Improving antimicrobial stewardship and sustainability by promoting oral metronidazole in eligible surgical patients at the Royal Alexandra Hospital
Intravenous (IV) metronidazole is commonly prescribed in the management of intra-abdominal sepsis; however, metronidazole has excellent oral bioavailability of 95-100%. Promotion of the oral route and timely IV to oral antibiotic switch (IVOST) are key antimicrobial stewardship (AS) initiatives providing benefits for patients, staff and the environment including: reduced risk of antimicrobial resistance (AMR), line infections and complications, reduced staff workload and costs and improved sustainability.
To increase the proportion of oral metronidazole prescribed to eligible surgical patients at the Royal Alexandra Hospital to 50% by February 2022.
Baseline data was collected and a quality improvement (QI) approach was used to engage and raise staff awareness to the benefits of oral metronidazole where appropriate. Methods used included: prospective audit/feedback, staff education, ‘Go Green IVOST’ posters in key ward areas and staff champions. Oral and IV metronidazole prescribing and usage data were measured over twelve months and a questionnaire was used to assess the impact of the project on nursing staff.
Baseline data (n=90) highlighted that only 7% (median) of eligible patients were prescribed oral metronidazole. Post change oral metronidazole prescribing in these patients increased to a median of 51%. IV metronidazole usage data decreased by 45% (320 less IV administrations per month) and metronidazole drug costs reduced by 30%. Nursing staff questionnaire results (n=10) reported many benefits including reduced workload and reduced plastic waste. All nurse grades (bands 5-7) reported proactive involvement in AS by promoting appropriate IV to oral metronidazole switch.
A QI approach to engage and raise staff awareness of the benefits of oral metronidazole resulted in a change in prescribing behaviour and increased the proportion of oral metronidazole prescribed to eligible surgical patients to 50%. This is important in terms of improved AS, patient safety, healthcare cost savings, workforce efficiency and sustainability.
1) Improving AS by changing prescribing behaviour
This project has changed metronidazole prescribing behaviour in our surgical wards reducing the proportion of IV metronidazole prescribed by 45% corresponding to 320 less IV administrations in the targeted wards every month. This is important in preventing patients being treated with IV antimicrobials for longer than necessary reducing AMR risk. This significant reduction in IV administration reduces patient risk of developing line infections, complications and AMR. The current scale and spread of this project to other Scottish hospitals will significantly expand the impact on AS and AMR.
2) Promoting a multidisciplinary approach to stewardship
This project has helped raise surgeons, junior doctors, pharmacists and nursing staff awareness of AS. Involving our permanent ward staff, particularly nurses in key AS initiatives has potential to achieve sustained stewardship improvement. Nursing staff questionnaires highlighted increased proactive nursing involvement in AS. Promoting a multidisciplinary approach to IV antimicrobial review has helped reduce antimicrobial overuse and the risk of AMR in our hospital. Scale and spread of this work to other Scottish hospitals will increase the impact on reducing AMR. This project has been shared at both local, national and international conferences.
3) Linking AMR with environmental sustainability
This project is the first in our health board to link promotion of AS and IVOST with environmental sustainability. This project has highlighted the importance of using the oral route whenever possible when treating infections not only to reduce staff workload and healthcare costs but to help drive improvement in AMR and environmental sustainability. Linking this AS project with environment sustainability and creating visual images to highlight the reduction in plastic waste has generated significant interest locally, nationally and on social media platforms. Combining the aims of reducing AMR risk and improving sustainability has created a powerful force for change!
1) Scale & Spread
This project is currently being rolled out to all NHS Greater Glasgow and Clyde (NHSGGC) hospitals by the antimicrobial pharmacist team.
The Association of Scottish Antimicrobial Pharmacists (ASAP) has highlighted this QI project for scale and spread within Scotland increasing the potential impact of this work in reducing AMR. This project has been shared at local, national and international conferences generating significant interest for further scale and spread.
2) Utilising Technology
Electronic prescribing (HEPMA) has recently been introduced to NHSGGC and this system is being utilised to introduce further ‘tests of change’ to promote appropriate metronidazole prescribing and review in the acute setting.
3) Expansion of project scope
The project is also being expanded to include other antimicrobial agents with excellent oral bioavailability to increase the potential for AS and sustainability improvement. The next phase of this QI project will be promoted in all hospital directorates including surgical, general medicine, older people services, ICU and HD.
SPARC – Surveillance and Prescribing of Antimicrobial usage, Resilience and Capacity Building
SPARC was rolled out by the Commonwealth Pharmacists Association in January 2022, with support form the Fleming Fund, with a remit to deliver Point Prevalence Survey training and develop a new App across 22 countries.
To that end the CPA – with guidance from FF developed a comprehensive programme of training including; Global Point Prevalence Survey training, Continuing Quality Improvement and Behaviour Change with the support of expert health psychologists from the Change Exchange to roll out both in-country, in-person, but also online and as video teaching resources to improve sustainability (to use as a refresher, or to train new colleagues in the future).
Alongside the GPPS and CQI training, the CPA worked with Tactuum – global providers of digital health resources – and colleagues from across the CPA, to collaboratively develop and design the Prescribing Companion, a fully customisable App platform for the offline delivery of AMS guidelines in country – to increase digital accessibility in some of the poorest internet connectivity areas across the globe.
1. Development of in-country teams, able to design and rollout a global point prevalence survey in their own, or other, clinical site, the go on to interpret and use the data for development and delivery of action plans to improve the appropriate use of antimicrobial medication in their site, district, or even nationwide.
2. Development of in-country multi-disciplinary teams, who understand and respect the importance of a collaborative approach to clinical treatment of patients, and the skill sets their colleagues can bring to the mix.
Development and roll-out of an offline-available, entirely customisable app, with fully trained CPA-App Champions to ensure engagement with the highest levels of the government, allowing for up-to-date guidelines to be made accessible to all areas of the country quickly and efficiently.
Initial training models and materials are now being translated into a range of languages, ensuring countries with less engagement in English language are able to benefit from the resources and guidelines.
A number of delivery models are also now ready to roll-out from “”completely online”” where internet access s considered excellent, and countries have some previous experience of GPPS methodology and/or CQI work, to completely in-country (with simultaneous translators) where a more hands-on approach is required.
Establishing a Veterinary Prescribing Champion network to promote antimicrobial stewardship across Welsh Veterinary Practices: Arwain Vet Cymru and Arwain DGC.
The overarching goal of our two projects, Arwain Vet Cymru and Arwain DGC, is to promote antimicrobial stewardship and improve prescribing for livestock in Wales www.arwaindgc.wales
The Arwain projects address two key outcomes of Welsh Government’s AMR in Animals and the Environment Implementation Plan: Improving standards of antibiotic selection and prescribing, and additionally, of antibiotic supply. We have achieved this by focussing on prescribing stewardship via close collaboration between veterinary practices, the animal health industry and academia.
To promote improved prescribing and encourage antimicrobial stewardship, we have recruited and trained the first national network of Veterinary Prescribing Champions (VPCs) from farm practices across Wales, to develop and implement key stewardship interventions.
The VPC network comprises highly motivated and trained veterinary surgeons acting as the responsible prescribing champion for their practice, whilst also representing their practice in the network. VPCs are supported by regular webinars, training workshops and discussion groups, fostering key motivational needs established within Self-Determination Theory for competence, autonomy and relatedness.
Our project has, to date, trained at least one VPC from close to 90% of veterinary practices working with farm animals in Wales. Each VPC has developed and developed a bespoke stewardship action plan for their practice, and VPCs have collectively co-created policy recommendations which include improving prescribing regulation, supporting vet-farmer relationships and promoting preventive medicine.
Two working groups established within the VPC network have developed a series of Clinical Treatment Guidelines for several key diseases of cattle and sheep, alongside an overarching voluntary Code of Conduct for prescribing within Welsh veterinary practice.
The project is funded by the EU Rural Development Programme and supported by the Office of the Chief Veterinary Officer. Dr Gwen Rees (Arwain Vet Cymru Project Lead) received the 2021 Royal College of Veterinary Surgeons (RCVS) Impact Award in recognition of the project work.
The Arwain projects have had significant impact on prescribing and stewardship of antimicrobials in cattle and sheep in Wales since 2019, as evidenced by the following outcomes:
Establishing a national veterinary stewardship community: The Arwain projects’ Veterinary Prescribing Champions Network currently has VPCs representing almost 90% of all practices in Wales who treat cattle and sheep. These VPCs meet regularly for facilitated discussion groups, to attend training webinars and work to develop the antimicrobial stewardship agenda in Wales. This pioneering training and engagement strategy, rooted in Self-Determination Theory (Rees et al., 2021), has inspired similar initiatives across the UK: For example, the Farm Vet Champions project.
Facilitating meaningful, vet-led prescribing and stewardship improvements: VPCs from the Network have developed and implemented action plans representing almost 100 individual interventions aimed at improving antimicrobial prescribing within Welsh veterinary practices, common examples include:
Development of a national prescribing Code of Conduct and a series of Clinical Treatment Guidelines for key diseases of cattle and sheep: Through the establishment of working groups within the VPC network, a national voluntary prescribing Code of Conduct has been developed which seeks to self-regulate veterinary prescribing in Welsh veterinary practices to improve antimicrobial stewardship. A series of clinical prescribing guidelines for key diseases of cattle and sheep have also been developed to aid practitioner decision-making. These outputs will be piloted in Welsh veterinary practices in early 2023 and will be rolled out nationally soon after.
We will deliver the following achievements prior to Arwain DGC project closure (July 2023).
1. Implementing profession-led prescribing changes: Launching in 2023:
(i) Code of Conduct for the Welsh veterinary profession
The Code of Conduct that has been developed by the working group will be rolled out across Welsh veterinary practices in 2023.This Code exceeds current guidance established within RCVS standards in its specificity and reach, defining “responsible antimicrobial use” (both as a guiding principle and in specific veterinary activities) and how the concept of ‘under our care’ could best be refined within the realities of veterinary practice.
(ii) Clinical Guidelines for six key diseases in cattle and sheep
Our Clinical Guidelines working group have critically reviewed current antimicrobial guidance available to the veterinary profession and combined this insight with up-to-date evidence on appropriate management and treatment practices, alongside clinical and creative expertise. Guidelines which have been drafted will be reviewed with wider stakeholders in spring 2023, followed by a profession-wide launch.
2. Mapping patterns of antimicrobial use (AMU) in the Welsh equine industry: Using qualitative, in-depth interviews and a quantitative national survey, we will produce a report detailing patterns of AMU in the equine industry, to shape future antimicrobial stewardship efforts in this sector.
3. Delivering policy recommendations: Based on a quantitative national survey of Welsh veterinarians on the acceptability, feasibility and impact of a range of potential antimicrobial initiatives utilised internationally to foster AMU change, we will deliver oversight on the future trajectory of antimicrobial stewardship in Welsh veterinary practice.
4. Creating a self-sustaining VPC network: We will support and maintain the VPC network for the lifespan of the current project, including an audit of remaining action plan delivery, prior to project closure. We will actively investigate sustainability of the VPC network, according to feedback, and seek to embed the network within voluntary ongoing initiatives and/or veterinary association group membership.
5. Supporting intervention implementation: This ‘Action Plan Autumn’ (September – November) will provide a programme of targeted training to support successful VPC engagement with both practice teams and clients, acknowledging that human behaviour change is at the heart of AMS endeavours. This will include workshops on (i) peer to peer sharing of AMS best practice; (ii) adopting evidence-based, change-oriented communication (Motivational Interviewing); and (iii) practical facilitation skills training.
6. Examining VPC intervention: We will examine the reach and impact of VPC interventions on prescribing and use of antimicrobials in cattle and sheep within our VPC community, via qualitative interviews and/or focus groups. Through these data, we will gain insight on the successes and challenges of network activity, in addition to the motivators and perceptions of those acting within this network.
7. Fostering One Health collaborations: We will continue to collaborate with Human health colleagues external to the project, such as within Public Health Wales, the Royal Pharmaceutical Society and local NHS Health Boards (Hywel Dda University; Swansea Bay University). At present, this collaboration includes producing One Health teaching materials for Welsh University students, contributing to cross-disciplinary conferences for medical practitioners and seeking collaborative grant funding to expand integration between veterinary and medical spheres in the pursuit of AMS.