SMC
Scottish Antimicrobial
Prescribing Group
[SAPG]
A National
Stewardship
Programme:
SAPG and Acute
Medicine
Dilip Nathwani
Chair of SAPG
Why antibiotic prescribing
and infection
management?
Antimicrobial Prescribing
Facts: Rule of “1/3”
• ~ 1/3 of all hospitalised inpatients at any
given time receive antibiotics
• ~ up to 1/3 to ½ are inappropriate
• ~ up to 30% of all surgical prophylaxis in
inappropriate
• ~ 30% of hospital pharmacy budgets.
• Stewardship programmes can save up to
10-30% of pharmacy budgets.
• 30% of hospital patients are on antibiotics
• Of these, 30% are prescribed because of
HAI: importance of Infection control
“Price of an antibiotic”
• Risk of resistance to the
•
individual ~ 2 fold for 2
months and up to 12
months1
• ~8- 10 fold risk of
CDAD up to 3 months2
–1BMJ 2010; 340: 1120;
–2CMI 2009; 15:427-434
– AGE
– Co-morbidity
– Type of antibiotic (~8
fold with
cephalsporins and 30
fold with quinolones)
Current landscape of hospital
antibiotic prescribing in Scotland:
National Survey June 2009
• 31 hospitals
• 27.8% patients on
•
•
•
•
antimicrobials
50.5% given
intravenously
76.1% reason
recorded in case
notes
57.9% compliant
with local guidelines
30.3% surgical
prophylaxis more
than one day
some room for
improvement!
ANTIBIOTIC’S AND “COLLATERAL”
DAMAGE: RESISTANCE AND CDI
Valiquette L et al. CID 2007; 45, S112-S121.
RESTRICTED ANTIBIOTICS AND IMPACT ON
CDAD AND MRSA: UK EVIDENCE
• Large UK [London]
•
•
•
hospital
CDI increasing
Restricted narrow
spectrum antibiotic
intervention
ITS analysis
• Reduction in rates of CDI
•
and MRSA
No change in mortality
Monthly count data for CDI, new cases of MRSA and numbers of admissions pre- and postintervention (July 2001)
Fowler, S. et al. J. Antimicrob. Chemother. 2007 0:dkm014v1-6;
doi:10.1093/jac/dkm014
Copyright restrictions may apply.
What is SAPG?
• Multidisciplinary national clinical forum
•
•
based on SMC collaborative structure
Staffed by Project Lead (pharmacist),
Project Officer & Information Analyst
Includes representatives from key
national stakeholders - SMC, QIS, ISD,
HPS, NES and SGHD and all mainland
NHS boards.
Antimicrobial Management
Team (AMT)
• Sub-group of NHS Board Area Drug &
Therapeutics Committee
• Key role in progressing SAPG work at local
level
• Lead doctor, Consultant Microbiologist,
Antimicrobial Pharmacist, Infection Control
Manager, Primary Care representative
Medical Director
Chief Executive
Area Drugs & Therapeutics
Committee
Infection Control Manager
Risk Management
Committee
ANTIMICROBIAL MANAGEMENT TEAM
(AMT)
Clinical Governance
Committee
Dissemination & feedback
Infection Control Committee
Antimicrobial Pharmacist
Prescribing support / feedback
Microbiologist / Infectious
Diseases Physician
Ward Based Clinical
Pharmacists
PRESCRIBER
A consortium of Antimicrobial
Management Teams
Aim:Scottish Antimicrobial
Prescribing Group (SAPG)
• Improve the quality of antimicrobial
prescribing and infection management in
hospitals and primary care
– Reduce amount and reduce broad spectrum
– Improve quality of prescribing [choice, route, dose,
duration, timeliness]
– Reduce harm (mortality,
CDAD, resistance)
– Measure improvement
– Measure unintended harm (complications e.g
nephrotoxicity and ototoxicity, readmissions, increased
ICU referral, resistance, other)
WORKSTREAMS
• Organisation and
Accountability
-Structures, Leadership,
Performance targets
• Education
– Multi-professional
– Team based
• National and Local
Information
– Antimicrobial Surveillance
– Antibiotic Consumption
– Dissemination and sharing
of data
• Infection management
– Protocols, Community
acquired Pneumonia
Improvement, acute
care infection
management
– Care Homes
HIGH IMPACT INFECTIONS IN
ACUTE MEDICINE
• Pneumonia/LRTI’s
• Infective exacerbation of COPD
• UTI
• Skin and soft tissue infections
• “Febrile illness”
• Sepsis syndrome
Why acute medicine ?
• “Front- end” of
•
•
•
empiric prescribing
High burden of
infection admissions
Some evidence of
poor quality of
prescribing
National TARGET for
antibiotic prescribing
in acute medicine and
other units
• Key Issues
– Identification of infection
[education]
– Severity assessment
– Use of “investigations”
– Over treatment and
under-treatment
– Appreciation of “collateral”
damage
– Discussion of unintended
consequences
– Timeliness of antibiotics
Clinical appropriateness and treatment success by
severity:SSTI’s
Marwick C et al in press
Treatment Classification
Appropriate
Over treatment
Under
treatment (%)
(%)
treatment (%)
Initial
treatment
successful (%)
Eron
Class
Total
I
92
21
62
13
71
II
66
30
21
33
71
III
35
29
29
37
54
IV
12
8
0
92
25
All
205
24
40
28
65
Why acute medicine?
•
•
•
•
•
Recognising infection and its severity
Appropriate “empiric” antibiotics
Maintain effectiveness but reduce “collateral damage”
Improve case record documentation
Reduce over diagnosis, over-treatment and undertreatment : UTI, SSTI
• Look at use and interpretation of investigations
• Engage the “team” in prescribing
• Improve timeliness
• Look how we can get reliable, sustained improvement
Health, Efficiency & Access to
Treatment (HEAT) Targets
“30% REDUCTION IN CDAD
BY MARCH 2011”
•Hospital-based empirical prescribing: antibiotic
prescriptions are compliant with the local antimicrobial
policy and the rationale for treatment is recorded in the
clinical case note in >95% of sampled cases
•Surgical antibiotic prophylaxis: duration of surgical antibiotic prophylaxis
is <24 hours and compliant with local antimicrobial prescribing policy in >
95% of sampled cases
•Primary Care empirical prescribing: seasonal variation in quinolone use
(summer months vs. winter months) is < 5%, calculated from PRISMS data
held by NHS Boards.
Compliance with a combined measure of
empirical antimicrobial prescribing in 14 NHS
Boards in Scotland (Data poster April 2010)
100
Target >95%
Percent compliant with combined measure
90
80
70
60
min
50
average_team
max
40
30
20
10
0
Jun-09
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10
JUDGEMENT V IMPROVEMENT
STEWARDSHIP: ARE WE WINNING?
•
2009M12
2009M08
2009M04
2008M12
2008M08
2008M04
2007M12
2007M08
2007M04
2006M12
2006M08
2006M04
2005M12
2005M08
2005M04
2004M12
2004M08
2004M04
DDD
20
04
M
20 04
04
M
20 08
04
M
20 12
05
M
20 04
05
M
20 08
05
M
20 12
06
M
20 04
06
M
20 08
06
M
20 12
07
M
20 04
07
M
20 08
07
M
20 12
08
M
20 04
08
M
20 08
08
M
20 12
09
M
20 04
09
M
20 08
09
M
12
DDD
Impact of restricted policy on CDAD at NWH
Vernaz N et al
Antibiotic Reduction
2'500
CDAD Impact
2'000
50
40
1'500
30
ciprofloxacin
model
1'000
0
700
600
500
400
300
cefuroxime
model
200
100
0
10
20
5
10
0
500
0
-5
-10
-15
I
II
2006
III
IV
I
II
2007
III
Residual
IV
I
II
2008
C.diff
III
IV
Model
I
II
2009
III
IV
I
2010M01
2009M10
2009M07
2009M04
C. diff cases
45
2009M01
2008M10
2008M07
2008M04
2008M01
2007M10
2007M07
2007M04
2007M01
2006M10
2006M07
2006M04
2006M01
LOCAL AND NATIONAL
IMPACT ON CDI
50
P <0.001
40
P<0.001
35
30
C.dif
25
model
20
15
10
5
0
Why acute medicine and
SAPG collaboration?
• “Our desire to move a
philosophy of restriction
[restricted policy] and
judgement [HEAT Target] to a
culture of clinical care that is
driven by measuring
improvement and learning”
• “The right antibiotic for the
right patient, at the right time,
with the right dose, the right
route and cause the least harm
to the patient and future
patients”