Smart use of antibiotics:
building confidence in
new approaches
Dr. Hayley Wickens
In this session
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Implementing antibiotic stewardship in the NHS
Start Smart then Focus
Gaps in our knowledge
Starting appropriately, building confidence in the stop
What is Antibiotic Stewardship?
“…an activity that includes
appropriate selection, dosing,
route, and duration of
antimicrobial therapy…”1
1. Dellit TH et al. Clin Infect Dis. (2007) 44 (2): 159-177
Antibiotic Stewardship in the NHS
• Acute Trusts in England2
– 99% have empiric abx policy
– 87% have iv-oral switch policy
– 36% have automatic stop policy
• Multidisciplinary Antimicrobial Management Teams
– Cons micro/ID, abx/ID pharmacist, lead clinician, surgeon, senior nurse,
senior pharmacist
– Evidence-based guidelines & audit, abx usage/R monitoring, education
– Smaller ward-based teams providing clinical review
• National steering groups
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England – ARHAI
N. Ireland – AMRAP implementation Group → ARAC
Scotland – SAPG
Wales - WARP
2. n=120, Wickens et al unpublished data 2011
Start Smart then Focus
DH (Eng) Nov 20113
• Start Smart
– Start abx on evidence of
bacterial infection
– Use local guidelines
– Document on drug chart
and notes: indication,
duration/review date, route
and dose
– Obtain cultures first
– Single dose surgical
prophylaxis where
evidence supports
• Then Focus
– Review diagnosis and abx
by 48 hours, make the
“Antimicrobial Prescribing
Decision”:
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Stop
Switch IV to Oral
Change/de-escalate
Continue
Outpatient Parenteral
Antibiotic Therapy (OPAT)
3.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/
documents/digitalasset/dh_131181.pdf
Are you feeling lucky?
Risk of undertreatment vs. risk of resistance
• Guidelines: minimise broad spectrum abx, use narrow spectrum
where possible
• “But my patient is different” - Drs prioritise individual health gain over
public health issue4:
– ‘Non-compliant prescribing was mainly too broad compared with
guideline-recommended therapy and rarely too narrow’
– 1/3 of all prescriptions too broad for empiric therapy; 2/3 too broad for
culture-driven therapy, ‘streamlining’ not practiced.
– ‘Availability of culture results had no impact on [policy] compliance in
case of sepsis, but was associated with more compliance in UTI, and
less compliance in LRTI’
– ‘Defensive behaviour may be driven by fear of high mortality rates and
the fact that inadequate bacterial coverage has been correlated with
increased mortality’
4. Mol PGM et al (2006) Eur J Clin Pharmacol 62:297-305
Are you feeling lucky?
Risk of undertreatment vs. risk of resistance
• Are we treating a bacterial
infection?
– ‘Syndromic diagnosis’ – what
combination of signs,
symptoms, biochemistry,
haematology will give us the
confidence that we are
treating a ‘real’ infection
• How likely are we to be
treating a resistant organism?
– Lack of prospective
epidemiology (apart from
HIV/TB); US/EU data –
transferable?
– National R data? Local?
5. Meyer RJ et al (1997) NZ Med J 110:349-52
• Severity Scoring (e.g. CURB-65)
– lack of validated scoring
schemes apart from CAP,
C.difficile, & low awareness5
– ‘low risk’ patients/confirmed
pathogen could have narrow
spectrum agents?
• Lack of evidence on deescalation
– All retrospective; outcomes
good but may be risk averse on
initiation.
– Longer treatment courses →-ve
effect?
Summary
• Implementing antibiotic stewardship in the NHS
• Start Smart then Focus
• Making sure the decision to start is sound
– need for research into the sensitivity and specificity of combinations of
signs/symptoms/biochemistry/haematology to predict bacterial infection
requiring antibiotics – syndromic diagnosis
• Choosing the narrowest-spectrum antibiotic that will cover the likely
organisms empirically
– need for research into evidence of (lack of) harm associated with
starting narrow spectrum in low severity infection, escalating to broad
spectrum if no response – any detriment to patient outcomes?
• Building confidence in the stop/de-escalation
– need for research into course duration and clinical outcomes; do longer
treatment courses produce negative effects?