Basildon and Thurrock University Hospitals

Provide a brief overview of your project?
Antimicrobial consumption at Basildon and Thurrock University Hospital was 26% above the average for non-teaching trusts. The usage of broad-spectrum antibiotics i.e.piperacillin/tazobactam and carbapenems were also higher at 35% and 45% above the average for non-teaching trusts. As part of the antimicrobial Awareness week 2018 we developed an online interactive quiz accessible for all staff at Basildon and Thurrock University Hospital to highlight important antimicrobial Stewardship practices to reduce the development of resistant organisms.

Our aim was to educate staff members on the challenges facing the trust as a whole on antimicrobial prescribing and the trust’s new Antimicrobial Prescribing Policy.

The trust intranet site was created using “concrete5”, an Open Source Content Management System (CMS). This allows users to create content using fixed pre-programmed blocks. We utilised this technology to create an online quiz.

The quiz included mandatory fields such as name, department and email address so we could contact the winners. The quiz was made up of 16 questions with multiple choice answers for all.

After completing the quiz, staff were taken to a webpage which included the answers for each question. Staff were also asked to complete a short survey online about how useful they found the quiz to be. Entrants were not scored on their results and three prizes were given based on a lottery system so all entrants had an equal chance of winning.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.
There was an increase in staff awareness about resistance due to antimicrobial awareness week quiz. A total of 147 staff entered the quiz from a variety of departments. The majority of entrants believed the quiz helped them to become more aware of the problem with antibiotic resistance, prompted them to think about how they use or prescribe antibiotics and they learnt new information from the feedback answers to the quiz.

The awareness was part of antimicrobial stewardship strategy for education and training in the Trust. This resulted in reduction in consumption of antimicrobials.

Total antimicrobial consumption reduced by 19%. Broad-spectrum antibiotics also reduced; piperacillin/tazobactam reduced by 41% and carbapenem reduction of 42.7% all compared to baseline figures of 2017/2018.
How is the project to be developed in the future?
The project will be developed further once electronic prescribing is implemented in the trust in order to ensure consistency in reduction of inappropriate prescribing.

University Hospital Southampton NHSFT

Provide a brief overview of your project?
There is a perception that poor prescribing practices contribute to the problem of antimicrobial resistance. However, there are limited data to confirm this. Reporting complete and consistent data about the prescribing and administration of antimicrobials is vital for quality improvement interventions to reduce antimicrobial resistance, but this is a major challenge for hospitals, even in hospitals that have ePrescribing, data analytics are not always available.

The ADAPTA project (Antimicrobials in Hospital – Development of Advanced Data Analytics) supported the development of two IT systems to address this. The project was developed by the pharmacy antimicrobial and research teams at University Hospitals Southampton NHSFT (UHS) in collaboration with the University of Edinburgh and Triscribe Ltd.

Triscribe supports the analysis of population level prescribing. Prescribing data is extracted from two electronic prescribing systems by Triscribe and provides benchmarking data of antibiotic administered to patients within the trust. This is a major step forward as previously analysis was based on dispensing data. Usage can be analysed by drug group, ward/care group, consultant speciality, patient age and gender. Analysis can be drilled down to the time period required and time periods can be compared as well as the split between IV and oral antibiotics. Prescriptions are analysed by length of prescribed treatment in days.

Our dashboard allows patient level prescribing review. The dashboard is able to:
– Identify patients for review on antimicrobial stewardship rounds based on individual patient parameters for example: speciality, drug or test.
– Following patient selection display of individual patient test results and medicines chronologically in order to make appropriate recommendations.
The aim of the system is to be able to direct specialist microbiology resource to patients prioritised based on the user’s requirements. For example patients on a broad spectrum antibiotics, patients within a particular care group or patients whose infection markers are deteriorating on antibiotic therapy.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. Use of the Triscribe system to show the trend in antibiotic use prior to a Clostridium Difficile outbreak within a specific care group as a tool for microbiologists to investigate whether prescribing was a contributory factor. The ability to interrogate the data to prescribed antibiotic, length of treatment over a specified time course allows an easy visualisation to be produced.
2. Use of the dashboard to identify patients for review as part of a focus on urinary tract infections. Real time identification of patients prescribed medications for UTI allows for a prospective review of patient care. We are able to identify and act on areas for improvement in real time which allows for education of prescribes and ensuring urine is sent for MC&S.
3. Enhance the efficiency of patient review and stewardship

How is the project to be developed in the future?
Further development of systems to allow:

• Review of Drug-Bug mismatch – the ability to identify patients on antimicrobials to which their presumed causative organism is resistant.
• Identification of patients on antibiotics at the 48/72 hour time point to allow review in accordance with start smart then focus criteria. This will include IV to Oral switch – and de-escalation from broader to narrower spectrum antibiotics.
• Identification of missed antibiotic doses.
• Identify patients on antimicrobials with a narrow therapeutic index where levels indicate a change in dose is required.
• Further analysis of population data to monitor and identify trends in prescribing to allow proactive planning for antimicrobial stewardship interventions.</li
• Inclusion of activity data to allow benchmarking between hospitals
• Develop Triscribe to support identification of best and worst practice to support learning and improvement in various teams

Prime Hospital- Dubai

Provide a brief overview of your project?
We are a medium-sized 100 bed acute care private facility in Dubai, despite limited ASP resources (no ID specialist, no dedicated clinical pharmacist, no junior medical staff who can collect data) and although starting antimicrobial stewardship program was not yet mandated in UAE by MOH, but we started our program voluntarily at the end of 2016 which consisted of developing a set of interventions and incorporated them to our Electronic Medical Record (EMR), among those are a list of all of the intravenous antibiotics used across the hospital, a list of restricted antibiotic which should be justified from a drop down list, antibiotics time out with automatic stop of the antibiotic and incorporation of clinical practice guidelines and hospital antibiogram in to EMR for quick review (figure 1).

A monthly report is generated from the EMR with information about antibiotics usage, duration, indication, dose and the justification to use it, prescribers and their units. This report is reviewed and analyzed on a monthly basis by the chair of ASP who advises and educates prescribers accordingly by using different ways of educations like CMEs, one to one meeting, emails, committee meetings and peer comparison.

Our EMR is an in-house developed application by our IT team who are part of ASP committee which enabled us to recommend and implement these enhancements without putting extra cost on our private organization. By doing this we saved a lot of time, efforts and money. We proved that it is possible to incorporate a tailored clinical decision support system (CDSS) in the -already existing- hospital EMR to serve ASP with minimal or no cost in small hospitals with limited ASP resources and we set as an example for the private sector in our country.

Outcomes of our program is shown below and in the attached figures.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. More than 50% reduction in the unnecessary use of Intravenous ceftriaxone and all forms of flouroquinolones (oral and IV) in our emergency department. Our focus was to target these two classes of antibiotics since the overuse/abuse of them is clearly linked to antimicrobial resistance and development of MRSA, ESBL and MDROs. This reduction in consumption of the antibiotic is bases on number of grams of ceftriaxone used monthly in ER and number of encounters where a fluoroquinolone was prescribed on discharge from ER. There was a corresponding reduction of the cost of antibiotics
2. Significant improvement in compliance with surgical antibiotics prophylaxis (SAP) over the last 4 years. Rate of compliance (1st generation cefazolin as the drug of choise) was 44% in 2016 and this has increased to 78% in 2019. That was accompanied with a reduction in the unnecessary use of third and fourth generation cephalosporins for SAP from 37% in 2016 to 11% in 2019.
   We demonstrated also a significant improvement in compliance with SAP guidelines in our Obstetrics department by choosing the right antibiotic (Cefazoin 2 grams), our compliance was 95% in the second half of 2019 compared to 71% in the 1st half of 2018
3. Reduction in rate of resistant bacteria (ESBLs, MRSA, MDR pseudomonas) in 2018 & 2019 compared to 2017 despite the increased trend for all of these organisms at the national level.
   MRSA: from 33.6% in 2017 to 31.3% in 2019
   ESBL E coli: from 32.5% in 2017 to 30% in 2019
   ESBL Klebsiella: from 26% in 2017 to 23.3% in 2019
   MDR Pseudomonas: from 18% in 2017 to 13.5% in 2019.

How is the project to be developed in the future?

1. We are planning to start prospective audit for carbapenems by AMS clinical pharmacist.
2. We are planning to involve more “antibiotic champions”from different department like the pediatric department where a large amount of ceftriaxone is being prescribed and the surgical department where carbapenems are used widely.

West Hertfordshire Hospitals NHS Trust

Provide a brief overview of your project?
Our project, The ART (Antibiotic Review Tool) of the drug chART, is another building block in our comprehensive antimicrobial stewardship programme (CASP).
Reviewing the antibiotic section of the drug chart used at West Herts Hospitals NHS trust came following an audit on antibiotic section of the drug chart to look at the antibiotic prescribing behavior. The result of this audit prompted us to introduce a new design to the antibiotic section of our drug chart to encourage clinical team to review antibiotics in timely manner, document the diagnosis and empower them to stop unnecessary antibiotics.

The ART tool on the drug chart is composed of two prescribing sheets and a review box:

1. The initial prescription sheet where only 3 days for prescribing are allowed (with an extra day (D4: only to be used if review was not done for legitimate reasons). In this case documentation of the reason should be done
2. A review box to be used to document the reason for continuation of antibiotic if they were to continued and re-prescribed on the initial prescription
3. A finalized prescription sheet: This is to be used when the diagnosis is confirmed, and antibiotic choice and duration are determined. Prescription can be done straight on this section without initial prescription if the diagnosis was confirmed at the time of prescription

The new drug chart was introduced in November 2019. Several teaching and education sessions were delivered across different specialties and grades. We then intensified our teaching on few wards. Re-auditing the antibiotic sections in these wards and comparing to audit done prior to introduction of ART showed:

1. Significant improvement in percentage of antibiotic reviewed (99% compared to 51%)
2. Increase in percentage of antibiotic course which are stopped (25% compared to 9%)
3. Increase percentage of antibiotic with documented indication (94% compared to 10%)

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.
Studies indicate that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate. There is no doubt that over prescribing and mis-prescribing is contributing to the growing challenges posed AMR. Improving prescribing practices in hospitals can not only help reduce antibiotic resistance but can also improve individual outcomes.

The following are three examples on how this project can contribute to reduction of AMR:

1. Total antibiotic consumption was reduced from 3310 DDD/1000 admission in October 2019 (prior to ART) to 3291 DD/1000 admission in January 2020 (2 months after ART) and this is compared to 3790 DDD/1000 admission in January 2019
2. The drug chart has prompted the appropriate use of antibiotic: 86.8% of antibiotic courses assessed were appropriate in term of choice relative to the indication
3. Combating AMR is everyone’s responsibility. This drug chart has empowered the clinical team and has given them the ownership and the autonomy required to review antibiotic. Engaging everyone in this battle against AMR is essential. The high percentage of antibiotic courses reviewed, without microbiology intervention, prove that the ART of our drug chart achieved its goal

How is the project to be developed in the future?

1. Extend our education sessions to other wards to improve prescribing
2. Addressing poor practice and identify areas for improvement. One of these areas is documentation of the duration and increase compliance with IVOS
3. Identify gaps in the design of the drug chart and challenges in implementing this particular design ( for example for patients with long hospital stay with recurrent infections or patients in ITU). The aim is to improve the design in a future version to ensure compliance with all elements of the antimicrobial stewardship.
   This will be achieved by auditing/ feed back from users of different specialties/grades
4. Study the effect of the ART on prescribing behaviour
5. Share our experience with other trusts with the aim of national implementation of the ART on the drug chART.

Infectious Diseases Institute – Makerere University

Provide a brief overview of your project?
The Infectious Diseases Institute (IDI) is a specialist HIV clinic in Kampala, Uganda with over 8000 patients. Each patient on average will visit the clinic thrice a year, greater than a patient in the general population would. This could facilitate increased inappropriate antibiotic prescribing.

In 2016, the IDI clinic set up an Antimicrobial Stewardship Committee comprising a pharmacist, statistician, medical doctor, laboratory technologist and expert client.

This was in response to a review of the electronic databases at the IDI that revealed a high rate of prescribing antibiotics (about 5.71% of the prescriptions made annually had an antibiotic prescribed, absolute number 12230 annual antibiotic prescriptions) without stating the indication for prescription. Antibiotics use when not clinically indicated is a recognized contributor to antimicrobial resistance .Provision of feedback to physicians about their prescription behavior, gentle nudges using commitment letters and individualized feedback have been shown to improve antibiotic prescription behavior in high Income countries. However, there is limited data about uptake of such interventions in low and middle Income countries.

Implemented interventions to improve antibiotic stewardship at IDI since 2016 to date include:

• Commemorating the annual world antibiotic awareness week in November with Continuous Medical Education dedicated to improving antibiotic use including leading journal club, audit on antibiotics prescribed and/or with an indication stated. Display of posters on antibiotic stewardship.
• Distribution of national guidelines on antibiotic use to each physician.
• Displaying of physician-signed commitment letters in individual clinic rooms to remind physicians on antibiotic prescription only when clinically indicated.
• In November 2019, a new intervention involving quarterly provision of individual feedback to physicians on their antibiotic prescription rates via sealed envelopes was introduced.

These interventions have shown a reduction in the antibiotic prescription rate and an increase in the percentage of antibiotic prescriptions with their indications stated over 5 years.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. The antibiotic prescription rate fell by 21.3% (95% confidence interval [CI] = 18.5% to 24.1%, P-value<0.001) over the 5 years since initial first intervention in 2015 at IDI HIV clinic. This corresponded with absolute reduction of 5826 antibiotic prescriptions made every year.
2. The rate of stating an indication for antibiotic use by physicians improved by 25% over the 5 years of intervention.
3. Over the 5 years of intervention, the trend of antibiotic prescription dropped by 3.0% (95%CI = 0.1 to 5.8%, P-value=0.041)between 2015 and 2016, then dropped by 4.7% (95%CI = 1.6% to 7.7%, P-value=0.003) in 2016 to 2017, then dropped by 18.0% (95%CI=15.3% to 20.6%, P-value<0.001), and then slightly increased by 3.8% (95%CI=0 – 7.8%, P-value=0.050).

How is the project to be developed in the future?
Continued engagement of the health workers at the IDI clinic through conducting quarterly continuous medical education on antibiotic stewardship.

Continue generating and providing feedback on individual antibiotic prescription behavior every quarter of the year.

Quarterly ranking of health workers by antibiotics prescription behavior and rate to allow for peer comparison.

Establish local clinic guidelines for antibiotic use which are currently under review. Currently clinic uses national guidelines.

Patient education on antibiotic resistance.

The clinic will also serve as a model center where other HIV clinics can come and learn as well as share their own experiences.

Entebbe Regional Referral Hospital

Provide a brief overview of your project?
Emerging resistance to the most commonly used antimicrobials at Entebbe Regional Referral Hospital (ERRH), Uganda, and in the entire country led to the introduction of Antimicrobial Stewardship (AMS) activities in the facility.

The Medicines and Therapeutic Committee (MTC) formed in June, 2019 with the overall aim of ensuring that effective, quality and safe medicines are available to the facility clients and they are appropriately used with support from Buckinghamshire Healthcare NHS Trust, Nottingham Trent University, and Makerere University. This partnership is supported by a project through Tropical Health and Education Trust (THET) and the Commonwealth Partnerships for AMS Scheme (CwPAMS). The committee is comprised of the supply chain, pharmacovigilance and AMS sub-committees. The MTC has 13 members from various disciplines, consultant Obstetrician and Gynecology is the chairperson, pharmacist is the secretary and hospital director is an ex-official. MTC seats every other month and is involved in organizing trainings and Continuous Medical Education sessions and developing policies on medicines’ use and reviewing usage patterns.
The committee has been involved in following;

1. Organized training on AMR and AMS for the hospital health workers including prescribers, pharmacy and laboratory staffs and nurses. The training included use of Uganda Clinical Guidelines and the CwPAMS app for optimal antimicrobial prescribing.
2. The development and implementation of policies regarding the appropriate use of antimicrobials including surgical antibiotic prophylaxis, dilution of concentrated disinfectants, limiting usage of injectables, and Standard Operating Procedure for the insertion of catheters.
3. Through the AMS sub-committee, training on nosocomial infections was delivered to equip the staff with knowledge on reducing their incidences and treatment of these infections using appropriate antimicrobials.
4. The committee organized the carrying out of the GPPS in the hospital. The results of this exercise will soon be disseminated to the MTC and the entire facility health workers.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.
As a result of the trainings, patient flow at the laboratory increased since most of the clinicians preferred prescribing after the patient has got laboratory results. More biological samples were sent to the laboratory enabling clinicians to select appropriate antibiotics. However, at first this overwhelmed the laboratory because of the limited resources available. This alerted the hospital management that the laboratory needed more capacity in terms of human resource and equipment but as a temporary solution for this, a meeting was called targeting the 3 departments that is to say laboratory, pharmacy and Out-Patient Department (OPD). From this meeting, it was agreed that simple tests such Malaria Rapid Diagnostic Test, HIV tests, Pregnancy tests, Syphilis tests etc be done from OPD to reduce on the patient numbers in the laboratory. This meeting laid a foundation for further quarterly meetings between the three departments to deliberate further on how to improve service delivery for their clients.

As a result of the formation of the MTC at the hospital, proposals have been sent to our implementing partners and the Ministry of Health for further support. With their support in terms of trainings and capacity building, the MTC will be strengthened hence strengthening AMS activities in ERRH and the lower level health facilities in our jurisdiction.

The project led to the development of five treatment protocols for the common infections at the hospital that is to say; malaria, Diarrhea, Respiratory Tract Infections, Urinary Tract Infection and Septicemias and Standard Operating Procedures dilution of concentrated disinfectants and insertion of catheters for inpatients.
How is the project to be developed in the future?
As a regional referral hospital, we have a number of lower level health facilities in 7 districts which are under our jurisdiction. Therefore, the MTC intends to visit these health facilities and build their capacity in AMS. We also intend to build links with other MTCs of other hospitals in other parts of Uganda on how best we can strengthen AMS and collaborate in future. We also intend to write more proposals for funding to further support AMS activities in the hospital and other facilities in our jurisdiction.

The committee is also intending to organize patient education avenues including playing videos and printing posters teaching patients about hand-washing skills, proper usage and storage of antimicrobials and seeking health care services from appropriate health facilities.

The MTC is also intending to start manufacturing disinfectants for the hospital. This will improve availability and reduce the expenditure of the hospital.

West Hampshire CCG

Provide a brief overview of your project?
Quality improvement programme in antimicrobial stewardship (AMS) in West Hampshire Clinical Commissioning Group (WHCCG) general practices.

In 2018, the WHCCG Medicines Optimisation Team (MOT) launched an AMS programme based on Public Health England (PHE) and Royal College of General Practitioners (RCGP) the TARGET antibiotic toolkit and Healthier Together resources in all 48 constituent practices. The main intervention consisted of a 1-hour TARGET interactive outreach workshop, facilitated by existing NHS clinical pharmacists and pharmacy technicians working in practices and covering topics previously described by McNulty et al.

In the year following the intervention, reductions in WHCCG mean antibiotic prescribing rates were greater than the national average. Comparing dispensed items (per 1000 patients) across WHCCG over a six-month winter period (October – March) 2018/19 to the same period in 2017/18:

1. Total oral antibiotic use fell by 11% (England equivalent 8% )
2. Oral co-amoxiclav use fell by 20%. (England equivalent 8% )
3. Antibiotic use children under 5 fell by 19% (England equivalent 6% )

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.
There is evidence to suggest that patient experience, outcomes and primary care efficiency/ sustainability are all improved by this proposal. By incentivising practices to undertake TARGET antibiotic workshops run by local facilitators and promoting the Healthier Together resources, WHCCG MOT members were able to

1. improve antibiotic use, thereby promoting responsible AMS,
2. reduce unnecessary patient exposure to antibiotics
3. reduce primary care workload associated with inappropriate antibiotic use

How is the project to be developed in the future?
We propose setting up a Wessex Antimicrobial Stewardship (AMS) Collaborative Train the Trainers (TtT) programme focusing on AMS in young children to facilitate the delivery of outreach programmes by all Medicines Optimisation Teams (MOTs) across Wessex; based on the learning from the pilot delivered in West Hampshire CCG. Early discussions with Dr Donna Lecky from PHE regarding co-operation with TARGET Antibiotics programme. In order to develop this project further, we propose the following:

• Creation of a Wessex Paediatric AMS Collaborative
• Creation of a network of CCG MOT (Paediatric) AMS Leads
• One half-day Train the Trainer workshop for CCG MOT AMS network leads at four different locations across Wessex
• Two follow-up Action Learning Set meetings in the year following the TtT workshops
• Setting up of WhatsApp communication group

Erskine

Provide a brief overview of your project?
Point of Care BRAHMS Procalcitonin (PCT) testing was introduced during winter 2019/20 to improve antimicrobial stewardship at two of Erskine’s Care Homes where 220 residents live. PCT is a biomarker greatly elevated in bacterial infection, PCT levels increase rapidly (2-3 hours) after bacterial insult, peaking at 12-48 hours and returning to normal as the infection is resolved.

PCT enables the clinician to promptly differentiate viral from bacterial infection which is typically challenging without the support of additional tests (e.g. blood culture). Care Homes are associated with higher rates of antibiotic use in comparison to the community; as practitioners will often err on the side of caution and prescribe antimicrobials inappropriately.

Erskine is the only care home service in Scotland to directly employ advanced nurse practitioners. Erskine has an advanced nurse practitioner (ANP) and one in training (TANP) who provide rapid on-site response to resident’s health care needs.

PCT is ideally suited for use in our context due to the rapid turnaround time (20 minutes) and minimally invasive finger prick analysis. It supports the process of appropriately treating our residents, which will in turn reduce the amount of ineffective antibiotic prescribing as part of the antimicrobial stewardship governance. The side effects of antibiotics can be unpleasant for anyone however, with our residents often increased frailty, it can have an increased impact on their quality of life. Timely and appropriate treatment can also potentially avoid an unnecessary admission to hospital.

PCT will not replace clinical judgment, but will augment assessment, care and treatment planning process.

It has been evidenced as useful in three main circumstances

• Where there is clinical suspicion of infection, as assessed by the ANP/TANP.
• Where a resident is not responding to (current antibiotic) treatment.
• To monitor the efficacy of antibiotic treatment (where initial levels were measured).

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

• Urinary Tract Infections: There have been several examples where Procalcitonin has supported antibiotics not being used for urinary symptoms/positive urine results. Since utilising Procalcitonin measurement as part of the assessment process in urinary tract infections, prescribing has reduced by 90%. Procalcitonin measurement has also supported switch in antibiotic therapy; a gentleman was prescribed Nitrofurantoin for urinary tract infection but Procalcitonin level continued to climb, the antibiotic was therefore changed to Trimethoprim and within a 24 hour period the clinical symptoms had improved and Procalcitonin level had decreased.
• COPD non infective exacerbation: Given the difficulty of differentiating between infective and non-infective Exacerbation of Chronic Obstructive Pulmonary Disease and the frequent prescribing of antibiotics in this specific group of residents, also with the limited resources within care home setting, timely treatment can be commenced without waiting for results of blood samples which are further delayed as they are reported to the GP, or waiting for sputum culture. The Procalcitonin measurement takes twenty minutes to process and has enabled specific antimicrobial prescribing only when bacterial infection is present. This can help avoid unnecessary stress for the residents as they may not be required to attend the general hospital for Chest X-ray and more intrusive procedures which are often done routinely e.g. blood gas analysis.
• Cellulitis/Sepsis: A female resident had what appeared to have a mild cellulitis but rapidly declined. It was hypothesised for a period that it was possible that that some of her presentation may have been related to cognitive impairment and exhaustion due to her lack of sleep. PCT results enabled us to identify that her presentation was indeed that of an unusually rapidly developing sepsis and informed the ambulance service of this in order to expedite her contact with secondary care services and commencement of treatment.

How is the project to be developed in the future?
The project has collected data and will continue to do so in order to enable audit and analysis. This research will be shared where possible and appropriate. We aim to share our learning through publication in professional journals.

Royal Pharmaceutical Society

Provide a brief overview of your project?
During 2019 the Royal Pharmaceutical Society developed a new, expert-led, structured AMS training programme for pharmacists practising in patient-facing roles. The programme aims to increase motivation and capability to design and implement behaviour change interventions to support the UK 5-year AMR action plan. It is approximately 100-days duration, supported by an AMS curriculum, and comprises of self-directed learning; one face-to-face training day; development and delivery of a quality improvement (QI) project; moderated peer discussions; a final professional discussion and portfolio-based assessment.

Pharmacists are increasingly being asked to lead improvements in medication management at a local level and regional level, however they often lack the confidence, understanding and support to deliver this. The incorporation of tutor support, group discussion sessions and end of training assessment in this programme is key to maximising the impact of this project in terms of sustainable AMS interventions and ability of pharmacists to identify and deliver future improvements.

In 2019, this training, developed in conjunction with our lead expert Dr Diane Ashiru-Oredope, Pharmacist Lead for Antimicrobial Resistance and Stewardship and HCAI at Public Health England, and delivered in collaboration with UKCPA Pharmacy Infection Network, was commissioned by the Health Education England AMR Innovation Fund for an initial cohort of up to 30 post-Foundation pharmacists in London and the South East. A baseline survey found that 96% of pharmacists self-rated their knowledge of QI techniques and tools as low or average, and 93% of learners self-rated their knowledge of behaviour change techniques as very low to average. This improved to 100% of learners self-rating as average to high for both areas post training. Evaluation and lessons learnt from the 2019 cohort was incorporated into an updated programme, commissioned for national delivery for up to 60 pharmacists in 2020.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

• Evaluation shows this programme demonstrates not only acquisition of knowledge and skills, but importantly, immediate application of learning in the workplace, resulting in improvement in processes and practice, thus supporting optimisation of care for patients
• Since 2019, 88 pharmacists have completed training in AMS priorities, behaviour change and QI methodology.

• Cohort 1, 19 learners identified and implemented Quality Improvement projects aligned to national Antimicrobial Stewardship priorities with evidence of outcome and process improvements, and collaboration with members of the wider MDT and management structures, thus spreading learning
• Cohort 2, despite COVID-19, 46 learners identified and devised improvement initiatives with 69% of pharmacists having engaged the MDT team in their workplace about their projects

QI Projects in Primary Care, Secondary Care, Community
Antimicrobial prescription review (selection, indication, duration) 25
Antifungal prescribing and monitoring 1
Antibiotic Allergy 3
Quality of data 1
Urinary tract infection 13
Community acquired pneumonia 5
Surgical prophylaxis 1
Upper respiratory tract infection 6
Sore throat 1
Long-term repeat prescriptions 12
Sepsis 1
Self management 1
Other 5
Total 65

8 of 17 learners who successfully completed the 2019 training pilot responded to a follow-up survey 12 months post completion of training. 5 out of 8 (63%) reported their QI project was continuing, and of these, 4 out of 5 (80%) had subsequently spread or expanded the implementation of their intervention since the training. 7 out of 8 (87.5%) respondents reported that they consistently and proactively use Data for Action, and 6 of 8 (75%) reported that they consistently embedded behaviour change principles in their practice.
How is the project to be developed in the future?

• We complete evaluations following every cohort, with learning embedded to improve engagement, outcomes and alignment with national priorities. For example: introduction of a requirement to deliver local training sessions with the wider MDT. We have since also secured support from the Royal College of Physicians, Royal College of General Practitioners and Royal College of Nursing through the Join Royal College Medication Safety group to support wider MDT engagement with learner projects and interventions, building an even wider network of AMS champions
• We are currently redesigning the face-to-face training day to an interactive online learning. This was prompted by COVID-19, however will allow us to deliver training across geographies and thus spread the learning
• We are looking to engage Global Health Fellows from the CPA CwPAMS programme as tutors and mentors for future programmes, to share their learning and enthusiasm.

Boots UK Ltd

Provide a brief overview of your project?
Uncomplicated lower urinary tract infections (UTIs) are common in women consulting primary healthcare, taking up GP resources. Delayed consultation can increase the risk of serious infections such as pyelonephritis or bacteraemia.

This project aimed to evaluate the effectiveness and uptake of a lower UTI test-and-treat service for women presenting with urinary symptoms within a community pharmacy in supporting self-care and appropriate use of antibiotics and reducing demand on other NHS resources.

The service was aligned to national guidelines to diagnose and treat lower UTI in women aged 16–64 years and used national resources to provide safety-netting and self-care advice. Consultation included clinical assessment and a urine dipstick test alongside a novel smartphone app, with diagnosis informed by test results. Women were provided with safety-netting advice and either advised on self-care, supplied with antibiotics or referred to their GP.

The community pharmacy-led UTI test-and-treat service for women aged 16–64 years presenting with urinary symptoms provided accessible and timely care aligned to national guidance, with 75.0% of consultations requiring antibiotic treatment.

The results of this project have been published recently (Thornley et al. Evaluation of a community pharmacy-led test-and-treat service for women with uncomplicated lower urinary tract infection in England. JAC 2020).
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

• Pharmacy teams were able to support females aged 16–64 years with uncomplicated lower UTI within the community pharmacy (the service evaluation included 764 women and lower UTI was found to be likely in 372/496 (75.0%) women, most of whom purchased antibiotics on the same day).
• Had the service not been available, approximately three-quarters of women who had completed the service and responded to the question would have visited their GP, therefore reduced demand on other NHS resources such as GP surgeries and urgent care settings.
• Women were provided with self-care advice, treatment (if necessary) or triaged to a more appropriate service, thus supporting the appropriate use of antibiotics.

How is the project to be developed in the future?
The service is currently being revised to reflect latest guidelines in light of CV19 – to make the service more accessible and to provide greater support to patients that may have issues with treatment failure (providing greater support to reduce resistance issues)

Homerton University Hospital NHS Foundation Trust

Provide a brief overview of your project?
Tom Elias¹, Sathyavani Subbarao², Luca Spada³, Edyta Staite³, Jeff Barron³, Kate Woods²
1Department of Medicine, 2 Microbiology, Department of Pathology, 3Biochemistry, Department of Pathology

Homerton University Hospital

Background
Procalcitonin (PCT) has emerged as a highly sensitive biomarker for bacterial lower respiratory tract infections (LRTI) and been shown to aid early antibiotic cessation sepsis. PCT was introduced at Homerton University Hospital Foundation Trust in May 2020.
We anticipate that targeted PCT testing in our trust will improve clinical decision making around the commencement and cessation of antibiotic therapy and thus minimise antimicrobial resistance. Furthermore, we believe that in potentially reducing average duration of antibiotic therapy, there will be shorter hospital stays and possibly cost savings for the trust.

Methods
Following an initial pilot study, reviewing PCT use in May, we collected PCT test data for June 2020 to establish whether it is being used appropriately, as per local guidance, and to begin to gain an idea of whether intended benefits are being achieved.

We analysed data on PCT test results, whether the tests were appropriate according to our local guidelines, and antimicrobial decision making in each case.

Results
A total of 95 non-duplicated, age appropriate PCT tests were analysed in our laboratory. 1 sample was haemolysed. The median result was 0.17 (Q1=0.00, Q3=1.45, <0.25 = bacterial infection unlikely). 55/94 (58.5%) tests were appropriate according to our guidelines. Of the tests conducted according to our guidelines, 43/55 (78%) had respiratory symptoms and 12/55 (22%) had sepsis. Where PCT was <0.25, antibiotics were either stopped or not started in 30/48 (63%) cases. Where PCT was ≥0.25, antibiotics were continued in 39/44 (89%) cases. In 14/55 (25%) cases there was documentation that PCT had been reviewed and acted on.
Please cite 3 examples of outcomes or impacts from the project on tackling AMR.
It is hoped that by the introduction of procalcitonin as a biomarker for bacterial infection will help clinicians distinguish better diagnose bacterial (versus non-bacterial) infection, reduce the number of patients for whom broad spectrum antibiotics are commenced, and reduce duration of antibiotic therapy.

By reducing the overall usage of antimicrobials, especially broad spectrum antibiotics, we hope to contribute to tackling AMR.
How is the project to be developed in the future?
From the initial data that we have analysed, we can see that further work is needed to improve the usage of PCT at our trust. Over the coming months we aim to analyse further data including working and final diagnoses, culture results, sepsis scores, and patient demographics, and begin to judge what improvements are necessary to try to improve PCT usage. We then aim to implement these improvements and continue to collect data on PCT usage, with the ultimate aim that using PCT judiciously will help to improve antimicrobial stewardship and tackle AMR.