NHS Improvement AMS Workshop London 5th May

Antimicrobial Stewardship
Workshop – Sharing success,
planning ahead and developing AMR
networks
Twitter #AMRWorkshop
Chair Dr Bruce Warner
Deputy Chief Pharmaceutical Officer
NHS England
LONDON 5th May 2016

Workshop objectives
1. Learn about what is new in 2016-17 – AMR CQUIN &
Quality Premium; PHE Fingertips; Behavioural strategies
for AMR
2. Sharing success – learn about what worked well
3. Discuss what this means for your local health economy
4. Start planning local AMR networks – what might these
look like? How to get started
2

UK 5yr AMRS: 7 key areas
for action
3

4
9.30 am Arrival and registration
10 am Chairs Welcome Dr Bruce Warner
Deputy Chief Pharmaceutical Officer
NHS England
10.10 – 10.30 AMR Quality Premium
Sharing success in 2015-16 and planning for 2016-17
Elizabeth Beech
National Project Lead HAI and AMR
NHS Improvement
10.30 – 10.50 AMR CQUIN
An introduction to the NHS England AMR CQUIN 2016-
17
Stuart Brown
NHS Improvement
10.50 – 11.10 AMR CQUIN
So what will this mean for your organisation?
Philip Howard
NHS Improvement
11.10 – 11.30 Table Top Discussion and Panel questions EB, SB, PB
11.30 – 11.50 Refreshments
11.50 – 12.10 How Health Education England are supporting
education for AMR and sepsis
Mohamed Sadak
Clinical Lead and Programme
Manager, Antimicrobial Resistance
and Sepsis.
Health Education England
12.10 – 12.30 Behavioural Matters Dr Tim Chadborn
Behavioural Insights Lead Researcher
Research, Translation and Innovation
Public Health England
12.30 – 12.50 Fingertips AMR Portal Dr Diane Ashiru-Oredope
Pharmacist Lead, AMR Programme
12.50 – 1pm Panel Questions MS, TC, D AO
1 – 1.50 Lunch

5
1 – 1.50 Lunch
1.50 – 3.20 Sharing successful antimicrobial stewardship
1.50 – 2.10 Delivering antimicrobial stewardship in an out of
hours provider organisation
Kym Lowder
Head of Medicines Management,
Integrated Care 24
2.10 – 2.30 Use of point of care diagnostics to improve
antimicrobial stewardship in respiratory tract
infections
Liz Cross
Advanced Nurse Practitioner
Attenborough Surgery
2.30 – 2.50 To Dip or Not To Dip – A patient centred approach
to improve the management of
UTIs in the Care Home environment
Elizabeth Beech on behalf of
NHS Bath and North East Somerset
CCG
2.50 – 3.10 Diabetic feet need antimicrobial stewardship too Naomi Fleming
Antimicrobial Pharmacist
Kettering General Hospital
3.10 – 3.20 Panel Questions
3.20 – 3.30 Refreshment Break
3.30 – 3.40 Using networks to deliver antimicrobial
stewardship
Elizabeth Beech
NHS Improvement
3.40 – 4.00 Table Top discussion and action plans for using
local networks
PH, SB, EB, D AO, MS, LM, BW
4.00 – 4.20 Table Top feedback on action plans
4.20 – 4.30 Summary and close Dr Bruce Warner
Deputy Chief Pharmaceutical
Officer
NHS England
Have a safe journey home

AMR Quality Premium – sharing
success in 2015-16 and planning for
2016-17
Elizabeth Beech
National Project Lead - Healthcare Acquired Infection and
Antimicrobial Resistance
Elizabeth.beech@nhs.net @elizbeech
5th May 2016

THANK YOU – this is what its all about
7

8
Improved antibiotic prescribing in
primary and
secondary care
This is a composite Quality Premium
consisting of three
parts:
Part a) reduction in the number of
antibiotics prescribed in
primary care
Part b) reduction in the proportion of
broad spectrum
antibiotics prescribed in primary care
Part c) secondary care providers
validating their total
antibiotic prescription data

Expectations exceeded!
data to Feb 2016
• 2.7 million fewer antibiotics were prescribed
compared to previous 12 months – 7% reduction
• 0.6 million of these were broad spectrum items – a
14% reduction
• Items/STAR-PU value for England reduced by 8%
to 1.098 (median CCG value = 1.091)
• % broad spectrum items value for England reduced
to 9.8% (median CCG value = 10.1%)
• All Trusts, except one, validated data
9

Success in NHS push to reduce avoidable
antibiotic prescribing – NHS England News
23 March 2016
Dr Mike Durkin, NHS National Director of Patient
Safety, said: “Antimicrobial resistance is a major
threat to the delivery of healthcare across the globe,
and these findings clearly show that NHS England’s
incentive programme is an important step in the right
direction. Healthcare staff across the country should
be congratulated for this significant achievement
10

NHS England Antibiotic Quality Premium
monitoring data set – CCG targets met
11

Reduction in broad spectrum antibiotics items –
all CCGs in England
14

Quality Premium Guidance for 2016/17 -
Antimicrobial resistance (AMR) Improving antibiotic prescribing in
primary care
This Quality Premium measure consists of two parts - each worth 50% of the
Quality Premium payment available for this indictor, which is worth 10% of QP
Part a) reduction in the number of antibiotics prescribed in primary care. The
required performance in 2016/17 must either be:
a 4% (or greater) reduction on 2013/14 performance
OR
equal to (or below) the England 2013/14 mean performance of 1.161 items per
STAR-PU
Part b) number of co-amoxiclav, cephalosporins and quinolones as a proportion
of the total number of selected antibiotics prescribed in primary care to either:
- to be equal to or lower than 10%, or
- to reduce by 20% from each CCG’s 2014/15 value
15

Antibiotic prescribing variability by CCG Jan15 – Dec15
16

Antibiotic prescribing variability by GP practice Jan15 – Dec15
17

So how do we continue to improve primary care
antibacterial prescribing in 2016-17?
Respiratory tract infections
• Delayed and No antibiotic prescription resources
• Bristol University NIHR funded research tools for use in
children
• Diagnostics – US Agency for Healthcare Research and Quality
• Vaccination
Urinary Tract Infections
• Link with the Think Kidney AKI programme
• Target nursing home residents
Education and Behavioural change
• Engage schools and universities
• Make every contact count – how can nurses help?
Local AMR Plans
19

Reduction in RTI antibiotic prescribing – all CCGs
in England
20

Finally
Continuing:
• NHSE Antibiotic quality premium monitoring dashboard
• PrescQIPP AMS Hub
Just arrived:
• PHE Fingertips AMR portal
Looking forward:
• CCG Improvement Assurance Framework (IAF) AMR
indicator
• Sustainability and Transformation Plans – opportunities?
• NICE guidance PHG89: Antimicrobial stewardship - changing
risk-related behaviours in the general population
22

AMR CQUIN 2016/17
Stuart Brown
Project Lead – AMR and HCAI
NHS Improvement
21st April 2016

Plan
• Background
• AMR CQUIN 2016/17
– Part A – Reduction in antibiotic consumption per
1,000 admissions
– Part B – Empiric review of antibiotic prescriptions
• FAQ’s

Health and Social Care Act 2008
26

Antimicrobial Stewardship – Documents
2015

Part A – Reduction in antibiotic consumption per
1,000 admissions
28

ESPAUR 2014
• First national survey
on Antimicrobial
Consumption for
primary and
secondary care
• Information on the
use of antibiotics
– Primary Care –
NHSBSA database
– Secondary Care –
obtained from data
held by IMS Health®

ARHAI – Quality measures
Advisory Committee on Antimicrobial Resistance and Hospital Acquired Infections (ARHAI) Recommended Antimicrobial Prescribing Quality
Measures. 2014. https://app.box.com/ARHAI-Minutes-Papers/1/2152374732/18606265032/1

Data Validation – Quality Premium
Part c) secondary care providers with 10%
or more of their activity being
commissioned by the relevant CCG have
validated their total antibiotic prescribing
data as certified by PHE

Reduction in antibiotic consumption per 1,000
admissions
• There are three parts to this indicator
– Reduction of 1% or more in total antibiotic consumption
– Reduction of 1% or more in carbapenem
– Reduction of 1% or more in piperacillin-tazobactam
• Each indicator is worth 0.2% of the CQUIN scheme with an
additional 0.2% for
– Submission of consumption data to PHE for years
2014/15 and 2015/16
• The baseline data set is from 2013/14
33

Example Spreadsheet for upload
34

Example Spreadsheet for upload
35

FAQs Part A
Why has the baseline year been set as 2013/14
As part of the 2015/16 Quality Premium (QP), acute providers were required to submit
antibiotic usage data to Public Health England (PHE) for validation against information held
within IMS. Data provided by acute providers was assumed to be correct and was invaluable
in improving the accuracy of data held within IMS. During the validation exercise data
provided by acute providers was taken as correct and provided an accurate baseline of
antibiotic usage.
Can I use data from 2015/16
As above, the baseline of 2013/14 was chosen as this is the only nationally available data
set to be used for comparison which has been validated
Does the Total antibiotic consumption reduction refer to just those antibiotics that were
submitted as part of the Quality Premium (QP) or all antibiotics including those not included
in the data validation i.e. Aztreonam, Co-trimoxazole etc
The data submitted for the QP represented greater than 90% of antibiotic usage reported by
acute providers. Information on the antibiotics not included as part of the QP will be taken
from IMS to give a total value of antibiotic usage. These values will be available on NHS
England shortly. As soon as they are available, they will be communicated out. Acute
providers will have the opportunity to upload a full antibiotic data set from 2013/14.
36

FAQs Part A
When should antibiotic consumption data for years 2014/15 and 2015/16 be submitted and
how will it be submitted?
Total antibiotic usage data for years 2014/15 and 2015/16 should be submitted by the end of
Q1 (June 2016). A spreadsheet will be made available on the NHS England website, which
can be downloaded and populated with acute provider usage data. Once completed this
spreadsheet should be e-mailed to PHE
How will I submit quarterly data for the year 2016/17
A spreadsheet will be available to download from the NHS England website, similar in design
to last years QP. Once the spreadsheet has been populated it should be e-mailed to PHE
and it would be advised to copy your CCG into this e-mail. PHE and NHS England will
produce a report within 4 weeks to show which acute providers have submitted data.
Where is admission data extracted from?
Admission data has been taken from HSCIC and is available online
(http://www.hscic.gov.uk/)
What if I submitted the wrong data or I have identified an error in the data submitted?
If an error has been identified following submission of data for last year’s QP then it would be
advisable to inform your CCG of the error and data for the year 2013/14. Data for the year
2013/14 can be resubmitted for validation and a new baseline calculated but PHE will require
information on why the original data was incorrect.
37

Part B – Empiric review of antibiotic prescriptions
38

Part B – Empiric review of antibiotic prescriptions
• Only one part to this element
– Percentage of antibiotics prescriptions reviewed within 72 hours
• Local audit of a minimum of 50 antibiotic prescriptions taken from a
representative sample across sites and wards
• Milestones
– Q1 Perform an antibiotic review for at least 25% of cases in the sample
40

Part B – FAQs
Which areas should be audited to collect the data for Part B?
A selection of wards and areas including Medicine, Surgery, Elderly Care, ICU, Neonates,
Obstetrics and Gynaecology should be included, with an aim to ideally include all areas and
specialities within each quarter. If this is not possible then all areas should be audited within
the year
Should I audit 50 sets of notes, 50 courses or 50 antibiotic prescriptions
Each month 50 antibiotic prescriptions should be audited. This may result in one patient
having two antibiotic prescriptions counted i.e. a patient prescribed IV Cefuroxime and IV
Metronidazole for five days would count as two antibiotic prescriptions.
Who should collect the data for Part B?
Any suitably qualified healthcare professional with experience of data collection e.g. Doctor,
Nurse, Pharmacist, Pharmacy Technician
41

Part B – FAQs
What is an empiric review
As part of good antimicrobial stewardship it would be expected that a review of an antibiotic
should take place within 72 hours of starting. This review will be based on Start Smart then
Focus (https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-
then-focus) and would include documented evidence of either:
• Stop
• IV to PO switch
• Change antibiotic
• Continue
• OPAT
This information can either be documented within the medical notes, on the medication chart
or electronically (if systems exist).
Is there a tool for uploading data for Part B of the CQUIN and how will commissioners know
if the data has been submitted?
PHE are developing a data submission tool for Part B (empiric review). It is recommended
that this form is used for data collection and submission. Following submission of the data to
PHE an e-mail will be sent to you and can be forwarded by you to your CCG as evidence of
data submission. A list of those organisations who have submitted data will be available on
the NHS England website as well as PHE’s AME Fingertips.
Example data sample tool (draft)
42

AMR CQUIN
• Two parts
– 1% reduction in consumption
– Antibiotic review within 72 hours
• Data collection forms will be released shortly and
will be available via NHS England
• Baseline data will be available shortly
44

What are the key
challenges in
implementing
AMR CQUIN?
Philip Howard
Consultant Pharmacist
AMR Project Lead
Twitter: @AntibioticLeeds
philip.howard2@nhs.net
#AMRCQUIN

1. Denial / shock
Things I’ve heard already
“I already have a perfect AMS programme in my
hospital, and can’t achieve any further improvement
…. We reduced our antibiotic consumption by a zillion
% and our only vial of pip-tazo and meropenem are
kept in the microbiology exhibits cupboard …”
TO
“not more work for the antimicrobial pharmacist
without any additional support ……. I might as well
give up an apply for one of those new GP prescribing
pharmacist posts like the rest of them …. ”

2. Reality check
“I knew something like this was probably coming for
months via the grapevine. If only I had heeded the
advice to get a plan in place for a once in a lifetime
opportunity to improve my AMS programme”
“actually, I know we’re not perfect from my
audit data, and feedback from my colleagues
in the hospital”
“When I chat to people at other hospitals, they’re
doing some really innovative things”

3. Where are we now?
Difference from 2013 to 2014
DDD/1000 adm (England)
• Total -0.7%
• Carbapenem +4%
• Piperacillin-tazo +7%
40% of hospital AB is OP & ED AB. Same AMS principles of checking
indication against guidelines still apply. Audit of PGDs?
RR8 = -46
RR8 = -1
RR8 = -1

4. Feasibility of achieving CQUINs

5. Feasibility (2) – getting ideas
What’s my biggest challenge? Total, carbapenems or pip-tazo or all of
them?
What guidelines recommend carbapenems or pip-tazo?
• Are there alternatives? Identify a lead for each to review.
• Does my restricted / protected AB policy really work? LTH 
Can I reduce my total consumption?
• Do we over-treat? Is it sepsis driven? LTH+37% IV AB in 2y 
• Is our prevalence high to peers? LTH <30% 
• Is our day 3 review outcome data good (vs peers)? LTH 70% continue
in notes & 85% on Rx 
• Do we send appropriate samples before AB? LTH 81% 
• Do we act on results within 24 hours? LTH 50% 
• Can we use diagnostic tests to delay or avoid starting or stopping
antibiotics earlier? CRP in ED, procalcitonin, etc

NHS Scotland: Use of pip-taz, carbapenems
and carbapenem sparing agents in acute hospitals*
(aztreonam, fosfomycin, pivmecillinam, temocillin)
* Excludes NHS Highland
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
DDDsper100,000popperday
Year/Qtr
Carbapenems Pip-Tazo Carbapenem Sparing Agents
“but they cost so much more than cheap mero or pip-taz”

NHS Scotland: Use of carbapenems,
carbapenem sparing agents and pip-tazo
in Jul-Sep 2015 in acute hospitals by NHS board*
* Excludes NHS Highland
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
DDDsper100,000popperday
Carbapenems Carbapenem Sparing Pip-Tazo

NHS-Scotland PPS: Compliance With Antibiotic
Policy
high for meropenem
lower for pip-tazo
Only 50% have
active restricted
(protected) AB
follow up. (Howard
JAC 2015)

FY 2015/6 Carbapenem sparing vs pip-
tazo + carbapenem

Has 2015-6 Sepsis CQUIN  ED IV AB use?
Overall 9.3%  in rolling 12
mth from April to March
(info from Rx-Info Define software)
CEM audit of IV AB in 60 mins:
2011 = 27% (IQR 17-37%)
2013 = 32% (IQR 20-44%)
CQUIN Sepsis
2015-6 Q2 = 49%, Q3 = 58%
61% of red flags required Abs
Day 3 review in 2016-7 CQUIN

Recommended annual AMS audits &
feedback to improve prescribing
ESPAUR 2014
LTH audits showed 50% & 81%
Only 10% could supply
results & outcome
(Llewellyn JAC 2015)
LTH 59% in notes

of antibiotic use & prescribing standards for Feb-16
Antimicrobial
Prescribing
Standards
LTH
ABDO
MED
SURG
(32)
ADULT
CRITICAL
CARE
(42)
ACUTE
MEDICIN
E (18)
CARDIO-
RESPIRA
TORY
(22)
NEUROS
CIENCES
(34)
CHAPEL
ALLERTO
N (20)
CHILDRE
N'S (14)
HEAD &
NECK
(28)
LEEDS
CANCER
CENTRE
(16)
TRAUMA
&
RELATED
(36)
URGENT
CARE
(24)
WOMEN'
S (12)
Indication (as per guideline) on chart 96% 97% 97% 96% 99% 100% 100% 86% 100% 98% 98% n/a 92%
Duration or review date on chart 94% 94% 97% 100% 100% 67% 100% 84% 100% 98% 92% n/a 75%
Follow AB guidelines 99% 97% 100% 99% 100% 100% 100% 100% 100% 98% 98% n/a 100%
Day 3 review completed 76% 66% 89% 81% 58% 71% 100% n/a 100% 89% 46% n/a n/a
All allergy boxes completed fully 92% 94% 97% 90% 90% 92% 100% 99% 100% 92% 80% n/a 100%
Overall performance             
Day 3 review outcomes Stop 2% 5% 0% 5% 0% 0% 0% n/a 0% 3% 0% n/a n/a
IVOS 6% 11% 0% 14% 0% 0% 50% n/a 0% 3% 0% n/a n/a
Oral to IV switch (escalate) 1% 0% 0% 2% 0% 0% 0% n/a 0% 0% 0% n/a n/a
Change AB 2% 0% 0% 7% 0% 0% 0% n/a 0% 0% 0% n/a n/a
Continue 89% 84% 100% 72% 100% 100% 50% n/a 100% 95% 100% n/a n/a
LTH
ABDO
MED
SURG
(32)
ADULT
CRITICAL
CARE (42)
ACUTE
MEDICINE
(18)
CARDIO-
RESPIRAT
ORY (22)
NEUROS
CIENCES
(34)
CHAPEL
ALLERTO
N (20)
CHILDRE
N'S (14)
HEAD &
NECK (28)
LEEDS
CANCER
CENTRE
(16)
TRAUMA &
RELATED
(36)
URGENT
CARE (24)
WOMEN'S
(12)
-10% -6% -7% -9% -18% -3% -19% -28% -11% 10% -28% -12% 17%
-5% 2% -3% -1% -21% 23% -52% -26% 17% 9% -20% -3% 22%
6% 4% -5% 14% 9% 11% 19% -8% 0% 11% 3% 12% 6%
1% -2% -9% 13% 5% 7% -19% -8% 26% 4% -5% -4% -1%
IV AB usage             
IV AB usage to Feb-16
Total IV - short term (3mth vs last yr)
Broad spectrum IV - short term (3mth vs last yr)
Total IV - long term (12mth vs last yr)
Broad spectrum IV - long term (12mth vs last yr)
Do you know your AMS performance?
• users like smiley faces – easy to understand

Do we actually make a diagnosis?
Bodansky 2012 Clin Med (Lond)
100 consecutive MAU admissions started on antibiotics over 3 days
• Do our guidelines give advice
about negative results?
• Driving D3 review with a sticker
put in notes by ward nurse

Chelsea & Westminster restricted /
protected AB follow up (Orla Geoghegan)
• Micro unaware 73% of 3048 restricted AB FY20145
• 14% deemed inappropriate. 56% stopped within 72h
• 677 interventions - 91 % were actioned. Avg 45min/day
UKCPA PIN Award 2015

E-Whiteboard to highlight IV AB
AB

IV to oral switch – day 3 sticker
Day 3 review of antibiotics
Micro results checked  Imaging 
Patient eating? IVOS  OPAT 
New diagnosis:
Next review date:

Diagnostic markers to delay or avoid
initiation or stopping antibiotics earlier
Health Technology Assessment of procalcitonin (Nov-15)
• 18 studies (36 reports): PCT algorithms were associated with:
• reduced antibiotic duration [WMD –3.19 days, 95% confidence interval (CI)
–5.44 to –0.95 days, I2 = 95.2%; four studies],
• hospital stay (WMD –3.85 days, 95% CI –6.78 to –0.92 days, I2 = 75.2%; four
studies)
• and trend towards reduced intensive care unit (ICU) stay (WMD –
2.03 days, 95% CI –4.19 to 0.13 days, I2 = 81.0%; four studies).
• no differences for adverse clinical outcomes.
• not clear that PCT testing is the main cause of these reductions, or
reproducible in UK hospitals
• may be cost-saving for adults with sepsis in an ICU setting and adults
and children with possible bacterial infection in EDs.
www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0005/156911/FullReport-hta19960.pdf

NICE diagnostics guidance
[DG18] on Procalcitonin testing
“procalcitonin tests …. show promise but there is currently insufficient
evidence to recommend their routine adoption in the NHS. Further
research on procalcitonin tests is recommended for guiding decisions to:
• stop antibiotic treatment in people with confirmed or highly
suspected sepsis in ITU or
• start and stop antibiotic treatment in people with suspected bacterial
infection presenting to the emergency department.
Centres currently using procalcitonin tests to guide these decisions are
encouraged to participate in research and data collection
Talk to your hospital Director of Quality if you consider this a
antibiotic sparing strategy. Some hospitals target patients.
Completion of a NICE non-conformity statement

Electronic systems for AMS
• Hosp e-Rx is poor (9%17%, but 50% in progress) + indn +
durn ~34% built in (2012 Global AMS survey UK data)
• Data warehousing (2% in UK) - links pathology & pharmacy
systems to patient admin system
• Can use data warehousing without e-Rxing if issue
antibiotics to patients
– Bug – no drug. Drug – no bug.
– Reporting systems of use & resistance
– Increases productivity by 50% of AMS staff (USA – Theradoc)
– Big savings on antibiotics & improved outcomes (USA)
• Use CQUIN money to get better AMS tools
• National specification for e-prescribing to improve AMS
(ESPAUR subgroup)

5. Feasibility (3) – investment
1. Carbapenem or pip-tazo sparing AB will cost more. How much?
• LTH: already use 24% carb sparing (vs 8% mean). New costs
from £5-£12/day to £80-100, but generic linezolid will save
me £400k/yr). Est £150-200k
2. Do we have antimicrobial consumption monitoring systems in
place?
• LTH: poor but use Rx-Info Define to benchmark nationally.
£6k for Refine (inward looking)
3. Do we need extra staff to collect / share data or AMS rounds?
• LTH: IT support for data sharing. Extra staff for collection ,
audit and education. £50k

New evidence for AMS Teams
Schuts (LID 2015) metanalysis: strong evidence
•  mortality: empirical guideline adherence, de-
escalation based on C&S, bedside consultation for
S.aureus bacteraemia)
• IV to oral switch = LOS + ££, cure
• TDM:  nephrotoxicity
• restricted antibiotics:  use (but  non-restricted) +
AMR
Taconelli (ECCMID 2016) – metanalysis of AMS on AMR
• AMR G+ve -43% (MRSA -49%), G-ve -28% (CRE -48%)

5. Feasibility (4) - leadership
Can we (AMS team) achieve this on our own?
• LTH: need to join sepsis & AMR CQUINs (start smart
then focus) into a single quality improvement
programme.
How will I keep the hospital senior leaders updated on
progress?
• LTH: ask! They will be asking you for a monthly
update – income stream

Summary: To meet the AMR and
Sepsis CQUINs
• Design systems to force better prescribing eg day 3 review for de-
escalation AND IV to oral switch
• Review guidelines containing piperacillin-tazobactam and
meropenem. Ensure they are followed through audit & feedback
• Quality improvement, not annual audit of AMS
• Merge sepsis and AMR CQUIN – start smart then focus
• Protected (restricted) antibiotic systems need to work
• Monitor & benchmark antibiotic usage
• Regular but varied communication on progress
• Local education & training at ward level
• Strong and effective multidisciplinary leadership (champions) at all
levels

Thank you to lots of people
• Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer,
Jason Dunne, Cheryl Mitchell, Mark Wilcox
• NHS England: Elizabeth Beech, Stuart Brown, Matthew
Fogarty, Lauren Mosley, Mike Durkin, Celia Ingham-Clarke
• PHE: Diane Ashiru-Oredope, Susan Hopkins, Cliodna
McNulty, Duncan Selby
• NHS Scotland: William Malcolm, Jacqui Sneddon, Alison
Coburn, Dilip Nathwani, Andrew Seaton, Susan Paton
• UKCPA PIN: Orla Geoghegan, Mark Gilchrist, Tejal Vegha
• ESCMID ESGAP: Celine Pulcini, Stephan Harbarth
• ISC: Gabriel Levy Hara, Ian Gould

Table Top Discussion and Panel Questions

How HEE is supporting
education for AMR and
sepsis
Mohamed Sadak, Clinical Lead and Programme Manager

www.hee.nhs.ukwww.hee.nhs.uk
What does HEE do?
Health Education England (HEE) exists to
support the delivery of excellent healthcare
and health improvement to the patients and
public of England by ensuring that the
workforce of today and tomorrow has the
right numbers, skills, values and behaviours,
at the right time and in the right place.

The Mandate identifies a number of priorities for the future, as well
as providing an opportunity to recognise the progress made in
meeting objectives set in previous mandates.
 Work with PHE to ensure that the competence and principles of
prescribing antimicrobials, as set out by the NPC and the ARHAI
advisory group are embedded in professional curricula.
 Work with universities, commissioners and employers to ensure
workforce capability, capacity and planning mitigates the risk of
antimicrobial resistance as set out in the UK AMR strategy.
 Take steps to ensure that training is also available so that
healthcare staff are competent in the recognition of, and response
to, acute illness such as sepsis as a key factor in preventable
mortality.
HEE Mandate 2015/16

Work streams
AMR
• Introductory e-
learning module.
• AMPS competence HEI
survey into curricula.
• AMR animation.
• AMPS competence
embedding by
professional bodies.
Sepsis
• Educational video on
paediatric sepsis.
• Educational resources
for primary care.
• Scoping work on
current training.
• GP spotlight project.
• Partnership with UKST.

Introductory e-learning module
http://www.e-lfh.org.uk/programmes/antimicrobial-resistance/

The Antimicrobial Prescribing and Stewardship (AMPS) Competences, (ARHAI & PHE, 2013).
45 universities and 100 course responses (17 Medical, 13 Pharmacy, 22 Independent Prescribing, 5
Dental , 24 Nursing, 13 Midwifery and 7 Allied Health Professional courses).
86 courses (86%) confirmed they were aware of these AMPS competencies.
Embedding AMPS competence
into HEIs curricula.
COMPETENCY Dent Pharm Med Midw Nurs Ind
Pres
AHP
1: Infection Prevention and Control. 100% 98% 99% 85% 86% 72% 94.2%
2: Antimicrobial resistance and antimicrobials 97% 100% 99% 59% 56% 75% 41%
3: Prescribing antimicrobials. 88% 81% 96% 41% 29% 90% 30%
4: Antimicrobial Stewardship. 73% 77% 91% 51% 42% 77% 25%
5: Monitoring and learning 50% 48% 63% 23% 16% 68% 14%
Total average 82% 81% 90% 52% 46% 76% 40.8%

AMR animation
https://youtu.be/oMnU6g2djm4

 Royal College of General Practitioners (RCGP).
 The UK Sepsis Trust (UKST).
 Public Health England (PHE).
 Royal College of Paediatrics and Child Health
(RCPCH).
 Royal College of Emergency Medicine (RCEM).
 Royal College of Obstetricians and
Gynaecologists (RCOG).
 Royal College of Surgeons (RCS).
 Royal College of Nursing (RCN).
 Royal College of Medicine (RCM).
 College of Paramedics (CP).
 Royal Pharmaceutical Society (RPS).
 Royal College of Physicians (RCP).
 Academic Health Science Networks (AHSN).
 A Patient Representative.
HEE sepsis working group

Short awareness video to help the healthcare
community recognise the signs of sepsis in children and
direct them to appropriate learning materials involving:
 Jason & Clara Watkins (Lost their daughter Maude to sepsis on
New Year’s Day, 2011).
 Dr Nelly Ninis (Consultant Paediatrician, Imperial College
Healthcare, NHS Foundation Trust).
 Dr Tim Fooks (Clinical Lead, Children and Young People, South
East Coast Strategic Clinical Networks).
Advisors:
 Dr Sanjay Patel (Paediatric infectious diseases and immunology
consultant at Southampton Children’s Hospital).
 Dr Hilary Cass (Consultant in paediatric neurodisability at the
Evelina Children’s Hospital, former President of the RCPCH and HEE’s
senior national clinical lead for children and young people’s health).
https://vimeo.com/165134226
Educational video on paediatric
sepsis: THINK SEPSIS.

E-learning package on the identification
and management of sepsis in primary
care.
Lead authors are 3 GPs;
 Dr Simon Stockley, the RCGP’s sepsis lead.
 Dr James Larcombe.
 Dr Alison Tavare.
The target audience for the modules will be
GPs, but our intention is to make them
available across primary care,.
Sessions:
1. Introduction on sepsis.
2. Adult sepsis.
3. Childhood sepsis.
4. Complex safety issues.
5. Care homes and the frail elderly.
Educational resources for
primary care: THINK SEPSIS.

Scoping the provision of learning materials available to support the recognition and
management of sepsis in different sectors of practice and across different healthcare
groups.
Our aim is to be able to promote existing good practice, identify gaps in the materials
currently available and make recommendations for the commissioning of new materials to
cover these gaps.
The organisations we have contacted as part of this work include:
All acute hospital trusts in England via the Directors of Medical Education and pharmacists via the
United Kingdom Clinical Pharmacy Association (UKCPA) Infection Management Group and Critical Care
Group.
Primary Care Pharmacists via the Primary and Community Care Pharmacy Network, Primary Care
Pharmacists Association and Primary Care Advisors Group.
All ambulance trusts in England via the Association of Ambulance Chief Executives Group / College of
Paramedics (x 13).
All Health Education England Local Teams (x 13).
All Academic Health Science Networks in England (x 13).
Royal Colleges
Scoping work

UKST:
“Sepsis Savvy” microteaching sessions for parents and lay people in order to help
raise awareness.
E-learning module on sepsis recognition in care homes (led by NWC AHSN).
RCGP:
 RCGP Clinical Lead for sepsis.
Coordinate and focus General Practice efforts to improve the outcomes from sepsis,
particularly to collaborate with colleagues across all health systems to reduce deaths
from sepsis in England.
Develop and deliver 4 regional workshops across England delivered through RCGP
Enterprises/Faculties.
Work with UKST and RCGP

 Julie Screaton (Director, London and South East, Health Education England).
 Ged Byrne (Director of Education and Quality, Health Education North).
 Alan Ryan ( National Programme Director, e-LfH).
 Andrew Frankel (Postgraduate Medical Dean, Health Education South London).
 Janet Flint (Programme Lead, Public Heath National Programmes, Health Education
England).
 Diane Ashiru-Oredope (Seconded to HEE March 2015 – September 2015).
 Rachel Alder (Fellow in Medical Education, Health Education South London).
 Antonio De Gregorio (Programme Coordinator – National Programmes, Antimicrobial
Resistance and Sepsis, Health Education England).
The HEE team.

Thank you for listening.
Questions / Thoughts /
Comments?
Visit: www.e-lfh.org.uk/programmes/sepsis
&
https://www.hee.nhs.uk/our-work/hospitals-primary-
community-care/prevention-public-health-
wellbeing/antimicrobial-sepsis-awareness
Contact: mohamedsadak@nhs.net

Antimicrobial Stewardship Workshop
AMR: a behavioural challenge
Dr Tim Chadborn & Anna Sallis CPsychol
Leeds 21April 2016

Aims:
1. Illustrate innovative behavioural approaches to AMR
2. Summarise key behavioural/social issues and
opportunities related to AMR
3. Share key examples of innovative behavioural
intervention

Wicked problems for behaviour change
90

Limitations of Traditional
Behaviour Change Theories
• The Health Belief Model – Becker (1974) Importance of beliefs, perceived benefits &
barriers to action, self-efficacy, stimulus/ cue to action. Limitations; focused on
conscious decision making and ignores habits.
• Social Learning Theory – Bandura (1977) Importance of social environment,
modelling and self efficacy
• Theory of Reasoned Action Ajzen & Fishbien (1980)/ / Theory of Planned
Behaviour – Ajzen (1985) Limitation; assumption people act in a rational way at all
times, not all behaviour is planned.
• Stages of Change Model / Transtheoretical Model – Prochaska and DiClemente
(1997) Assumption behaviour change occurs in a linear fashion, progression through a
series of stages.
Key limitations:
• Effectiveness of predicting behaviour change
• Intention-behaviour gap
• Not addressing automatic motivation, habits and impulsive behaviour.
91 3 Public Heath England - Behavioural Insights

Behavioural challenges in dispensing
92
Causes
• Failure to check
• Lack of concentration
• Poor handwriting
• Design of dispensary
• Busy workplace / distractions
• Stress
• Staff shortages
• Lack of clinical knowledge
• Medicines with similar names
• Medicines with similar packaging
Recommendations
• Verification
• Take breaks
• Check – involve two people
• Clutter free / organised dispensing
• Minimise disruptions
• Limit workload
• Maintain appropriate staffing
• Limit roles to competent staff
• Alert staff
• Alert staff
3 Public Heath England - Behavioural Insights
Leyla Hannbeck et al. www.npa.co.uk // James et al. IJPP 2009
Are these appropriate to change the
behaviour?

Characterising interventions using a
comprehensive model of behaviour change
Identify gaps /
opportunities
Deliver current
interventions
smarter
Michie et al (2011)

Behavioural analyses
Literature

Antibiotic prescribing:
literature review and behaviouralanalysis
Structured search using Ovid Medline® to 18 November 2013.
95
629 down to 197. 529 down to 54.
What do we know
(or think) might
contribute to AMR?
What do we know
(or think) might
improve stewardship?
BMJ Editorial
Behaviour occurs as interaction between:
Michie et al. (2011)
Identified behavioural drivers of antibiotic prescribing
Behaviour pathways

Key findings from behavioural analysis –
focus on prescribing in primary care
96
Feel unwell with
self-limiting
infection
Visit GP
Inappropriately
prescribed
antibiotics
Recovery
Inappropriate
attribution of
recovery to
antibiotics
Reinforcement
of health
seeking
behaviour
Intervention
opportunities
GP prescribes
antibiotics to
patients as norm
with insufficient
professional or
personal
consequence
Patient is satisfied
– linked to GP
performance pay
Some possible solutions:
• Address GP concerns of
consequences of not
prescribing
• Improve GP belief in the
consequences of
overprescribing
• Enhance GP perceived
capability regarding the
impact of their personal
behaviour on AMR
• Make consequences of
AMR more immediate,
visible, salient and
personally relevant
• Increase credibility of
pharmacy advice
Consequences of
AMR are unclear to
the public
Do not realise that
antibiotics will not
improve their symptoms
for viral or self-resolving
infections
Societal benefits but few
immediate personal benefits
- lack of incentive to change
current behaviour

Intervention design and implementation

COM-B – dual process model
98
Michie et al (2011)
Cane et al (2012)
Behaviour
Capability
Psychological
Physical
Motivation
Reflective
Automatic
Opportunity
Social
Physical
Skills, strength, stamina
Knowledge, skills, memory
Attitudes, beliefs, intentions
Emotions, impulses, habits
Norms, cues, acceptability
Time, resources, cues

Behavioural Insights Intervention
12 Lancet. 2016 Apr 23;387(10029):1743-1752.
Randomised Control Trial -
reducing antibiotic prescribing
through behavioural science
1581 GP practices in top 20% by
prescribing rates randomised to:
1. Education materials for patients
2. Social norms feedback letter
from the Chief Medical Officer
3. Combination of the two
4. No intervention (control)
2 x 2 factorial design determines
independent effects of the two
interventions
Published in Lancet in Feb 2016
“The great majority
(80%) of practices in
[NHS Area team]
prescribe fewer AB
per head than yours”

Reductionin antibioticsdispensedamongpractices
sent the letter comparedto controls - at low cost
2014 2015
Reduction of 3·3% in top 20% - equates to 0.83% across all GPs
Estimated 73,406 fewer antibiotic items dispensed
Cost of £4,335 - saving £92,356 in just prescription costs
13
Graph shows the effect of letter only as no reduction from educational materials
Letter reduced
prescriptions
Letter
intervention
Letter reduced prescriptions
in control group

Other key references
101
JAMA 2016; 315 (6): 562-570
NICE Medicines and Prescribing Centre – Neal Maskrey / Jonathan
Underhill
 Evidence-informed decision making
https://vimeo.com/115958879 & https://vimeo.com/115958880
 MeReC Bulletin Vol.22 No.01 August 2011 - Making decisions better

We won’t tackleAMR if we don’t
change behaviour
Focus on behavioural issues and opportunities – incl. system and
context – considering practicality/sustainability/opportunity costs
Immediate focus on what works, rather than basic understanding
(but aware of and considering wider evidence developments)
Few influences of AMR do not involve behaviour. Behavioural and
social science cut across areas of action in the UK AMR Strategy
(start from behaviour we want to change – not ‘we want to do ……….’)
Need to apply evidence-based frameworks for behaviour change
103

Implementation of national AMS toolkits in England Dr
Diane Ashiru-Oredope
Become an Antibiotic Guardian today
(available via mobiles)
104
Thank you - questions

Antimicrobial Stewardship:
tools for local action
NHS Improvement and PHE
Antimicrobial Stewardship Workshop
21April 16
Dr Diane Ashiru-Oredope
Pharmacist Lead;
Antimicrobial Resistance Programme
Twitter - @DrDianeAshiru #AntibioticGuardian

Outline
Fingertips – tool for local action
Implementation of national antimicrobial stewardship interventions in national
toolkits
• Systems and processes
• Toolkits
• Education and training
• Engaging with patients and the public
Tools available for local action
• Fingertips
• Data submission for CQUIN
106
Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr

UK 5-yearAMR Strategy 2013-18:
Seven key areas for action
PHE
Human health
DH – High Level Steering Group (cross government)
Defra
Animal health
DH
1. Improving infection prevention and control
2. Optimising prescribing practice
3. Improving professional education, training
and public engagement
4. Better access to and use of surveillance
data
• Improving the evidence
base through research
• Developing new drugs,
vaccines and other
diagnostics and treatments
• Strengthening UK and
international collaboration
Impact of EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope & Ms Katerina (Aikaterini) ChaintarliEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope
107

108
Antimicrobial Stewardship
Tools NHSI_PHE
#AMSWorkshop Dr Diane

Complete NICEAMS baseline assessment
109
Antimicrobial stewardship : NICE quality standard
(Was due for publication : 20 April 2016) - postponed

What tools are available:
110

Antimicrobialstewardshiptoolkits:PHE in collaborationwith
severalprofessionalsand professionalorganisations
111
Treating your infection
ntibiotics and always return any unused antibiotics to a pharmacy for safe disposal
Leaflet developed in collaboration with these professional socie

TARGET LEAFLET – GP, OOH, Community
Pharmacy
TREATING YOUR INFECTION LEAFLET: GPs; Out of Hours practice; Community
Pharmacy
• A leaflet for health professionals working in primary care to use when provide
advice to patients. The leaflet provides practical advice on how to treat symptoms
of common self limiting infections and warning signs for serious illness.
Developed by Public Health England 112

113

AMR Education and Training
114
% Acute
Trusts
(n=100)
%CCG
s
(n=82)
Has a written Antimicrobial Education and Training Strategy 24 1
Competency assessments carried out for prescriber 17 *
Competency assessments are mandatory 20 *
Teaching on induction for all nurses 27 6
Teaching on induction for all pharmacists 69 6
Teaching on induction for non-medical prescribers 18 7
Mandatory e-learning for senior doctors (registrar and higher) 17 4
Mandatory e-learning for junior doctors 24 4
Antimicrobial prescribing and stewardship training is left to
individual trainers to decide
* 33

E-Learning for Healthcare (HEE)
AMR; WLMHT Physical Health Conference Dr Diane Ashiru-Oredope
Free for all with
NHS email address
115
Open access for ALL
Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

Specialists in primary and secondary care
Primary Care
Prescribing advisors/medicine
management pharmacists in 66% of
CCGs
Specialist antimicrobial pharmacist
in 5%
Quality leads and nursing clinical leads
in 6%,
GP clinical leads in 2%.
Specialist antimicrobial pharmacists
spent 4-7 times longer on these
duties than non-specialists such as
prescribing advisor/medicine
management pharmacists, quality
leads, nursing clinical leads or GP
clinical leads
Secondary Care
90% of responding Trusts had a
specialist antimicrobial pharmacist
at band 8a and above in post.
116
Pharmacist Grade % Acute
Trust
(n=100)
Pharmacy technician - band
5 or higher
2
Pharmacist - band 7 9
Pharmacist - band 8a 59
Pharmacist - band 8b 17
Pharmacist - band 8c 2
Consultant Pharmacist (≥8c) 5
None 4
No answer provided 2
Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

117
Antimicrobial Stewardship #AMSworkshop
Dr Diane Ashiru-Oredope
See Posters

Information for local action
• With access to PHEs Fingertips
portal, data for stakeholders
regularly in a timely fashion
• Fingertips can be used information
for action in each of key areas
• antimicrobial stewardship
• antimicrobial prescribing
• antimicrobial resistance
• infection prevention and control
• healthcare associated infections
118
Antibiotic Guardians per 100,000 population by CCGs

PHE Fingertips Web Portal
(http://fingertips.phe.org.uk/)
119

PHE Fingertips Web Portal
120
Published: 5 April 2016
Questions?
Email: espaur@phe.gov.uk

121
Domain Quality Indicators
AMR • % of E. coli from blood tested for susceptibility to carbapenems
• Gram-negative BSIs and resistance to key antibiotics
Prescribing • Community prescribing (CCG)
HCAI • Mandatory bacteraemia surveillance data
• Mandatory CDI surveillance data
• Mandatory SSI surveillance data
IPC • ERIC data on single rooms/single rooms with ensuite (by Trust);
• PLACE cleanliness scores
• Healthcare worker influenza vaccination
AMS • Antibiotic Guardians per 100,000 population per year (CCG)
• SSTF review and action plans (by Trust);

122 AMR Local Indicator122 Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

AMR Local Indicator
Domains
Click these to change between domains, note that
indicators will only display if there is an indicator
for the Area type chosen
All indicators that are available for Acute Trusts and CCGs are available in the
“All Trust” and “All CCGs” domains.
123Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

AMR Local Indicator
Area type
This dropdown allows you to switch between GP
Practice, CCG and Acute Trust indicators

AMR Local Indicator
Area
Use this to select the individual GP practice, CCG
or Acute Trust you would like to view all data for

AMR Local Indicator
Area
grouped by
This dropdown will determine how the data is
aggregated, sub-regions are the default for this
profile

AMR Local Indicator
Sub-region
This dropdown will determine which sub-region
the system will display data for

Benchmark
The default for this is England, in some cases a
benchmark against sub-region values will be
allowed.
128

AMR Local Indicator
View tabs
These offer alternative ways of displaying the
data, further detail in the later slides

AMR Local Indicator
Some indicators display a coloured background on their values. This is to denote a
comparison to the benchmark value.
A legend is provided by the system at the top.

AMR Local Indicator
In the overview mode, you view multiple indicators within a domain simultaneously.
This will only display the indicators for the chosen area type and the appropriate sub-
region and national value.

In this view you can change between sub-regions. The grey left and right arrows allow
you to scroll between all the CCGs/ Trusts within the selected region.
132

AMR Local Indicator
Scatterplots to be drawn between different health indicators. Indicators are chosen from
the drop down menu
You can highlight individual GP, CCG, Trusts

AMR Local Indicator
Treat with caution due to concerns over time release of data from different indicators
and potential misuse due to not fully appreciating caveats of individual indicators.
Trendlines will only display if R2 > 0.15

The mapping function gives a strong visual
representation of the indicator as well as
regional fluctuations.
The system does not currently have the
facilities to map at trust or GP level.
The scale can be altered to be matched
against the benchmark, by quartiles,
quintiles on a continuous scale.

AMR Local Indicator
Able to monitor the trend of an indicator over time.
Can be done along with or independently from a benchmark against a chosen area or
areas within a single area-grouping
View a single indicator or all indicators within the same domain and area type
simultaneously.

AMR Local Indicator
Additionally, users can view a single area or multiple areas within a region
simultaneously.

The data can be viewed for just the selected sub-region or at a national level.
Data can be sorted by Area, Count or Value.
95% CI are presented if the data is sample of the total population
138

AMR Local Indicator
Multiple indicators can be viewed at once within a single domain. Users are able to see
where their chosen area falls among the range of all values for that indicator.

AMR Local Indicator
Users are able to see the highest and lowest values recorded for any indicator as well as
the value for their chosen area.
Further information on the interpretation of a high or low value can be found in the
definitions tab.

141 AMR Local Indicator
Within the definitions you will find the full explanation of each indicator, where the data is
sourced from and how the indicator was produced.
Information on how this data should be interpreted and any data caveats for the indicator
will be listed here.
141

This tab allows you to download the data
as an excel file.
Note the timescale of the data if you are
looking to download the data regularly.

This slide is for All Trust data
AMR Local Indicator
All Acute Trust indicators displayed together

This slide is for all CCG data
All CCG indicators displayed together.
144

This slide is for National GP Profile Page
AMR Local Indicator
For an individual General practice you can see the trend data across the
indicators.

You can also create a scatter plot with any other indicator on the GP profile,
identifying outliers with particular patient groups.
146

FutureAMR local indicators
147
Domain Quality Indicators
AMR •Number of AMRHAI confirmed CPE by Trust
•Trimethoprim resistance in community urine samples by CCG
Prescribing • Nitrofurantoin: trimethoprim ratio, by GPs and CCGs
HCAI • Surgical Site Infection Surveillance datasets
• Other GN-BSI by CCG (and in future Trusts)
• HCAI mortality data
• Number of Blood cultures sets and Clostridium difficile tests
IPC • Healthcare worker Flu vaccination
AMS • Start Smart Then Focus Audits, by Trusts

Antimicrobial Stewardship Surveillance:
CQUIN - data collection form and
submission tool
148

AMS Surveillance tool piloted
149

Participants stated whether they collected the following information
and provided the percentage of patients who met these criteria
150
% Trusts that
collected these
data (n=28)
Mean percentage of
patients achieving
this indicator
Range of the
proportion of patients
meeting this indicator
Indication documented
on drug chart (inc
severity where
appropriate)
89.29 83 27-100%
Stop or review date
documented
92.86 73 30-99%
Antibiotic courses
reviewed with formal
documentation at 48-72
hours after initiation of
therapy
35.71 71 10-96%
Compliant with local
guidelines (dose,
frequency, duration) or
reason for variance
78.57 84 30-98.5%
C&S samples taken
before starting
antibiotics
14.29 58 10-88%
Antimicrobial allergy
documented
60.71 93 30-100%

Tool adapted to focus on CQUIN data
submission
151

152

153

National Point Prevalence Survey 2016
Voluntary participation
England’s fifth point prevalence survey (PPS) on HCAI and second national
survey on antimicrobial consumption and prescribing quality indicators.
At a national level the PPS will act to improve knowledge and understanding of
antimicrobial resistance (AMR), HCAI and AMU – a key aim of the cross-
government UK 5 year AMR strategy
At a hospital level the data generated could be utilised to demonstrate
compliance with criteria one and three of Code of practice.
Letters sent to Chief Pharmacists and DIPCs of all acute Trusts.
Please consider including this in your 2016/17 IPC and antimicrobial
stewardship work plan and nominate two surveillance leads
(suggestion: lead IPC nurse and antimicrobial pharmacist) and email
names to ppsengland@phe.gov.uk by April 1 2016.
154

Engaging with
patients & the
public

Educating the public
Moving from awareness to engagement:
Antibiotic Guardian calls on everyone inUK tobecome
Antibiotic Guardians – Behaviour change – ‘if-then’approach
pledge system: http://antibioticguardian.com/
Combating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope
EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope156 AMR; WLMHT Physical Health Conference Dr Diane Ashiru-Oredope156 Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

Evaluation summary
• Good response of an overall representative sample
• Increased self-reported knowledge and changed self reported behaviour
particularly with those with prior AMR awareness
• Increased commitment to tackling AMR by both HCPs and members of the
public
• Less successful in engaging general public most likely due to modes of
promotion
• Majority thought the campaign was well promoted
157 Overview of AMR in England & AMR campaigns: Dr Diane Ashiru-Oredope
In Press
157

EAAD and WorldAntibioticAwareness Week
16 – 22 November 2016
307 organisations registered their
antibiotic awareness activities with
PHE, 69% were NHS organisations and
13% were universities.
During WAAW, 6510 individuals became
Antibiotic Guardians.
Of AGs who registered during WAAW, 49%
were healthcare professionals, 31%
were members of the public and 20%
were students or educators.
158
Antibiotic Guardians per 100,000 population by CCGs &
registered orgnisations

PLANS FOR EAAD/AG 2016/17
• Healthcare Students
• Young families: suggestions included promotion through council-run
nurseries, building on the success of “Listen to your Gut” campaign
materials. Encouraging local authorities to promote Antibiotic Guardian
alongside flu vaccination campaign.
Plans are currently underway to develop a “Junior Antibiotic Guardian” through
the use of digital badges. This is in collaboration with PHE nursing
directorate, eBug and Makewaves (https://www.makewav.es/).
The Public through Community Pharmacy
NOTE: THERE WOULD STILL BE MATERIALS AVAILABLE FOR
ENGAGING WITH OTHER PLEDGE GROUPS
159

Developed by Public Health England
National Awards
12 May 2016, Birmingham
Categories include:
Staff engagement: How have staff promoted Antibiotic Guardian and stewardship within their
organisation?
Community: How has your organisation worked within the community to highlight Antibiotic Guardian?
Prescribing: How has your organisation tackled prescription and prescribing antibiotics effectively?
Innovation: Tell us how you have demonstrated innovation to address Antimicrobial Resistance?
Antibiotic Stewardship: How have you improved or measured antibiotic usage in your area or
community?
AMS Research: How have you demonstrated development of research to support
Antimicrobial Stewardship?
79 entries. Shortlist on www.antibioticguardian.com
160

Questions for delegates:
Feedback on Fingertips presentation
Are IPC and AMS teams working together? If not, how can we do this?
How can we make better use of existing networks?
Is there emphasis on education on AMR and AMS in addition to IPC which is
currently part of most Trusts mandatory training in addition to the statutory
training?
161

162

Distribution ofAntibiotic Guardians between
13 October 2015 - 31 March 2016, n=16,173.
163

HowAntibiotic Guardians reporting hearing
of the campaign, asked as part of sign up
164

Formerly South East Health
Antimicrobial
Stewardship in an Out of
Hours Provider
Kym Lowder
Head of Medicines
Management and NICE
Medicines & Prescribing
Associate

Service Variations: Q4 12.13
0
1
2
3
4
5
6
7
8
9
10
% Items Ceph & Quin of all Antibiotics
Nat Average

OOHs Challenges
• Patient expectations
• Primary Care access
• Relationships
• Access to patient records
• Transient Workforce (600 clinicians/month)
• Shift patterns
• Benchmarking & Numbers
• Data issues
• Worzel Gummidge Effect
• No carrots
• Demands on unscheduled care
• Activity & Service development
• Increased care out of hospital

OOHs Advantages
• No hiding place.....
• Customised software
• Information updates
• Timely information
• Stock management

Generic Service Actions
• Removal of Cephalexin from OOH formulary (c. 2010)
– no stock available for supply OOHs
• Antibiotic guidelines based on HPA
• Locality guidelines
• Quinolone stock minimal
• Newsletter reminders
• Locality Comparisons
• Highlighting NICE guidance e.g. CG69
• RCGP audit toolkit – focus on antibiotic use

Updated actions
• NICE AMS Guidelines
• Baseline assessment and action plan
• Use of QP data/MO KTT as benchmarks
• Participation in health economy AMS groups
• Regular data analysis and feedback

Locality Specific Actions
• Run report for Prescribing Patterns for Quinolones and Cephalosporins
• Identify GPs with “higher” than average prescribing rates
• Ascertain whether outliers are NMPs/local GPs/agency/IC24 salaried
• Place information message re key antibiotic messages on intranet
• Ensure antibiotic guidelines are easily accessible to staff
• Write to all prescribing outliers, individually, highlighting key antibiotic
messages
• Raise with AMDs and Nurse Manager re salaried staff performance
• Sample calls/Review prescribing practice if rates remain high
• Include Co-amoxiclav in reporting and analysis

Apr-Jun12 (Apr-Jun 15) Cephalexin Ciprofloxacin
Total FP10 Prescriptions 478 (98) 204 (92)
Number of individual
clinicians who have
prescribed specified drug
in time frame
105 (59) 84 (48)
Number of individual
clinicians categorised as
‘high’ prescribers
17 (16%)
4 (7%)
4 (5%)
5 (10%)
% of prescriptions
accounted for by ‘high’
prescribers
52% 25%
No. High Prescribers: Local
GPs
13 4
No. High Prescribers:
Agency Locums
1 0
No. High Prescribers:
NMPs
3 0
NOOH

West Kent
• 17 (6/66) ‘high’ Prescribers (Av 90 (130)
clinicians/month)
• 3 GPs requested feedback and info
• GP1: 8.8% (17% inc Co-amox) reduced to 5.97%
• GP2: 7.7% reduced to 3.85%
• GP3: 15.5% reduced to 5.79% BUT Co-amoxiclav
16.8% to 20.5%.
• WK OOH Av 6.92% reduces to 5.34% inc FP10recs
• New ‘offenders’

0
2
4
6
8
10
12
WK CCG DGS CCG WK OOH WK OOH (2)
C&Q Percentages Q1 2013

0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
Corby Daventry Kettering Northamptonshire Wellingborough Nene CCG Average
% Cephs & Quins Prescribed NOOH Q1 -Q4 2012/13

To Summarise
• OOHs is a complex environment
• Data doesn’t tell the whole story
• Peer review can work
• Individualised approaches
• Happy to work with commissioners particularly if
IC24 is an outlier
• Co-amoxiclav!
• Constant Review
• Now have NICE NG15 & MO KTT to support the work

Liz Cross, Advanced Nurse Practitioner
Attenborough Surgery
Hertfordshire
Winner of NHS Innovation Challenge Prize (acorn category) 2015/16

 C-reactive protein (CRP) is a major acute-
phase plasma protein displaying rapid and
pronounced rise of its serum concentration in
response to infection or tissue injury
 CRP levels are typically highest in patients
with a bacterial infection
 A Simple CRP blood test (finger prick) takes just 4 mins
 Standard of care in many European countries9,10,11

 Nearly 80% of antibiotic prescribing is in Primary
Care 4
 Over half of antibiotics prescribed in Primary Care
are for respiratory tract infections (RTI)5
 There is strong evidence that primary care CRP
testing for RTI reduces antibiotic prescribing and
enables patient education and the consultation
discussion.6 Especially:
.
(i) where there is a high degree of diagnostic uncertainty
(ii) for patients who are very worried and/or demanding antibiotics
(iii) to differentiate the seriously ill from the non-seriously ill.

Community-acquired pneumonia
 Consider a point-of-care C-reactive protein test for patients
presenting with lower respiratory tract infection in primary
care if it is not clear after clinical assessment whether
antibiotics should be prescribed.
 Use the results of the C-reactive protein test to guide antibiotic
prescribing as follows:
 Do not routinely offer antibiotic therapy if the C-reactive protein concentration is
less than 20 mg/litre.
 Consider a delayed antibiotic prescription (a prescription for use at a later date if
symptoms worsen) if the C-reactive protein concentration is between 20 mg/litre
and 100 mg/litre.
 Offer antibiotic therapy if the C-reactive protein concentration is greater than 100
mg/litre


• ‘Use of C-reactive protein point-of-care tests as an adjunct to clinical examination
likely reduces antibiotic use in primary care patients with acute (lower as well as
upper) respiratory infections without affecting patient recovery rates or the
duration of illness. ‘

• Economic evaluations show cost-effectiveness of POC CRP
over existing RTI management in primary care.16
• Results from a recent UK 3 year decision analytic model of
CRP testing in the pathway for managing antibiotic
prescribing in primary care for respiratory tract, showed
that a GP plus CRP test and practice nurse plus CRP test
model cost less and resulted in more quality of life years
gained (QALYs) than current practice.17
• Cost savings come as a result of reduced re-attendance
rates to primary care and out of hours as well as reduced
antibiotic prescriptions

 To reduce the antibiotic prescribing rates for
uncomplicated LRTIs in line with NICE guidelines in a
GP based ANP minor illness clinic.
 The secondary objective was the conduct a cost and
workflow analysis to support a larger scale roll out to
10 sites.

 Over a 3 month period, patients presenting to an ANP
clinic were offered POC CRP testing under the
following conditions
◦ 18-65 years old, the patient had a suspected LRTI of duration
<3 weeks or the patient requested abx for an acute cough
◦ Exclusion criteria- pregnant, immunocompromised, terminally
ill, intubated in the past year, acute pneumonia requiring
hospital admission, under follow up for COPD.

Figure 1. NICE recommendations for use of CRP point of care testing in patients presenting with a lower respiratory tract infection
Adult presents in primary care with symptoms of LRTI
Clinical assessment & diagnosis
Pneumonia not diagnosed or not clear
if antibiotic should be prescribed
CRP rapid test
< 20mg/L
Do not routinely offer
antibiotic therapy
20-100 mg/L
Consider a delayed
antibiotic prescription
>100 mg/L
Offer antibiotic therapy
Pneumonia diagnosed
See NICE pathway

70%
25%
5%
<20 mg/L 21-99 mg/L >100 mg/L

CRP level
(mg/l)
n
Immediate
antibiotics
prescribed
Delayed
antibiotics
prescribed
No antibiotics
prescribed
<20 47 0 (0%) 3 (6%) 44 (94%)
21-99 17 3 (18%) 3 (18%) 11 (65%)
>100 3 3 (100%) 0 (0%) 0 (0%)

No antibiotics
prescribed
Delayed
antibiotics
prescribed
Immediate
antibiotics
prescribed
Unscheduled
follow up
within 28 days
2014/15
No CRP testing
(n=106)
51% 18% 31% 28%
2015/16
CRP testing
(n=67)
84% 9% 8% 13%
Reduction
of 23%

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Winter
2014/15
Winter
2015/16
No antibiotics
prescribed
Unscheduled follow
up within 28 days
Reduction in re-attendance of
>50% when antibiotics not
prescribed

 70% of patients presented with a suspected LRTI had a
CRP <20mg/L
 31% of patients were prescribed antibiotics on their
initial presentation during winter 2014/15, compared
with 8% the following year when POC CRP testing was
implemented – reduction of 23%
 Unscheduled follow up within 28 days for patients who
were not prescribed antibiotics reduced by >50%

 POC CRP testing was easy to incorporate into the
consultation and didn’t increase the work load of the
clinic
 Patients were more accepting and reassured when
they weren’t prescribed antibiotics as demonstrated by
reduced presentation rates

 Implementing POC CRP testing helps responsible
prescribing, reducing unnecessary prescriptions
 The reduction in re-attendance rates infers a level of
patient satisfaction and represents significant cost
savings to GPs and wider urgent care services.
 Cost savings are made due to reduced antibiotic
prescriptions and re-attendance rates
 POC CRP testing does not increase work load in clinic

• Encourages appropriate antibiotic prescribing
• Facilitates patient education and self- management
• Responsible prescribing helps to slow down the
spread of antimicrobial resistance
• Results in saving to the NHS and society from fewer
prescriptions and antimicrobial resistance related
costs

 Wide spread adoption in the UK
 Funding models and increasing access
 Other applications within the NHS,
pharmacies, OOH, urgent care

1. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018. Department of Health. 2013
2. STTP
3. O’Neill review
4. Public Health England ESPAUR Report 2015
5. Royal College of General Practitioners, Public Health England and The Antimicrobial Stewardship in Primary Care (ASPIC). TARGET Antibiotic toolkit.
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx
6. Andreeva E, Melbye H. Usefulness of C-reactive protein testing in acute cough/respiratory tract infection: an open cluster–randomized clinical trial with C-
reactive protein testing in the intervention group. BMC family practice 2014;15:80
7. Verlee L, Verheij TJ, Hopstaken RM, Prins JM, Salome PL, Bindels PJ. Summary of NHG practice guideline 'Acute cough'. Nederlands tijdschrift voor geneeskunde
2012;156:A4188.
8. Little, P. et al. (2013). Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster,
randomised, factorial, controlled trial. Lancet 382(9899):117-82.
9. Bjerrum et al. (2011) Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised
multifaceted intervention programme. BMC Family Practice 2011, 12:5215.
10. Huang Y, et al., (2013) Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-
analysis of primary care studies. The British Journal of General 63(616):787-94.
11. Jochen W L Cals, Christopher C Butler, Rogier M Hopstaken, Kerenza Hood, Geert-Jan Dinant. Effect of point of care testing for C reactive protein and training in
communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374
12. ECDC Report 2014 http://www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/esac-net-database/Pages/Antimicrobial-consumption-rates-by-
country.aspx
13. ‘Limit antibiotic use to combat drug resistance, GPs told.’ General Practitioner July 2013
14. Aabenhus R, Jensen JU, Jørgensen KJ, Hróbjartsson A, Bjerrum L.Biomarkers are point of care tests to guide prescription of antibiotics in patients with acute
respiratory infections in primary care. Cochrane Database Syst Rev. 2014 Nov 6;11:CD010130
15. Cooke J. Butler C. Hopstaken R. Dryden M. McNulty C. Hurding S. Moore M. Livermore D. Narrative Review of Primary care point-of-care testing (POCT) and
antibacterial use in respiratory tract infection (RTI). BMJ Open Respiratory Research 2015; Accepted for publication.
16. Oppong R, et al., (2013) Cost-effectiveness of point-of-care C-reactive protein testing to inform antibiotic prescribing decisions. British Journal of General
Practice, July 2013.
17. Hunter, R., (2015) Cost-effectiveness of point-of-care C-reactive protein tests for respiratory tract infection in primary care in England. Advances in Therapy,
32(1):69-85.
18. National Institute of Health and Care Excellence. Pneumonia: diagnosis and management of community-and hospital-acquired pneumonia in adults; published
as CG191; 2014.

To Dip or Not To Dip – a patient centred
approach to improve the management of
UTIs in the Care Home environment
Sharing success AMS Workshop Leeds & London 2016
Elizabeth Beech
Pharmacist - NHS Bath and North East Somerset CCG
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS Improvement
elizabeth.beech@nhs.net @elizbeech

To Dip or Not To Dip – a patient centred approach to
improve the management of UTIs in the Care Home
environment
• This is an evidence based systematic approach to improve the diagnosis and
management of UTIs in residents in all 23 Nursing Homes in Bath and North
East Somerset - Residential homes were not included
• It was delivered by the CCG care home pharmacist service working during
2015-16, aligned to the existing GP enhanced nursing home service, and
funded by the CCG as a quality improvement project in 2014 - <£10K
• Why did we do this? Local clinical audit in 2013 identified residents were
frequently prescribed antibiotics (19 - 48% of residents per care home)
based on use of urine dip sticking

Scatter plot of both National Antibiotic QIPP indicators, Q2 Jul-Sep 2013-14,
for all GP practices in England, with practices in NHS Bath and North East
Somerset identified.

To Dip or Not To Dip – early results
please do not publish as submitted to RPS2016
Early evaluation shows
• 56% reduction in the proportion of residents who had an antibiotic for a UTI
143 / 690 residents had at least one antibiotic for a UTI in 6 month period
Jul-Dec 2015 after implementation
• 67% reduction in the number of antibiotic prescriptions – 153 fewer in 8 NH
with pre and post data
• 82% reduction in the number of residents prescribed antibiotic prophylaxis
13 / 690 residents had antibiotic prophylaxis in 6 month period Jul-Dec 2015
after implementation
• Unplanned hospital admissions for UTI, urosepsis and AKI reduced in NH
population following implementation

To Dip or Not To Dip - the what we did
• Clever commissioning – CCG incentivised nursing homes using a
shadow CQUIN
• The care home pharmacist team – already existed, so extra
funding was obtained to allow them to develop & deliver the intervention
• Documentation and education – used SIGN 88 guidance to
structure documentation for UTI diagnosis, and implemented within an
educational bundle in every nursing home delivered by the pharmacist
• Communicated with everybody – but could have done this better
• Monitoring – for unintended harm resulting in urosepsis
• Evaluation – pre and post audit occurred and a census

Older patients (>65) with suspected UTI (urinary tract infection)
Guidance for Care Home staff
 Complete 1) to 4) and patient details and fax to GP. Original to patient notes.
 DO NOT PERFORM URINE DIPSTICK – No longer recommended in pts >65 years
 CLEAR URINE – UTI highly unlikely
 Consider MSU if possible if ≥ 2 signs of infection (especially dysuria, Temp>38⁰C or new
incontinence)
2) Patients who can communicate symptoms: Y / N 3) All Patients: 4) Catheter
Sign/Symptom Tick if
present
Temperature above 38.3⁰C or below 36⁰C or
shaking chills (rlgors)in last 24 hours
Heart Rate >90 beats/min
Respiratory rate >20 breaths/min
Blood glucose >7.7 mmol/L in absence of
diabetes
Diabetic?
Y / N
Bloods taken?
WCC >12/µL or < 4/µL
WCC:
CRP:
New onset or worsening confusion or
agitation
1) Signs of any other infection source? Y / N If Y circle any NEW symptoms which apply:
Cough Shortness of breath Sputum production Nausea/vomiting Diarrhoea Abdominal pain Red/warm/swollen area of
skin
Patient:………………………………………………………
……
DOB:…………………………………………………………
…….
Nursing
Home:………………………………………….…….
Date:……………………………
Carer:……………….…..
NEW ONSET
Sign/Sympto
m
What does this mean? Tick if
presen
t
Dysuria Pain on urinating
Urgency Need to pass urine urgently/new
incontinence
Frequency Need to urinate more often than usual
Suprapubic
tenderness
Pain in lower tummy/above pubic area
Haematuria Blood in urine
Polyuria Passing bigger volumes of urine than
usual
Loin pain Lower back pain
5) GP Management Decision - circle all which apply: Prescribing guidance at http://www.bcapformulary.nhs.uk/5-
infections
• Review in 24 hours
• Mid Stream Urine specimen (MSU) – if possible if ≥ 2 signs of infection (especially dysuria, Temp>38⁰C or new incontinence) or failed
treatment
• Uncomplicated lower UTI
• Pyelonephritis Antibiotic prescribed:
………………………………………………………………………….......
• Other …………………………………………………………………………………………………………………………………… Signed: …………………………………….…Date:
………………………..
Yes / No
If YES:
Reason for
catheter:
Temp / Perm
Date changed:
26/1/2015
1/2Healthier, Stronger, Together

Public Health England – guidance for diagnosis April 2011
https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis
URINE CULTURE IN WOMEN AND MEN > 65 YEARS
 Do not send urine for culture in asymptomatic elderly with positive
dipsticks
 Only send urine for culture if two or more signs of infection,
especially dysuria, fever > 38 o or new incontinence.4,5C
 Do not treat asymptomatic bacteriuria in the elderly as it is very
common.1B+
 Treating does not reduce mortality or prevent symptomatic episodes,
but increases side effects & antibiotic resistance.2,3,B+
URINE CULTURE IN WOMEN AND MEN WITH CATHETERS
 Do not treat asymptomatic bacteriuria in those with indwelling
catheters, as bacteriuria is very common and antibiotics increase
side effects and antibiotic resistance.1B+
 Treatment does not reduce mortality or prevent symptomatic
episodes, but increase side effects & antibiotic resistance.2,3,B+
 Only send urine for culture in catheterised7B- if features of
systemic infection.1,5,6C However, always:
 Exclude other sources of infection.1C
 Check that the catheter drains correctly and is not
blocked.
 Consider need for continued catheterisation.
 If the catheter has been in place for more than 7 days,
consider changing it before/when starting antibiotic
treatment.1,6C, 8B+
 Do not give antibiotic prophylaxis for catheter changes unless
history of symptomatic UTIs due to catheter change. 9,10B+
Public Heath England – treatment guidance October 2014
https://www.gov.uk/government/publications/managing-common-infections-
guidance-for-primary-care
http://www.sign.ac.uk/guidelines/fulltext/88
/index.html
References: Nina, S et al (2014). Investigation of suspected urinary tract infection in older people. BMJ 349.
TARGET toolkit for training on UTI’s from RCGP Autumn 2014 http://www.rcgp.org.uk/courses-and-events/online-learning/ole/urinary-tract-
infections.aspx26/1/2015 Mandy Slatter/Elizabeth Beech, BANES CCG. Contact
Elizabeth.beech@nhs.net 2/2

To Dip or Not To Dip - what we do next
• Commissioning – the CCG will fund continuation of the model, and
will adopt a similar approach for the AKI programme
• The care home pharmacist team – has extended to cover
residential homes so we will now audit UTI management here now
• Documentation and education – need to review and improve use
of the documentation and continue a rolling education bundle
• Communicated with everybody – but could have done this better
and now need to share the results locally and nationally
• Monitoring – retrospective audit in all nursing homes every 6 months to
produce a run chart for CCG care home quality dashboard
• Evaluation – need to continue to improve antimicrobial stewardship
and documentation lots still to do

Antibiotic prescribing for UTI in all Nursing
Homes over 6 month period post implementation
66
81
24
23
8 2
Antibiotic choice as a proportion of 204 antibiotic prescriptions for UTI
in 143/690 residents in 22 nursing homes - after implementing use of
Sign 88 diagnostic criteria 6 months Jul-Dec 2015
Nitrofurantoin
Trimethoprim
Cefalexin
Co-amoxiclav
Ciprofloxacin
Amoxicillin

environment - Key messages for CCG reporting to NHSE
• Use of an evidence based algorithm to diagnosis UTI in nursing
home residents does improves care
• 56% reduction in the number of residents prescribed antibiotics for
a UTI based on a urine dip stick test
• 82% reduction in the number of residents prescribed antibiotics
prophylactically
• 67% reduction in the number of antibiotic prescriptions
• Improved appropriate management of UTI
• Reduction in unplanned admissions for UTI, urosepsis and AKI
• Reduced calls to GP practices for inappropriately diagnosed UTI
• Include hydration messages within the educational content

environment
Published as an Innovation poster at RPS2015
Shared the concept with many CCGs, some are adopting/adapting
Submitted to RPS2016
Elizabeth Beech
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS Improvement

Diabetic feet need antimicrobial stewardship too
Naomi Fleming: Antimicrobial Pharmacist

What is Antimicrobial Stewardship?
The selection of the most appropriate antimicrobial
treatment, optimization of drug dosage and duration of
therapy needed to cure infection, improve patient
safety through reducing risk of toxicity and adverse
effects and control of resistant strains
Ultimate goal is improved patient care and
healthcare outcomes
The term ’antibiotic
stewardship’ is used to capture the twin aims of ensuring
effective treatment of patients with infection and minimizing collateral
damage from antimicrobial use (Allerberger 2009; Davey
2010; Dellit 2007; MacDougall 2005).

Health and Social Care Act:
Code of Practice
Criterion 3:
Ensure appropriate antimicrobial use to optimise patient
outcomes and to reduce the risk of adverse events and
antimicrobial resistance
3.1 Systems should be in place to manage and monitor the use of
antimicrobials to ensure inappropriate and harmful use is minimised and
patients with severe infections such as sepsis are treated promptly with the
correct antibiotic. These systems draw on national and local guidelines,
monitoring and audit tools such as NICE guidelines, guidance on patient group
directions, the TARGET toolkit in primary care and Start Smart then Focus in
secondary care (SSTF).

Diabetes and Infection
Infection occurs with greater frequency and severity in
diabetic patients.
People with Diabetes twice as likely to be hospitalised due to infection.
Increased risk due to reduced immune response, neutrophils, inflammatory
mediators, leucocytes.
◦ Reduction in neutrophil activity, neutrophils play an essential role in host inflammatory
response.
◦ Decreased responses to inflammatory mediators eg histamine and bradykinin
◦ Increased leucocyte apoptosis
◦ Reduced oxidative activity of neutrophils
Decreased availability of insulin partly responsible and insulin treatment can
improve functional neutrophil activity.
Hyperglycaemia partly responsible
High glucose in tissues and body secretions provides ideal environment for
bacteria to survive

Background diabetic foot
•Diabetes is one of the most common chronic diseases in UK, prevalence is increasing,
with predictions of 5 million by 2025.
•Life expectancy shortened by up to 15years, 75% die of macrovascular complications.
•The risk of foot problems is increased, due to either diabetic neuropathy or peripheral
arterial disease (PAD) or both.
• Diabetes most common cause of non-traumatic limb amputation, 80% are linked
with diabetic foot ulcers and the majority of these with infection.
•Mortality rates are high, with up to 70% of people dying within 5years of having an
amputation and around 50% dying within 5years of developing a diabetic foot ulcer.
•Foot problems with diabetes significant financial impact on NHS ~£650million pa (£1in
every £150) spent on foot ulcers/ amputations each year
•Variation in practice in preventing and managing diabetic foot problems, amputation
rates still vary up to fourfold in the UK.
•This variation in practice results from a range of factors including availability of
healthcare professionals for the MDT with expertise in the management of diabetic
foot problems. Antimicrobial stewardship input into the MDT may improve this.

Treatment of diabetic foot ulcers:
Off-loading to alleviate mechanical load on the ulcers eg: heel
protectors, appropriate mattress, scotch cast boots and potentially
complete non-weight bearing status
Assessment for limb ischaemia. Patients with clinically significant
limb ischaemia should be assessed by a vascular surgeon
depending on severity.
Antibiotics will be required if there are symptoms of infection, they
should be used to treat infection, not to heal the wound which
usually takes longer.
Optimisation of glycaemic control is crucial in the ulcer healing
process. Ensure that the patient is not in DKA or Hyperosmolar
Hyperglycamic State (HHS previously referred to as HONK).
Consideration of changing oral treatment to SC or IV insulin if
appropriate.

IDSA guidelines diagnosing infection:
•Clinicians should evaluate a diabetic patient presenting with a foot wound at 3 levels:
the patient as a whole, the affected foot or limb, and the infected wound.
•Infection generally includes classic signs of inflammation (redness, warmth, swelling,
tenderness, or pain) or purulent secretions.
•Secondary signs (eg, nonpurulent secretions, friable or discolored granulation tissue,
undermining of wound edges, foul odour).
•Factors that increase the risk for infection include a wound for which the probe-to-
bone (PTB) test is positive; an ulceration present for >30 days; a history of recurrent
foot ulcers; a traumatic foot wound; the presence of peripheral vascular disease in
the affected limb; a previous lower extremity amputation; loss of protective
sensation; the presence of renal insufficiency; or a history of walking barefoot
•Clinicians should use a validated classification system, eg PEDIS developed by
(IWGDF) or IDSA.
•Clinicians should diagnose infection based on the presence of at least 2 classic
symptoms or signs of inflammation (erythema, warmth, tenderness, pain, or
induration) or purulent secretions. They should then document and classify the
severity of the infection based on its extent and depth and the presence of any
systemic findings of infection.

Challenges of Diagnosing Diabetic Foot
Infection
•Open wounds are always colonised, therefore growth of
microorganisms from swabs alone is not diagnostic.
•Classical clinical manifestations of erythema, warmth, swelling,
and pain can either be mimicked by or diminished by peripheral
neuropathy and vascular disease.
•Patients with a neuropathic or neuroischaemic feet often have
little or no pain leading to a delayed presentation and diagnosis.
•Inflammatory markers such as CRP and WCC may not reflect the
severity of the infection.
•Patients may present with an ‘asymptomatic’ limb or life-
threatening infection with the only clue being deterioration in
glycaemic control.
•Foot architecture

Investigations (NICE NG 19)
1.6.1 If a diabetic foot infection is suspected and a wound is present, send a
soft tissue or bone sample from the base of the debrided wound for
microbiological examination. If this cannot be obtained, take a deep swab
because it may provide useful information on the choice of antibiotic
treatment.
1.6.2 Consider an X-ray of the person's affected foot (or feet) to determine the
extent of the diabetic foot problem.
1.6.3 Think about osteomyelitis if the person with diabetes has a local
infection, a deep foot wound or a chronic foot wound.
1.6.4 Be aware that osteomyelitis may be present in a person with diabetes
despite normal inflammatory markers, X-rays or probe-to-bone testing.
1.6.5 If osteomyelitis is suspected in a person with
diabetes but is not confirmed by initial X-ray,
consider an MRI to confirm the diagnosis.

Treatment (NICE NG 19)
1.6.6 All hospital, primary care and community settings should have
antibiotic guidelines covering the care pathway for managing diabetic
foot infections that take into account local patterns of resistance.
1.6.7 Do not offer antibiotics to prevent diabetic foot infections.
1.6.8 Start antibiotic treatment for suspected diabetic foot infection as
soon as possible. Take cultures and samples before, or as close as
possible to, the start of antibiotic treatment.
1.6.9 Choose the antibiotic treatment based on the severity of the
diabetic foot infection, the care setting, and the person's preferences,
clinical situation and medical history and, if more than one regimen is
appropriate, select the regimen with the lowest acquisition cost.
1.6.10 Decide the targeted antibiotic regimen for diabetic foot
infections based on the clinical response to antibiotics and the results of
the microbiological examination.
1.6.11 Do not offer tigecycline to treat diabetic foot infections unless
other antibiotics are not suitable.

Which antibiotic?
1.6.12 For mild diabetic foot infections, initially offer oral antibiotics with
activity against gram-positive organisms.
1.6.13 Do not use prolonged antibiotic treatment (more than 14days) for
the treatment of mild soft tissue diabetic foot infections.
1.6.14 For moderate and severe diabetic foot infections, initially offer
antibiotics with activity against gram-positive and gram-negative
organisms, including anaerobic bacteria, as follows:
Moderate infections: base the route of administration on the clinical
situation and the choice of antibiotic.
Severe infections: start with intravenous antibiotics and then reassess,
based on the clinical situation.
1.6.15 Offer prolonged antibiotic treatment (usually 6weeks) to people
with diabetes and osteomyelitis, according to local protocols.

Likely pathogens
Mild infection in an antibiotic naïve person is likely to be caused by
Staphylococcus aureus or beta-haemolytic streptococci.
Moderate and severe infections in antibiotic naïve patients are likely to be
caused by Staphylococcus aureus or beta-haemolytic streptococci, obligate
anerobes are often associated with limb ischaemia, gangrene, necrosis or
wound odour.
People with chronic infections, who are not antibiotic naïve may have
polymicrobial infections including aerobic gram-negative bacilli,
enterobacteriaceae.
Organisms that are usually colonisers but may cause infection include
coagulase negative Staphylococcus and Pseudomonas aeruginosa, these may
also need treatment if empirical therapy is failing following discussion with
microbiology and the diabetes foot team.
Severe infections should always be treated in hospital.
Renal function, antibiotic allergies and Clostridium difficile risk should be
assessed when deciding on antibiotic choices for further treatment.

Input of antimicrobial pharmacist
to MDT:
•Timely antibiotic review
•Interpretation of microbiology results
•Recommendations of antibiotics for specific organisms
•Recommendations with specific patient factors
•Advice to patients
•Restrictions
•Referrals and liaison
•Follow up
•Service development

Final messages:
AMS in DFI complex and needs an understanding of both
DFI is not SSTI
Correct management can save limbs and lives
Get involved
Thank you for listening
naomifleming@nhs.net

How local networks are enabling
antimicrobial stewardship activity in the
South West
Elizabeth Beech 8th March 2016
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS England

Five core features of effective
networks
1. common purpose
2. cooperative structure
3. critical mass
4. collective intelligence
5. community building

CCG footprints aligned within the West of
England Academic Health Science Network

SWAG – South West Antimicrobial Pharmacist
network
• Membership is hospital
antimicrobial pharmacists
• Share clinical audit, education &
best practice, professional
support
• Collaborate on delivery of the
2016-17 AMR CQUIN
• Link with other networks –
microbiologist network
• SWAG network provides a
reliable communication cascade
system
• Example: working together to
develop a methodology for 48
hour review as part of SSTF

BGSW Bath and North East Somerset, Gloucestershire, Swindon, Wiltshire
Clostridium difficile Infection Commissioner Group
• Membership is NHS England
quality lead, CCG quality leads
& pharmacists, and PHE field
and epidemiology staff
• Strategic and operational
content to support NHS CDI
objectives, and 2015-16 AMR
Quality Premium
• Share intelligence – IPC, AMR
and AMS data and practice
• Enhanced surveillance of
Community Attributed CDI led
by PHE, to drive improved
management of CDI

BGSW Antimicrobial Stewardship Network
• NHS England led (building on CDI
network) - membership open to
all organizations including
councils and PHE, and all
healthcare professionals
• Established to support delivery of
the 2015-16 AMR Quality
Premium
• Shares intelligence and successful
practice fast; including sharing
educational resources and
expertise
• Example: EAAD 2016 planning

Bristol, South Gloucestershire, North Somerset, Bath and North
East Somerset Antimicrobial Stewardship Network
• Membership is CCG and provider
organization pharmacists, and
links to BGSW network by
overlap
• Established to support delivery of
the 2015-16 AMR Quality
Premium
• Shares intelligence – AMS audit
data and practice
• Example: sharing community IV
antimicrobial service activity,
AMS audit data

Bath and North East Somerset Health Strategic
Healthcare Infection Prevention
and Control Collaborative
• Originally established to support
HAI & IPC agenda - now evolved
to include AMR and stewardship
• Led by the CCG, multi
organizational, multi disciplinary,
acute provider hosted 8 weekly
• Operational and strategic, shares
intelligence and expertise
• Example: whole health
community dataset for all cases
of CDI; improving transfer of
information across care
boundaries; learning from
norovirus to improve
preparedness

Bath and North East Somerset AMR Group
• Set up under Health and Well
Being Board, reporting to Health
Protection Board
• Chaired By CCG Clinical Chair
• Membership will represent the
whole community, including
patient representation
• Strategic role to support delivery
of National AMR strategy and PHE
local AMR plans
• Example: Public engagement with,
and education about, resistant
infections – prevention and
appropriate use of antimicrobials

What will you lead?
• What networks already exist
in your local health
economy?
• What pharmacy involvement
looks like?
• How can you improve
effectiveness?
• What will you take away
today?
• Your pledge to……

Table Top Discussion on action plans for
using local networks

Table Top feedback on action plans

NHS Improvement AMS Workshop London 5th May

NHS Improvement AMS Workshop London 5th May

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