 admissions over the 6 month duration of the Antimicrobial Stewardship Program (July-December 2018) and a 22.23% decrease in DDDs/1000  from December 2017 to December 2018 (data obtained from Refine).

2) We also observed an increase in compliance to antimicrobial prescribing guidelines Trust wide from 79% – 85% (r = 0.81 (p = 0.097), with significant increases in surgical specialties (General surgery: 61% – 83% (r = 0.95 (p < 0.05); Burns & Plastics: 50% – 75% (r = 0.94 (p < 0.05)).

3) Using the COM-B system’s framework for understanding behaviour we have addressed Junior Doctor’s obstacles to using the antimicrobial prescribing guidelines app using a combination of teaching sessions, awareness campaigns and adaption of the guidelines themselves.

How is the project to be developed in the future?

Initially we will continue work to ensure the Trust meets CQUIN targets relating to Antimicrobial Stewardship. We hope to publish our results soon then share our methodology with other Trusts and CCGs. We also hope to expand the behavioural intervention to address diagnostic stewardship: specifically addressing the tendency of clinicians to treat a working diagnosis with broad spectrum antibiotics rather than making a specific diagnosis that can be treated with narrower spectrum antibiotics.

NHS Lanarkshire

Provide a brief overview of your project?

Within the Hospital at Night team in NHS Lanarkshire, there was wide variation of antibiotic prescribing by the group of Advanced Nurse Practitioners.  A team approach was utilised between the ANP/s and Pharmacy Antimicrobial Lead to adopt a Quality improvement approach to improve practice and reduce variability. An initial audit was conducted of current practice within the team. To clarify fact – a measurement of current practice was taken against the national audit tool for antibiotic prescribing. This showed the all prescriptions were appropriate to be commenced. However there were many cases where practitioners prescribed only 1 dose and awaited further medical review by patients own tea  to decide if Antibiotic was to continue. On many occasions, the prescription of antibiotics  was delayed until medical review (despite a full ANP review having already taken place) It became clear that the confidence was the biggest obstacle. We actively sought feedback from our medical colleagues to ascertain if they had any concerns about  drug choice when antibiotics were prescribed . we feed these back with the results of the national audit to staff. Furthermore, education was delivered in the form of a power-point presentation and also the NES Antimicrobial Module. Following this, the staff were asked to complete a post questionnaire. The results are summarised below.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Following the intervention,  there were no delays in patients being prescribed Antibiotics awaiting medical review. The ANP prescribed the appropriate Antibiotic at the correct time for the patient.
The ANP confidence pre intervention ranged form no confidence to some confidence (1-3) and post this increased to little confidence to very confident (2-5) with the majority scoring from confident to very confident (3-5).
This increased confidence empowered the ANP to decide whether to prescribe or not  , conscious of the need for antimicrobial stewardship.
Single dosing was no longer an issue with all the ANPs identifying a change in practice to prescribing a course of Antibiotics rather than a one of dose awaiting medical review. This reduced the risk of missed dosing or incomplete dosing regimes.

How is the project to be developed in the future?

The plan to role this same improvement process out across the two sister DGH within the trust.
Building upon this, the plan is to undertake planned review for those patients prescribed Antibiotics by the team to ensure that an ongoing management plan is in place and decisions to address IVOST and termination of therapy are considered within the clinical context of the patient.

Pennine Acute Hospitals NHS Trust and Masanga Hospital, Sierra Leone

Provide a brief overview of your project?

Whilst volunteering in Sierra Leone, myself and a medical student, Ian Bugg, designed and implemented a quality improvement project on improving antimicrobial stewardship by formalising prescribing practices.

Sierra Leone has suffered over the past three decades from a prolonged civil war and then from an epidemic of Ebola, and this is reflected in its healthcare system, regarded as one of the least developed in the world.

Antibiotic stewardship in low-income and middle-in- come countries (LMICs) faces even more challenges than in the developed world and yet there is a comparative paucity of data on the appropriateness of antibiotic use in LMICs, in fact we believe our project to be unique in the literature.

We wrote an entire 15-page antimicrobial guideline using a variety of sources, including international guidelines, internet sources and discussions with Consultant Microbiologists. These guidelines were specific to the local setting based around drug availability and cost. The advantage of a written guideline is that it is more sustainable than relying on the knowledge of short-term international volunteers.

At baseline, 57 of 66 (86%) of patients were prescribed at least one antimicrobial. There were 243 prescriptions with 161 (66%) of the choices deemed appropriate and 86 (35%) of those had the correct drug, dose and course-length.

After introduction of our guidelines this increased to 85% appropriate antimicrobials with 53% of those fully correct, although these results had degraded slightly on re-audit a few months later.

We are aware that the prize is likely for work in the UK but given we are both UK healthcare professionals and also the unique nature of our project in an area of supreme need, we hope you would consider our work for these awards.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

As stated above, after introduction of our guidelines this appropriate antibioitc prescribing increased to 85% correct choice of antimicrobial with 53% of those fully correct (dose and course length), although these results had degraded slightly on re-audit a few months later.

During the project we had several small-group or one-to-one teaching sessions with national staff about their antibiotic prescribing practices. We used this to encourage them to think about the accuracy of their diagnoses (for example, 30% of patients were treated for a single diagnosis, typhoid fever, a fact they had no insight into) and prescribing. They were also given a printed copy of the guideline to take to review and keep in their OPD consultation room to examine whenever required. A soft copy was also added to the computer in the seminar room and the staff were encouraged to download it onto their devices for portability.

A copy of the surgical prophylaxis section was also printed, highlighted and placed in a plastic wallet in theatres on the wall by the table where the surgeons congregated. It is hoped that this reminded the surgical team to think carefully about antibiotic prophylaxis, although this study did not collect data to examine this.

Our project has been published and can be found at https://bmjopenquality.bmj.com/content/7/4/e000495.info

How is the project to be developed in the future?

In the short-term we hope that future volunteers this summer will re-audit this work to look at its long term impact.
In the more medium- to long-term we hope to design a teaching syllabus on antimicrobial stewardship for the national staff.
There is also a grant proposal in place for funding for a microbiology laboratory to be able to test for drug resistance in vitro.

SpaMedica

Provide a brief overview of your project?

Cataract surgery is the most commonly performed elective procedure in the NHS (approximately 330,000 operations a year) and the number of operations are expected to increase dramatically over the next 10 years due to increasing life expectancy.  SpaMedica is the largest provider of cataract surgery in England.

The evidence suggests that topical antibiotics have no impact on the prevention of severe eye infections (endophthalmitis) following cataract surgery, however, this is still standard practice.

In September 2018 we stopped giving topical antibiotic prophylaxis following routine cataract surgery.  We have performed over 12,000 cataract operations between September 2018 and February 2019, we have had no cases of endophthalmitis/infection.  Furthermore, we have reduced the number of calls to our telephone helpline in relation to gritty/sensitive eyes following surgery (this was most likely due to antibiotics we previously used).
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

This is the largest UK study to demonstrate that topical antibiotics are not necessary for routine cataract surgery.  If this was adapted by all NHS providers, there would be a significant reduction in the amount of unnecessary antibiotics prescribed (330,000 cataract operations performed each year currently).  This would have a significant impact on AMR, particularly as our cohort of patients (elderly with multiple co-morbidity) are at increased risk of AMR infections.

How is the project to be developed in the future?

We have stopped using topical antibiotics for all our routine cataract operations, we have submitted this research to the European Society of Ophthalmology Conference and plan to publish and disseminate our findings to the Ophthalmology Community.  We would like this to be standard practice for all routine cataract surgery in the United Kingdom.

Synergy Farm Health

Provide a brief overview of your project?

We are a large farm animal only practice in the South West, responsible for over 48,000 dairy cows and 50,000 breeding ewes who has championed reducing antibiotics across multiple sectors. Since 2013 we have been using antibiotic benchmarking for dairy and sheep business to facilitate discussing regarding antibiotic usage on farm (both High Priority Critically Important Antibiotics HP-CIAs and non- critically important antibiotics) and targeting reduced and rationalised usage through preventative veterinary health.

We developed an electronic tool to benchmark businesses with similar production levels, business sizes, organic vs. conventional and holding type which is taken to all health planning visits to facilitate discussion. This was initiated prior to the compulsory requirement by Red Tractor in 2018 with the ethos “you can’t manage what you don’t measure” and “higher health reduces antibiotic usage and improves performance”.

Our approach has required a whole team approach which was propagated by internal training meetings and collaboration from our senior purchasing team through to the veterinary surgeons, dispensing team and veterinary technicians. Our approach has been evidence based and contributing to ongoing research projects has been a crucial part of our broader willingness to advance farm animal medicine (Hyde et al., 2017, Davies et al., 2017).

Achieving reduction initially focused on extensive training of farmers in skills including on-farm culture of mastitis to reduce treatments delivered to animals likely to self cure e.g. E coli mastitis; neonatal lamb post-mortems to facilitate engagement with #everylambcounts and #colostrumisgold and therefore reducing oral antibiotic prophylaxis in lambs; and Safe use of Medicines courses including species specific courses. As of 2018 we also began to deliver MilkSure® through BCVA. Fundamentally we have sought to build the confidence of our clients in preventative strategies including vaccination, diagnostics and monitoring to reduce their usage of antibiotics on farm.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

DAIRY: In the past five years we have reduced overall usage in this sector 32.1% reduction in mean adult cow calculated courses and a 3.5% reduction in mean youngstock cow calculated courses. In addition prior to the compulsory removal 2018 removal of HP-CIAs, we had already achieved a reduction of 80% in mean adult HP-CIA’s across our dairy herds.  Adult Cow Calculated Courses have decreased significantly in consecutive years.

SHEEP:  Our current practice average mg/PCU is 6.7mg/PCU is 41% below the 2017 national average (of Davies et al., 2017 of 11.4mg/PCU) and ahead of the RUMA reduction targets. Additionally, in 2018 we reduced our oral antibiotic sales for lambs by 42% despite the worst spring in recent seasons whilst maintaining lamb survival which we also benchmark. We have already therefore exceeded the RUMA target of 10% reduction by 2021. We continue not to use HP-CIAs in our sheep flocks. Additionally we have presented our work at the Dairy Sheep and Goat Conference (2018), Sheep Veterinary Society (2017) and BCVA (2017).

TRAINING AND EDUCATION: Over 350 farmers have attended courses in the past two years with 45 on Safe Use of Medicines (Bovine ), 38 on Safe Use of Medicines (Sheep), 44 on Milksure and 51 on lameness management courses for dairy cattle. In addition we have run multiple clinical clubs (internal training for veterinary surgeons) for our 30 practitioners. We continue to contribute to ongoing research work the University of Liverpool, University of Edinburgh, University of Nottingham and the University of Bristol.

How is the project to be developed in the future?

We continue to champion reducing antibiotic and as our understanding and global application of metrics evolves we anticipate refinement of our antibiotics reports. We aspire that there will be further integration and emphasis of these reviews within the context of the Herd Health plan and annual and regular farm reviews
Our specific targets include ongoing work with youngstock and the beef sector with an ongoing project to further analyse and benchmark our antibiotic usage with our national integrated beef chain calf rearing client.
We believe our role in research as large practice is important and that our responsibilities extend beyond the frontiers of our practice given our pride in what our farmers continue to achieve. We are involved with a research project in conjunction with RAU Cirencester to develop alternative approaches to oral antibiotic feeding in calves looking at calf selection, immune bio-markers and improved management practices.
As ever, our clients are farmers in the South West are fundamental to uptake of research and these strategies. Our clients have been receptive to our recommendations and the achievements we have outlined are a testimony to vision, responsibility and team work of both our vets and our farmers

Wirral University Teaching Hospitals

Provide a brief overview of your project?

It was identified through audit that the indication for antibiotic use was documented within the electronic patient notes but not on the prescription. This is a recommendation of Start Smart then Focus. Additionally antibiotic reviews were not always undertaken within 72 hours of antibiotic initiation and documentation was poor leading to a lack of assurance that all available clinical results, eg microscopy, culture and sensitivity (M,C&S) results were being utilised appropriately.
Groups of clinicians were consulted and indicated that;
• They were not always aware an antibiotic review was due or assumed someone else had undertaken it.
• M,C&S results are returned in the electronic laboratory system under that date they were ordered and they were not aware they had been returned to view.
• Junior colleagues were reticent to stop antibiotic initiated by seniors incase they had ‘missed’ the rationale for the initiation.
These comments formed the basis for the development of the electronic stewardship tool. The tool mandates the documentation of antibiotic indication on each prescription and, for ease, provides a ‘favourites’ list which mimics the terminology utilised in the Trustwide antibiotic formulary.
Clinicians are prompted to undertake antibiotic review by an alert that fires 24 hours after antibiotic initiation and remains within the patient specific task list as an outstanding task until completed.
The antibiotic, indication, full prescription including duration and any M,C&S cultures ordered or associated results are all able to be viewed on the same page as the template. This ensures that they are all seen as part of the review.  An additional benefit of the template is it provides a structured documentation of the review and prompts clinicians to consider aspects they may have forgotten.
The review tool has recently been refined in response to feedback from pilot wards and is now ready for implementation.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

The electronic template will have the following impact.
1. Increase in reviews undertaken in a timely fashion
Clinicians are prompted to undertake antibiotic review by an alert that fires 24 hours after antibiotic initiation and remains within the patient specific task list as an outstanding task until completed. The colour of the font changes from green (<48hours after initiation), to amber (49-72 hours) and then red (>72hours). This was developed as feedback from clinicians was that they were not always aware of the need to undertake the antibiotic review.
2. Improvement in antibiotic review quality.
The electronic stewardship package mandates documentation of antibiotic indication at the time of prescribing which empowers clinicians undertaking the review to stop the antibiotic if the initial infective diagnosis has been ruled out.
All outstanding orders and results from specimens sent for microscopy, culture and sensitivity can also be viewed on the antibiotic review template alongside the antibiotic and its documented indication for use. This was in response to clinician feedback that they were not previously aware there were new M,C&S results to review as they were returned in the lab system under the date on which they were ordered.
These changes have increased the recording of antibiotic indication on prescription from 0% to >95% Trustwide and the documentation of M,C&S results as part of antibiotic review from 33% (Feb 2018) of those available at the time of review to 72% (Nov 2018). This indicates that culture results are being utilised as part of the antibiotic review which should enable targeted antibiotic use.
3. All antibiotic templates completed since admission can be viewed which gives an overarching picture of antibiotic use for complex patients as a timeline. This enables treatment plans to be devised more easily without the need to interrogate past patient notes.

How is the project to be developed in the future?

Documentation of antibiotic indication is mandatory and thus fully embedded into practice Trustwide. The review template has been refined in response to clinician feedback on pilot and the next step is a Trustwide engagement programme led by the ward based antimicrobial stewardship team to ensure its use as part of each antibiotic review.
Currently the completed antibiotic review template can be viewed on the stewardship tab within the electronic prescribing and noting system but does not pull into the clinical medical notes. This has been accepted within the next phase of development.
The addition of antifungals to the list of agents which automatically triggers the electronic stewardship package will promote and enable antifungal stewardship, an area in which the Trust needs to develop.
The long term vision for the package would be that clinicians ‘prescribe’ a condition rather than an antibiotic. This ‘prescription’ would electronically order appropriate specimens for microscopy, culture and sensitivity, add a task to the nurses’ task list to collect and send these, give the prescriber options for treatment as per the formulary, including options for common allergies whilst allowing them to appropriately deviate from the formulary where necessary but with a mandatory field for the rationale for this deviation. This is still some years off delivery as it requires much developer time.

ABP UK (Commended - Antibiotic Guardian Awards 2018)

Provide a brief overview of your project:

At ABP Blade Farming, we understand that our farmer suppliers provide the raw materials that drive our business. As such, we’re dedicated to nurturing our farmer relationships. Blade are promoting the responsible use of antibiotics within our owned farming operations. This demonstrates how we are fulfilling our commitments to promote responsible use of antibiotics while not compromising animal welfare. We are educating our staff, and measuring and monitoring antibiotic use across the beef sector.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

1. We have successfully measured lifetime antimicrobial usage across our Blade Farming operation. This consists of 36 Calf rearing units and 10 Finishing units. This has allowed us to calculate lifetime mg/PCU figures for each animal as well as annual mg/PCU, mg/KG and DDD figures per farm.
2. All Blade calf rearers and managers attended a veterinary-led workshop on antimicrobial resistance and how we can be responsible with our use, understanding classifications of different antimicrobials, improving herd management and using alternatives as a first line of defence such as calf jackets or vaccinations. Blade Farming rearers have also been educated in how to ensure strict biosecurity protocols on farm to prevent the spread of disease between pens of animals or from one farm to another.
3. Utilising technology in our calf rearing units has enabled ABP to ensure we create the optimum environment for calves and to detect early onset of disease. Environmental monitors and weather stations are used to measure and monitor environmental conditions, allowing our calf rearing mangers to adapt the shed to changing conditions to maintain a consistent environment. Automatic milk machines enable detection of early signs of disease, such as loss of appetite or change in drink speed. Automatic weigh plates give accurate daily weights allowing correct dosage of any antibiotics that must be used. And we are currently working with other industry members trialling pedometers to try and detect the onset of disease earlier on in its lifecycle.

How is the project to be developed in the future?:

• Incorporating on farm diagnostic tools in our health protocols to enable faster and more accurate diagnoses of illness and disease in calves. This will allow more accurate treatment with antibiotics rather than a more broad-brush approach. Detecting onset of disease earlier will ultimately create a faster reaction time to treat any sick animals so hopefully reducing the spread.
• We are also looking at automatic calibrated vaccine guns that are linked to our EID Weighing crates that talk to one another and it is able to calibrate weight to drug usage to ensure each animal has the exact amount of vaccine required.
• Continued work with our Veterinary Partners Westpoint Vets to review and improve our health protocols, and stay up to date with alternative treatment options. We have also partnered with VetIMPRESS to trial and develop their medicine book app that allows live reporting of mg/PCU figures as well as more detailed information on individual animal health.

Heart of England NHS FT

Provide a brief overview of your project:

Heart of England NHS FT (HEFT) is a three-site trust serving a large population with regional specialities in haematology/oncology and cystic fibrosis. These specialities place a huge demand on the use of broad spectrum antibiotics.

At HEFT there has been an active multi-faceted campaign over the last 3 years to deliver a reduction in the consumption of broad spectrum antibiotics such as piperacillin/tazobactam and carbapenems. The messages of appropriate use have been delivered throughout the year in multiple formats and reinforced as part of the World Antibiotic Awareness Week (WAAW) and the national Antibiotic Guardian Campaign in November 2017.

NHS England launched a national CQUIN in 2016-17 to stimulate a reduction in use of carbapenems which has continued through to 2017-18. At HEFT we have succeeded in delivering these targets despite the numerous antibiotic shortages that have increased the pressure to use carbapenems.

Since January 2013 HEFT has delivered a reduction in use of carbapenems from 521 DDD’s/1000 admissions to 291 DDD’s/1000 admissions. This has been achieved through innovative practice and a genuine multi-disciplinary team effort involving communications team, infection control, microbiology as well partners from the Clinical Commissioning Group and Aston University.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

The last 12 months we have sought to engage and spread the messages of antibiotic resistance and protection of antibiotics through social media. To continue the good work planned by a colleague (and previous winner of Antibiotic Guardian Award) who sadly passed away unexpectedly a unique hashtag was promoted; #Doit4Das. This allowed us to track the profile of our campaign and reinforce the messages to use broad spectrum antibiotics responsibly. Between 31st October 2017 and 8th December, there were 151 unique Twitter users who tagged their tweets with #Doit4Das, with an excess of 1500 tweets and re-tweets.

Technology was used to aid the identification of patients on carbapenems. An innovative dashboard was developed using data from the Electronic Prescribing (EP) system. This allowed the infection specialist to identify and review patients on carbapenem antibiotics as soon as they were admitted onto an inpatient ward area. This timely review ensured patients who were prescribed carbapenems were on them appropriately and advice to patients/nursing staff/ patients reinforced. Advice given for these patients was logged electronically which is available for all clinical staff to view.

Face-to-face ward rounds, education and stands were used to promote the work to reduce the usage of carbapenems.  Stalls were set up in areas around the hospital with a high footfall, and a series of pamphlets were given to staff and patients highlighting antibiotic resistance. A new smartphone app and intranet portal for hosting the antibiotic guidelines were also launched during WAAW to ensure prescribers were selecting appropriate therapy. The stands were run by microbiologists, pharmacists and infection control nurses. The campaign also involved community antibiotic pharmacy leads, as well as students from the University of Aston, who helped with stands. Antibiotic awareness t-shirts were worn to promote the messages, and all the photos of pledges and activities were published on twitter with the hashtag #Doit4Das.

How is the project to be developed in the future?:

We aim to continue to reduce the prescribing of carbapenems through the following actions:

1. Monitoring and real-time feedback of consumption data as measured in DDD’s
2. Targeting hotspots of high consumption such as haematology and cystic fibrosis
3. Continued engagement with clinical staff including independent non-medical prescribers as well as senior prescribers in emergency department. Aim to provider greater granularity of data e.g. deliver prescriber specific data
4. On-going campaign of antimicrobial stewardship with increased activity during WAAW and annual promotion of #Doit4Das.

Hospital Serdang, Malaysia

Provide a brief overview of your project:

Title: Promoting rational antimicrobial prescribing at Cardiology Centre Serdang Hospital, Malaysia

Background:

Improper prescribing and excess antimicrobial contributes to resistance. Introduction of electronic antimicrobial prescribing and other strategies supports the initiatives of Antimicrobial Stewardship Committee (AMS) in promoting rational antimicrobial use.

Method:

A cross sectional study from year 2014 to 2017 to evaluate the impact of antimicrobial usage, resistance rate of multi-resistant organism (MRO) following application and indirectly on costing spent on antimicrobial.

Results:

Total costs spent on antimicrobials reduced tremendously and cost saving of RM 231,221.18 (2014 vs. 2015) by limiting durations via electronic prescribing. This cost saving continued around RM 200,000 every year (2016 vs. 2017). Defined Daily Dose (DDD) for antimicrobials demonstrated decreasing trend from year 2015 to 2017. For DDD per 1000 patient’s days of Colisthemethate and Polymyxin B, reduced from 8.49 to 4.22. Similar pattern showed in number of MRO Acinetobacter baumanii isolates (infection and coloniser) and resistance rate (%) Acinetobacter sp towards sulbactam were reducing trend from 2015-2017. Subsequent enforcement of carbapenem countercheck method, DDD showed decreasing trend from year 2015 to year 2017 respectively (54% and 21%). Demands for AMS team in referral and reviewing cases increased 195% from 2015 to 2017.

Discussion:

An electronic antimicrobial prescribing was introduced in year 2014. Duration of antimicrobial prescribed was restricted from 14 days to 4 days. Preauthorization for Colisthemethate and Polymyxin B were enforced that involves all disciplines starting 2015. Carbapenem restriction was employed to ensure appropriate prescribing via countercheck method. Clinician fill up Carbapenem form manually and ordering must be done through electronic prescribing. Carbapenem were supplied after both methods have been fulfilled. Clinical pathways have been developed with multidisciplinary team approached. Routine rounds for AMS started from 2015 regularly reviewing and discussing cases.

Conclusion:

Different strategies should implemented in promoting appropriates antimicrobial prescribing.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Restrictive antimicrobial duration:

Duration of antimicrobials prescribed was limited to 4 days to ensure justification made whether it’s empirical or prophylaxis treatment. A repeated order shall be made if requires prolonged antimicrobial as definitive based on clinical and cultures proven.  It served as reminders to review the indication of antimicrobial initiation by escalate, deescalate or stopped antimicrobial 4 days after the release of culture and sensitivity results.

Preauthorization of Colisthemethate and Polymyxin B

Clinicians who started Colisthemethate or Polymyxin B required consulting with authorized consultant before initiation.  List of authorized consultant is responsible from each department to authorize and allow clinicians before initiation. It also helps preventing unnecessary treatment being started for example isolates with coloniser or true infections. Judicious use of colisthemethate and polymyxin B shall preserves susceptibilities of polymyxin as it was commonly served as last resort of antibiotics for the treatment of extensive drug-resistant (XDR) Gram negative bacteria. Guidance of indication and dosing regimen of polymyxin were based on recommendations in local guidelines.

Carbapenem Restriction

Carbapenem restriction was employed to ensure appropriate prescribing via countercheck method. Clinician fill up Carbapenem form manually and ordering must be done through electronic prescribing. Supplying carbapenem can be done after both methods have been fulfilled. Pilots study is carried to certain wards from intensive care, medical and surgical. Database of all patients on carbapenem were created and audit on carbapenem use was carried out periodically. The carbapenem form were improvised based. Prevention of emergence of Carbapenem-resistant Enterobacteriaceae can be controlled by using Carbapenem judiciously. Indication and dosing regimen of carbapenem were based on recommendations in local guidelines. All these strategies were to preserve the susceptibilities of carbapenem.

How is the project to be developed in the future?:

This electronic antimicrobial prescribing, preauthorization of Colisthemethate and polymyxin B with carbapenem restriction were cost effective, easy and simple methods which serves as part of AMS strategy in role of decelerate the rate antimicrobial resistance. This method can be applied to other antimicrobials and is suggested to be adopt by all hospitals in Malaysia with electronic prescribing software in order to preserve the antimicrobial use in future.

Kettering General Hospital

Provide a brief overview of your project:

Antimicrobial stewardship principles advocate switching from IV to oral antibiotics promptly when safe to do so.  21% prescriptions for IV antibiotics delivered at home on discharge from KGH were prescribed empirically for cellulitis. Oral linezolid has the same bioavailabilty and antibacterial cover as IV teicoplanin the most commonly used IV antibiotic at home for cellulitis.

The use of teicoplanin in two areas (ambulatory care and at home) cost the trust £22400 annually. An intervention where teicoplanin is actively switched for linezolid was proposed by the antimicrobial pharmacist. This reduces drug spend by £7.30 per day, reduces nursing time, releases capacity for other patients to go home with IV antibiotics and reduces line complications. It is also in alignment with the HoPMOp top ten medicines optimisation targets.

The proposal was agreed with the medical director, chief pharmacist, antibiotic lead, consultant microbiologists and director of infection prevention and control. The antimicrobial team rolled out the pathway and attended relevant meetings and wards to answer questions and improve awareness. The pharmacy team supported use of this pathway at the assessing stage of teicoplanin prescriptions and by checking for interactions with patient’s regular medicines and advising on dose reductions as necessary.

The pathway was implemented in November 2017. The drugs savings and IV days saving have been calculated over the first four months as  £4693 and  643 IV days respectively. A reduction can be seen in the percentage of patients discharged with IV antibiotics for cellulitis. Where teicoplanin has been prescribed, the recorded indication of cellulitis has also fallen.

The implementation of this pathway has been a successful new way of working due to the early support of key stakeholders and the implementation on the ground with support from the antimicrobial and wider pharmacy team.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

This project has several benefits including the following antibiotic stewardship features:

Prompt IV to oral switch in patients that would normally be treated with IV antibiotics.

Reducing line infections therefore reducing further antibiotic prescribing.

Reducing selective resistance pressure to develop glycopeptide resistant enterococci.

Improved capacity for home IV antibiotics where appropriate.

Reducing exposure of patients to other hospital acquired infection as they can be treated at home.

This is a simple intervention that has positive impact on the perception of antimicrobial stewardship and what benefits it can offer to the trust, patients and costs. This has built relationships with the teams involved with increased awareness and buy in to other antimicrobial stewardship priorities. The teams have invited education and training on the wards and there has been an increased request for antimicrobial input on patients from the antimicrobial team.

How is the project to be developed in the future?:

This pathway will continue to be promoted in ambulatory care and instead of IV antibiotics at home where appropriate The pathway can be rolled out across the hospital including A+E. This will prompt doctors to consider  oral antibiotics as part of routine practice and encourage antibiotic review with the IV to oral switch guidelines. This pathway will pave the way for further IV to oral switch initiatives including bone and joint infection on publication of the OVIVA trial.

NHS Tayside – (JM-HK) (Commended - Antibiotic Guardian Awards 2018)

Provide a brief overview of your project:

Multidisciplinary antimicrobial stewardship programmes are essential in optimising antimicrobial use and preventing associated collateral damage. Partnerships between medics and pharmacists are well documented within the literature offering optimal results in stewardship activities. However, the collaboration of a nurse and pharmacist with prescribing abilities and expertise in antimicrobial stewardship is both innovative and unique.

A SOP was developed for the NMP service provision which enabled triage (supporting documents) of patients who would require specialist ID review. The aims of the project were to evaluate the inclusion of non-medical prescribers in gram-negative bacteraemia review by measuring the quality of the NMP clinical decision making skills.

Methodology

Direct comparisons of clinical decision making of the NMPs and infectious disease specialists informed the evaluation of the non-medical prescriber gram-negative bacteraemia using the model in supporting documents.

Results

Within the pilot project, concordance of NMP clinical decision making and prescribing was 86% with 14% of patients requiring specialist ID review.

Conclusion

Through the introduction of the NMPs to gram-negative bacteraemia review, capacity has been released within the current service provision of the Infection specialist team. Additionally, capability of the team will be enhanced as NMP prescribing competence and confidence grow.

The nurse/pharmacist led gram-negative bacteraemia review has provided additional support for prescribers in this area, promoted prudent use of antimicrobials in the treatment of gram negative bacteraemia and provided an opportunity for feedback/education to medical and nursing teams on the use of antimicrobials, the principles of stewardship, the management and prevention of gram-negative bacteraemias and offers a multidisciplinary approach which incorporates the additional aspects of infection prevention and control such as device management.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Increasing the Reach of the AMT

The integration of a nurse /pharmacist into the prescribing team to manage gram-negative bloodstream infections has many benefits and offers a unique and innovative approach to antimicrobial stewardship whilst maximising the existing resource.

The projected rise in AMR infections will impact the available medical infection specialist resource as they will be required to manage an increasingly complex cohort of patients. By incorporating non-medics with infection management knowledge and clinical experience into the multi-disciplinary antimicrobial management team, enables the ID team to focus on the complex cohort of patients that is anticipated whilst supporting and mentoring non-medical team members in the management of uncomplicated infection management, thus building capacity and capability within the wider team.

Integration of Professional Knowledge

Whilst conducting the gram-negative bacteraemia (GNB) review, both the ANP & AAP can incorporate existing professional knowledge and clinical practice to facilitate engagement and provide leadership in action among their respective professions.

The AAP is ideally placed within this partnership to offer support, advice and guidance to ward staff on the optimisation of antimicrobials incorporating specialist knowledge on pharmacokinetic and pharmacodynamic properties and minimising the possibility of drug interactions.

The ANP is also a qualified Infection Control Nurse and can therefore apply this knowledge and skill set whilst reviewing patients with a confirmed GNB such as the requirement for isolation, transmission based precautions and preventative measures.

Optimising Patient Safety

Patient safety is essential within healthcare, therefore aspects of the current Scottish Patient Safety Programme can be incorporated into the review process such as optimising the use of high risk medicines, safe use of peripheral vascular cannulas/central venous catheters (PVC/CVC) and prevention of catheter associated urinary tract infections (CAUTI). The NMPs can provide learning opportunities in the prevention of HAIs to the MDT to minimise GNB incidence.

How is the project to be developed in the future?:

How is the project to be developed in the future?

1.As the initial project was carried out in select wards in one hospital, there is the potential to expand the NMP service to incorporate other wards and acute hospitals within the geographical region.

2. Following a similar process, there is the potential for the NMPs to incorporate the review of gram-positive bacteraemia’s into their service delivery which in turn would generate capacity and capability within the wider ID team.
3. As a standard operating procedure has been developed for the process of NMP GNB bacteraemia review, the service is easily transferable to other health boards and trusts. Discussions have already taken place with one health board who are keen to adopt this process.

NHS Tayside (HS-JM)

Provide a brief overview of your project:

Protected time for care home staff in Angus to attend training was funded from integration monies.  NHS Tayside Antimicrobial Team provided a two hour session on prevention and management of UTI in the older adult.  Follow up sessions consolidated learning and addressed any further learning needs.

One event was held in each of four localities and each care home was offered two places.  Attendance was open to all care homes in the local authority, independent or corporate sectors.  Commitment was sought for cascade training.  The majority of attendees were not trained nurses but were the primary caregivers for their clients.

The training was an interactive session with 8 to 12 participants; and was based on NHS Education for Scotland (NES) “Scottish Reduction in Antimicrobial Prescribing (ScRAP)”.   This toolkit helps support a reduction in unnecessary antibiotic use.  It can be delivered as modules therefore the most appropriate material was selected to match the client group.   Practical activities were also included in the session.  These were based on an algorithm developed by the Scottish Antimicrobial Prescribing Group (SAPG) to guide management of suspected UTI in the elderly.

Sessions were made as interactive as possible with discussion of current processes and understanding as well as case studies and sharing of good practice between the attendees.  The sessions were delivered by the Antimicrobial Pharmacist for Primary Care (HS) and Advanced Nurse Practitioner for Antimicrobial Stewardship (JM). Follow up used semi-structured questions to evaluate learning and changes implemented as a result of the teaching sessions.

Twenty two care homes with 680 beds in total were represented.  A total of 38 staff attended between the four sessions.  Feedback forms were completed by 21 attendees, all of whom rated the session as “very useful”.   The follow up sessions showed extensive learning and implementation in all areas.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Each care home provided an ‘action plan’ for implementation of their training. The detail of these action plans varied slightly but three key strategies were included in each action plan.

1. Prevention of UTI. Although the mainstay of prevention of UTI in the older adult was relatively consistent throughout each action plan i.e. promoting good hydration, avoiding constipation, appropriate infection prevention practices and good toileting practice, care homes implemented this in novel ways. These included information sheets for staff, eye-catching designs for hydration charts which could be used by clients and carers; and the use of red water jugs to highlight residents who require additional support to ensure good hydration.  (Images will be provided)
2. Implementation of SAPG Decision Aid. Copies of the SAPG decision aid were used in the practical sessions and issued for use within the care home. This document helps to guide care home staff through a basic assessment of the patient and appropriate action to consider.  Feedback from staff both in general practice and care homes after implementing this decision aid has been very positive particularly in terms of provision of consistent and useful information between care homes and general practice.  This helps to ensure appropriate assessment of the patient’s symptoms allowing antibiotics to be used prudently.
3. Liaison with Community Nursing. A key learning point within the sessions was the need for catheter change as part of management of caUTI. The majority of attendees at the sessions were unaware of the requirement to change indwelling urinary catheters at the time of diagnosis of caUTI and highlighted that this was not current practice.  This could lead to multi-resistant and repeated infections.  Improved communication with community nursing staff and appropriate catheter management will improve outcomes in caUTI as well as potentially reducing the need for additional antibiotic treatment for unresolving caUTI.

How is the project to be developed in the future?:

Due to the success of this project further developments currently underway include

• Live and recordable webinar based training to allow easy access to training by shift and remote workers. This will also allow consolidation of earlier face to face learning.
• Further face to face training with different topics (considerations include respiratory tract infections or skin and soft tissue infection)
• Roll out to other areas in Tayside (dependent on strategic funding being available to release staff)

Royal Brompton NHS Trust

Provide a brief overview of your project:

There has been an expansion of fungal infections in patients with chronic lung disease over the past decades, which is associated with rapidly increasing costs to healthcare systems.  A corollary of this has been the increasing incidence of antifungal resistance seen amongst clinical isolates.

An antifungal stewardship team was created in our tertiary cardiopulmonary hospital, consisting of a medical mycologist and antimicrobial pharmacist, providing weekly stewardship ward rounds, multidisciplinary team meetings and a dedicated weekly outpatient clinic.  A database was set up to record the activity of the stewardship team and an audit was performed with data on patient demographics, underlying diagnoses, fungal diagnosis, therapeutic drug levels, microbiology, serology, radiology, and advice given.  Calcofluor white fluorescence was used in sputum and bronchoalveolar lavage (BAL) samples.  Laboratory culture was used to identify moulds by morphology, and in-house susceptibility testing was performed, with samples also being sent to the Public Health England Mycology Reference Laboratory.  Aspergillus IgE and IgG, and Aspergillus galactomannan were performed weekly in-house, with β-glucan levels sent to the Reference Laboratory.  Therapeutic drug monitoring (TDM) was also performed in-house for the triazole antifungals. During the first year of implementation the antifungal stewardship team had reviewed 178 patients, with 285 recommendations made to inpatients, and 287 outpatient visits.  There was a significant, sustained reduction in monthly antifungal expenditure and antifungal daily defined doses.  There were no significant changes in expenditure on diagnostic tests.  The reduction in expenditure has largely derived from the reduction of intravenous treatment, which would have the additional benefit of reducing inpatient stays and attendant costs. Mortality outcomes were also considered.

The audit showed that an effective antifungal stewardship programme can significantly reduce expenditure, ensure appropriate antifungal use, improve antifungal tolerance and ensure the fungal disease of patients with chronic lung disease is appropriately managed.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

1.Therapeutic drug monitoring (TDM) was performed in-house for itraconazole, voriconazole, and posaconazole. This was used to tailor antifungal drug dosing to ensure patients with fungal disease were achieving adequate drug levels and prevent dose related side effects.

2. Use of microbiology, serology, radiology to determine criteria for stopping/starting antifungal therapy.
3. MDT working ensured appropriate choice, escalation or de-escalation of antifungal therapy

How is the project to be developed in the future?:

– To expand to further areas-

• Paediatric respiratory patients
• Lung transplantation patients – on long term triazole as prophylaxis. These patients will be on immunosuppressants and are more prone to infections.

-Become a centre to provide support in the management of patients with chronic fungal lung infections.

Royal Free London NHS Foundation Trust

Provide a brief overview of your project:

Over the period 2012-2017 we achieved 3 antibiotic stewardship goals. 1)Reduction in resistance to piperacillin-tazobactam amongst blood isolates for E.coli, Klebsiella spp and Enterobacter spp from 19% to 12%. 2) Reduction in consumption of ertapenem by 58%. 3) Reduction in consumption of piperacillin-tazobactam by 71%. This was achieved by introducing temocillin into the formulary and incorporating it into antibiotic policies. Over this period, resistance amongst blood isolates for E.coli, Klebsiella spp and Enterobacter

spp to ertapenem and temocillin remained largely unchanged (≈1% and

3-4% respectively).

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Increasing heterogeneity of antibiotic prescribing within the Trust formulary

Increasing empiric use of a carbapenem (and piperacillin-tazobactam) sparing agent

Increasing de-escalation from piperacillin-tazobactam and carbapenems to a targeted spectrum agent.

How is the project to be developed in the future?:

Further expansion of this stewardship initiative using other carbapenem and piperacillin-tazobactam sparing agents as more such agents become available.

NHS Leeds North Clinical Commissioning Group

Name: Heather Edmonds, Head of Medicines Management

Provide a brief overview of the project: Audit to improve antibiotic prescribing in primary care.

For the last few years Leeds North CCGs have asked their GP practices to undertake an antibiotic review as part of the prescribing engagement scheme.
The specific aims of the audit are to:-
1. To maintain and/or improve evidence-based and appropriate prescribing of antibiotics across Leeds and compliance with local antibiotic guidance.
2. To reduce the risk of antibiotic resistance and maintain the usefulness of existing agents
3. To reduce the risk of Healthcare Associated Infection (HCAI).
4. To ensure all prescribers can demonstrate they have the necessary competencies to prescribe antibiotics.
5. To implement the NICE guidance NG15 “Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use”.
6. To ensure practices have a process to use and record the use of delayed/back-up prescriptions.
7. To support the patient awareness antibiotic campaign.

The GP practices are asked to review a sample of patients on a monthly basis, covering a different group of antibiotics each month so that all antibiotics are reviewed twice a year. For each patient being reviewed, the indication for antibiotic is reviewed against the guidelines to ensure that the correct antibiotics is being prescribed, at the correct dose, by the correct route for the correct length of course and including any reasons for deviation, this is recorded and submitted to the CCG medicines optimisation team on a quarterly basis.

We also asked all our prescribers to undertake the prescribing competence in, the antibiotic prescribing competencies tool produced by PHE and report the number of prescribers who had completed.

We also asked out GP practices to develop and implement a process within their practice for recording use of back-up /delayed antibiotic scripts.

The medicines optimisation feedback the progress to practices on a monthly basis via our reporting dashboard and the progress for the audits six monthly at our prescribing leads GP meeting.

Please see copy of the audit tool send in the separate email.

List any supporting partners or organisations worked with: Leeds North CCG
GP practices within the Leeds North CCG area
Local Care Direct (out of hour’s provider)
Walk-in centres

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Over the last 3 years there has been a gradual improvement in the compliance with the guidance in all areas, as demonstrated in the graphs (sent via a separate email). Reviewing the patients like this ensures that the guidelines are reviewed and practices are aware of any changes. We have encouraged the GPs to critically review prescribing and reflect on changes that they can make. The drop in trimethoprim prescribing reflects when we made changes to the UTI guidelines.
With regards to delayed/back-up prescriptions, the GPs were quite reluctant to use this approach. However so far this year we have identified 249 occasions where this approach has been used and on at least 29 occasions the patient didn’t get the prescription dispensed. More practices are using delayed/back-up scripts that the previous year.
We have also identified that out of 184 prescribers within our GP practices, that 70% of these prescribers have completed the antibiotic prescribing competencies tool produced by PHE.
This approach has also reduced the amount of antibiotic being prescribed within the Leeds North CCG area. Items/STARPU for 12 months up to Nov 16 was 1.037, which was a reduction compared to the previous 12 months. Please see graphs sent in separate email which demonstrates the continued reduction of both total antibiotics/STARPU and percentage broad spectrum antibiotics of the total antibiotics prescribed.
This seems to be also having an effect on resistance as the average proportion of ‘multi-drug resistant’ E. coli blood specimens from key antimicrobials (gentamicin, ciprofloxacin, piperacillin/tazobactam, 3rd-generation cephalosporins, carbapenems;) by CCG and by Quarter is gradually reducing as shown in the information send via email.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics

• The overall improvement in compliance with the antibiotic guidance, including correct antibiotics, dose, route and duration.
  • The number of prescribers that have completed the antibiotic prescribing competencies
  • The continued reduction of antibiotics being prescribed and the positive effect this is having on resistance.

Key outcomes of project?: The continued improvement in the compliance with guidance, in respect to antibiotic choice, dose, route and duration. This is noticeable with the reduction of trimethoprim use, when we changed the guidance, which does demonstrate this is a good method of checking GPs are aware and implement the guidelines.
That about 70 % of our prescribers have completed the antibiotic prescribing competences and have the basic education to ensure that antibiotics are prescribed appropriately.
More GPs are using delayed /back-up prescriptions as a tool to aid appropriate use of antibiotics and we have demonstrated that not all these prescriptions are dispensed.
Antibiotic prescribing continues to reduce for all antibiotics and that this is having a positive effect on antibiotic resistance

How is the project to be developed in the future?: Each year we review the content of the audit to ensure we support achievement of national measures. This year we have taken some elements out such as the antibiotic prescribing competencies. We have added in some NICE quality standards around testing for UTIs and also added a section around accurate recording of penicillin allergy status and continue to provide education and feedback.
We ensure that all our providers such as out of hour’s providers and walk-in centres also complete this audit and we promote our audit to the other local CCGs.

Click here to find out more about the project

NHS Tayside

Name: Heather Kennedy

Provide a brief overview of the project: Antimicrobial resistance is a major global health problem and as such healthcare professionals should be aware of the basic principles of stewardship in order to retain the effectiveness of our finite resource of currently available antimicrobial agents. Historically the stewardship agenda has always been addressed by a pharmacist or physician and so this project aimed to promote the key concepts of stewardship using a pharmacist and nurse partnership. An antimicrobial /infection ward round was introduced in two surgical wards within an acute teaching hospital with the aim of promoting optimal antimicrobial management, promoting best practice in antimicrobial prescribing, promoting timely de-escalation and creating a multidisciplinary approach to infection management. Surgery was chosen as the clinical specialty due to the high burden of antimicrobial consumption and also the minimal resource available by the ward pharmacist.
The Advanced Nurse Practitioner (ANP) for stewardship along with the Advanced Antimicrobial Pharmacist (AP) attended one consultant led ward round on each ward per week and all interventions and outcomes collated. The primary focus of these ward rounds targeted and encouraged compliance with antimicrobial policy – more specifically indication, route, duration, suitability for IVOST and review of microbiology so as to streamline treatment.
Data was collected over a 6 month period on various parameters including prevalence, compliance, number of interventions and the number of interventions accepted by the clinical teams. Due to the education aspect of our project, it was important to decipher if a change in behaviour had occurred so these two wards were re-audited 4 months after the intervention to determine whether a sustainable change had taken place.

List any supporting partners or organisations worked with: NHS Tayside Antimicrobial Management Team

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? This project highlighted stewardship in a number of ways throughout its course. Compliance with policy is paramount when promoting antimicrobial stewardship within any clinical area. Policies within NHS Tayside are produced in line with national recommendations and highlight agents to be used which will minimise harm and provide the best patient outcome. This project audited compliance and the improvement in compliance over time demonstrating that prudent prescribing was more prevalent after the task. Duration of antimicrobial therapy is another factor which is vitally important when looking at overall consumption and burden of agents within a health board. The review of IV antimicrobials regularly should be engrained into daily practice. Oral antimicrobials should be prescribed for the shortest duration to ensure the patient receives the best outcome but also to address the national agenda of antimicrobial resistance. Again this venture addressed this as documentation of duration was one of the principles audited and education provided. Education and training of ward staff is important to instil sustainable change at ward level. All staff should be aware of the stewardship agenda and how they can impact by rolling out a few key messages within their daily role. Infection control can also be enforced and issues around line care, hand washing and contamination etc can be addressed. By carrying out this project, learning was provided to the clinical teams in real time while discussing the patient’s management. Collaborative working is hugely important to ensure the patient receives optimal care and management. Multi professional working is essential when implementing change to ensure sustainability. This project demonstrated the benefits of a collaborative approach and how the disciplines can work together and share learning to ensure optimal patient care and management. Safer and effective use of medicines is another concept addressed in this project. The AP and ANP provided advice and recommendations around the prescribing of all antimicrobials as it happened. Also advice about future prescribing decisions could be addressed to ensure the patient received the safest and most appropriate treatment plan.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics? The first example which highlights the promotion of the protection of antibiotics is compliance with antimicrobial policy. Within NHS Tayside our antimicrobial policies are regularly reviewed and scrutinised so that all of the high risk c.difficile agents have been removed as first line options. Broad spectrum agents have been replaced with a combination of narrower spectrum to preserve these key drugs for more resistant organisms.
The second example which highlights the promotion of the protection of antibiotics is by ensuring antimicrobials are reviewed and prescribed for an appropriate duration. A key aspect of this project was to ensure that IV antimicrobial agents were reviewed daily as an integral part of the ward round process. Also that oral antimicrobial agents had a documented duration on the medical chart and/or medical notes which was compliant with local and national guidance.
The third example which highlights the promotion of the protection of antibiotics is around the streamlining of treatment and assessing the suitability for IV to oral switch. As part of the project all patients who were on IV therapy were reviewed to see if they were suitable for an oral agent. A combination of empirical agents is appropriate on admission, but it is critical that microbiology is reviewed and treatment is de-escalated accordingly. Within NHS Tayside, guidance exists around eligibility criteria for switching to an oral agent and this was adhered to throughout the audit.

Key outcomes of project?:

Ward A – 124 patients on antimicrobials
Antimicrobial prevalence Compliance with policy No of interventions No of interventions accepted
Overall 31% (124/405) 95% (118/1124) 43 (35% 43/124) 34 (79% 34/43)
26/6-16/9 33% (75/228) 94% (71/75) 36 (53% 36/68) 27 (75% 27/36)
23/9-02/12 28% (49/177) 96% (47/49) 7 (14% 7/49) 7 (100% 7/7)

Ward B – 126 patients on antimicrobials
Antimicrobial prevalence Compliance with policy No of interventions No of interventions accepted
Overall 29% (126/427) 95% (120/126) 41 (32% 41/126) 33 (80% 33/41)
04/7-18/9 32% (72/225) 93% (67/72) 36 (50% 36/72) 28 (77% 28/36)
25/9-27/11 27% (54/202) 98% (53/54) 5 (9% 5/54) 5 (100% 5/5)

The number of interventions made by the AP and ANP between the first and the latter phases in both clinical areas reduced significantly (p <0.0001) demonstrating that a behaviour change had been adopted. Although not statistically significant, the number of interventions accepted by the surgical teams increased in both ward areas. This suggests that over time, the AP and ANP gained credibility and the confidence of the surgical teams.
In both wards it can be shown that over the audit time antimicrobial prevalence is decreasing along with number of interventions. Also compliance with policy is increasing and so these findings highlight the positive impact attending the ward round along with continual education and training had on patient outcomes.

How is the project to be developed in the future?: This project can be further developed in the future by introducing a pharmacist and nurse led ward round in other clinical areas to see if the positive results are repeated in other clinical specialties. Developing a work program for nursing staff to compliment ward round intervention would be hugely beneficial. Liaising with the clinical ward pharmacist so they can continue to educate and integrate themselves into the team while addressing the stewardship agenda.

Birmingham CrossCity CCG

Name: Rakhi Aggarwal

Provide a brief overview of the project? Birmingham CrossCity CCG Antimicrobial Stewardship project has run for the last two years; Key points of the project include:

1. Antibiotic focus in General Practice as part of CCG ACE Foundation initiative: Every practice appointed an Antibiotic Lead and all prescribers undertook CPD module from the TARGET Toolkit. Audit of antibiotic prescribing was carried out by Prescribing Support Pharmacists in collaboration with prescribers. All GP practices were given printed copies of the ‘Antibiotic Guardian’ leaflet and the ‘Treat your infection’ leaflet to use with patients.2. Continued promotion of Pan Birmingham Primary Care Antimicrobial Guidelines and education about antimicrobial resistance and antimicrobial stewardship (see below for methods used – all of which were supported by Dr Das Pillay, Consultant Microbiologist PHE at Heart of England NHS Foundation Trust).• Education events held for:
   1. Medicines Management Team
   2. Practice nurses and nurse prescribers
   3. GPs
   4. Care Homes• A series of prescribing newsletters for primary care prescribers focussed AMR and AMS.• Quarterly ongoing feedback to practices of antimicrobial prescribing to individual practices (items/STARPU and % as ceph/quinolones/co-amoxiclav)• AMS awareness for CCG staff through Team Stand Up presentations.• Community Pharmacy awareness campaign (see below for more detail)• Meetings with out-of-hours providers.3. All GPs, nurses, practice staff, CCG staff and Care home staff were encouraged to become an Antibiotic Guardian.4. Antibiotic Guardian Social media campaign through November 2015 and November 2016, run jointly by the Medicines Management Team and the CCG Communications team – including Facebook, Twitter, local media, CCG website.5. Community pharmacy campaign (Feb 2017). Birmingham CrossCity CCG organised a Public Health community pharmacy campaign promoting AMS. Delivered in collaboration with PH (Birmingham), local NHS Hospital Trusts and Birmingham Local Pharmaceutical Committee. We invited Birmingham South Central CCG and Sandwell and West Birmingham CCG to take part and support the campaign, in order to ensure we covered the whole Birmingham geography. The campaign was one of the six mandatory PH campaigns within the contract and comprised of a launch educational event with resources provided to be used in the following month to promote antimicrobial stewardship in the community. Resources included: A poster; ‘Antibiotic Guardian’ leaflets; Antibiotic Guardian Checklist’ (a reminder of the counselling points when dispensing antibiotics); ‘self-care guide to help treat your infection’, leaflets.

List any supporting partners or organisations worked with: Heart of England NHS Foundation Trust- especially Dr Das Pillay
University Hospitals Birmingham NHS Foundation Trust
Public Health (Birmingham)
Birmingham Local Pharmaceutical Committee
Birmingham South Central CCG
Sandwell and West Birmingham CCG

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Max 400 words: https://fingertips.phe.org.uk/profile/amr-local-indicators/data#page/4/gid/1938133070/pat/46/par/E39000033/ati/19/are/E38000012/iid/92377/age/1/sex/4 shows a 12% decline in total antibiotic prescribing (twelve month rolling total number of prescribed antibiotic items per STAR-PU) from June 2014 to September 2016. This decline was greater than that shown at national level.

https://fingertips.phe.org.uk/profile/amr-local-indicators/data#page/4/gid/1938133070/pat/46/par/E39000033/ati/19/are/E38000012/iid/92350/age/1/sex/4 shows a 48% decline in twelve month rolling percentage of prescribed antibiotic items from cephalosporin, quinolone and co-amoxiclav. This decline was greater than that shown at national level.

https://fingertips.phe.org.uk/profile/amr-local-indicators/data#page/4/gid/1938132929/pat/46/par/E39000033/ati/19/are/E38000012/iid/92350/age/1/sex/4 shows Antibiotic Guardians per 100,000 population per calendar year by CCGs. The highest count in England, with one of the highest rates in our region.

Recognition from PHE for number of healthcare professionals undertaking AMR module from TARGET toolkit http://elearning.rcgp.org.uk/course/info.php?popup=0&id=167 The CCG had 169 responses 6 were nurses, 3 were pharmacists and 160 were GPs. This was in the time frame of 22/12/2014 – 13/06/2016. ( personal communication).

Awaiting feedback from Community Pharmacy campaign, so far 158 out of 354 pharmacies have provided feedback, deadline to provide feedback is 31st March 2017.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics? Max 400 words: 1. Clinical audit carried out in 100% of practices ( appropriate use of PAN Birmingham Primary Care antimicrobial guidelines)
2. Community Pharmacy Campaign: education and promotion of the ‘self-care guide to help treat your infection’, leaflet.
3. Education sessions with variety of healthcare professionals, supported by Consultant Microbiologist.

Key outcomes of project?: – Reduction in total number of prescribed antibiotic items per STAR-PU
– Reduction in percentage of prescribed antibiotic items from cephalosporin, quinolone and co-amoxiclav
– Increase in Antibiotic Guardians
– Educational impact was not measured with any quantifiable tool

How is the project to be developed in the future?: Having provided and resources on general AMR and AMS, this financial year we are focusing on key infection syndromes as these areas were highlighted as those needing further education or resources from the clinical audits which were completed in 2016 in general practice:
UTIs – correct diagnosis (promotion of PHE UTI leaflet and quick ref guide once update published)
UTIs – prophylaxis. A guide for the prophylaxis of recurrent UTIs has been produced in collaboration with Birmingham Antibiotic Advisory Group.
Acne – A need for local guidelines was identified and is planned for 2017/18
Azithromycin for respiratory conditions – A local guideline is in development.
We are also continuing the social media campaign and education events in 2017/18. Education will focus on the pending update to the antimicrobial guidelines and on diagnosis, treatment and prophylaxis of UTIs.

Abertawe Bro Morgannwg University Health Board

Name: Debra Woolley

Provide a brief overview of the project: ABMU Health Board has, for a number of years had the highest antibiotic prescribing in Wales and one of the highest across England and Wales combined. Prescribing data also shows wide variation in the prescribing of antibacterials.
The Medicines Management team had implemented a variety of antimicrobial stewardship improvement interventions over several years with limited success which culminated in the successful case for a funded Big Fight Campaign with a dedicated team of staff which commenced in early 2016. The team includes an antimicrobial pharmacist, infection control nurse and data analyst.
The Big Fight Campaign aims to improve patient outcomes and minimise the potential risks for increasing antibiotic resistance and C. difficile infection (CDi) through the development and implementation of a multidisciplinary programme through which the principles of prudent healthcare can be applied to improve antimicrobial stewardship in primary care.
Key stakeholders include:

• Patients, carers and the public
  • Local authorities
  • Healthcare professionals (including GP practices, community pharmacies and care homes)
  • The Big Fight team were able to access a variety of support through the Bevan Commission Exemplar programme. This support enabled the team to take a ‘fresh look’ at implementation of improved antimicrobial stewardship in the community and develop a programme of work.Goal and targets include:
• A reduction in overall antimicrobial prescribing in primary care across ABMU Health Board.
  • A reduction in variation of overall antimicrobial prescribing in primary care across ABMU Health Board.
  • That more key stakeholders across ABMU Health Board (including care home staff, GP practice staff and community pharmacy staff as a minimum):
  o understand the importance of and feel well informed and supported regarding antimicrobial stewardship.
  o have a good working knowledge of prevention and optimal management of C. difficile infection, re-infection and relapse.
  • A reduction in inappropriate GP appointments for self limiting viral infections across ABMU Health Board.
  • A reduction in overall C. difficile infection cases in non-inpatients across ABMU Health Board.

List any supporting partners or organisations worked with: The Big Fight Campaign is a Bevan Academy Exemplar and the Big Fight Conference was supported by 1000 lives

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? The Big fight team have progressed a number of priority actions to improve antimicrobial stewardship in the community. Two such examples are reported as separate posters (‘GP Practices’ and ‘Enhanced Antimicrobial Stewardship in Care Homes’).

Others include:
• Engagement with key stakeholders
• Utilisation of the ABMU Health Board ‘GP Practice Prescribing Management Scheme’ to:
o Introduce non-clinical local Big Fight Campaign Managers in GP practices
o Facilitate GP Practice based antimicrobial stewardship improvement plans, clinical audit and patient engagement activities
• Production of a toolkit to support cluster based pharmacists and technicians to support antimicrobial stewardship activities.
• Provision of resources to support patient education and co-production.
• Analysis and dissemination of GP level prescribing data linked to the Welsh National Prescribing Indicators
• Inclusion of Antimicrobial Stewardship in GP Cluster Plans across the ABMU Health Board area
The Big Fight team undertook a stakeholder engagement event in November 2016 – ‘The Big Event’ was multidisciplinary with over 100 attendees (including from GP practices, care homes and patient representatives), which generated a wealth of ideas around engagement with the population of ABMU Health Board.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?

• Messages will be co-produced with members of the public to educate and raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance. This will help to manage patient expectation/demand for antibiotics during GP consultations.• Education/support for members of the public about self care of self limiting infections will better enable them to choose well when seeking support i.e. community pharmacist advice. It is anticipated that this will also help to reduce inappropriate GP consultations.• Improved cost effectiveness of antimicrobial prescribing.• A reduction in harm e.g.
  o Likelihood of receiving an unnecessary prescription for antibiotics and associated potential for side effects, drug resistance etc
  o It is anticipated that improved antimicrobial stewardship in the community will minimise the potential risks of increasing antibiotic resistance and C.difficile infection• Enhance antimicrobial stewardship knowledge of GPs and other key stakeholders in the community e.g. practice nurses, Care Home staff etc which will:
  o Reduce variation of antimicrobial prescribing practice.
  o Improve communication, knowledge sharing and links between key stakeholders in the community regarding antimicrobial stewardship.
  o Improve quality of antimicrobial prescribing by Primary Care prescribers, through increased monitoring, audit and education.

Key outcomes of project?:

Primary Care:
Recent prescribing data shows that ABMU Health Board is reducing overall prescribing of antibacterials at a greater rate than the rest of Wales.

The rates of C difficile infection in the community has reduced more than other Welsh health Boards.

All GP Practices have a nominated (Antimicrobial Steward)

All GP practices have a local Big Fight Campaign Manager (Antimicrobial Champion), a non clinical member of the primary care team.

80% of practices participated in EAAD 2016
Infection prevention and Control
established and strengthened Big Fight and IPCN relationships with care home staff.
• Improved knowledge as evidenced by post session questionnaires
• Positive feedback evidenced through post-training evaluations.
• Self assessments completed by staff also demonstrate that they perceive they have increased knowledge after the training.
• Identified baseline knowledge amongst staff is variable requiring a flexible training approach

How is the project to be developed in the future?: This year the project will increase the engagement with other healthcare professionals such as community pharmacy, through a number of initiatives linked to the pharmacy contract. The public health campaign will focus on World Antimicrobial Awareness Week and EAAD. A multidisciplinary audit will look at delayed prescribing