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Welcome to the Antibiotic
Guardian Leeds Workshop
#antibioticguardian
Introduction
Dr Diane Ashiru-Oredope, Pharmacist Lead,
AMR Programme, Public Health England &
Department of Health Expert Advisory
Committee on AMR & HCAI (ARHAI)
#antibioticguardian
Strengthening infection prevention
and control practices
Suzanne Calvert – Senior Health Protection Practitioner
Yorkshire and the Humber PHE
21st September 2016
Antibiotic Guardian Roadshow: tackling
antimicrobial resistance locally
Introduction
UK Five year Antimicrobial resistance strategy 2013-2018
number of hard-to-treat infections continues to grow…increasingly difficult
to control infection in routine medical care settings …
antibiotic resistance cannot be eradicated, it can be managed to limit the
threat to, and minimise the impact
‘the medicine cabinet is empty for some’
‘Everyone has a responsibility and a role to play in making this happen’
*
4
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
UK AMR strategy 2013 – 2018
WHO global action plan 2014
European Press release 2016
Tackling drug-resistant infections Globally – O’Neill May 2016
5
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
European, International resources
Key considerations
6
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
“ The basics of public health – clean water, good sanitation and
hygiene, infection prevention and control and surveillance –
..critical for reducing the impact of antimicrobial resistance and
infectious disease control’
Infection Prevention and Control needs to be embedded as
a priority for health systems at all levels.
A return to the attitudes pre-antibiotic era,
when infection prevention was a priority, cures were limited.
Top-down priority-setting have a valuable role in bringing this
issue higher up the priority
UK 2016
Government press statement at the close of the G7 summit:
‘global health…the urgent need to tackle antimicrobial resistance’.
‘…the catastrophic consequences if we do not act – 10 million excess deaths a year
by 2050. If we do nothing …. the potential end of modern medicine as we know it’.
Dame Sally Davies, Chief Medical Officer for England – ‘antibiotic apocalypse’
Jane Cummins – Chief Nursing Office - prevent infections and control their spread,
….reduce the need for antibiotics and limit opportunities for antimicrobial resistant
strains to develop.
7
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Definitions
Infection is the invasion of body tissues by disease -causing agents,
their multiplication, the reaction of host tissues to these
organisms and the toxins they produce
Prevention action of stopping something from happening or arising
Control the power to influence or direct people's behaviour
a means of limiting or regulating something
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Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
What do the regulations say?
Outcome 8: CQC`s Essential Standards for Quality and Safety on cleanliness
and infection control
 Must… ensure that:
• service users, persons employed, others who may be at risk of exposure to a health care
associated infection
‘are protected against identifiable risks of acquiring such an infection ……..’
 assess the risk
 appropriate standards of cleanliness and hygiene
*The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
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Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Infection prevention - thoughts
Microbes spread from person to person – varying routes
Mobile genes spread between microbial species
Infection control mistakes
Basic infection control precautions are key to preventing spread -
opportunities
Whole health economy involvement
How do we assure ourselves that what should be happening is really
happening?
Should we have more targets?
10
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
IPC Opportunities
11
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Contact time - opportunities
‘Staffing levels impact upon the ability of nursing and midwifery staff to provide high
quality care’
NHSE: Safer Staffing: A Guide to Care Contact Time
Nov.2014
‘Unnecessary extra workload created by lack of
clear systems and processes for practices and
hospitals to communicate with each other regarding
shared patients…’
Making time in General practice’ 2015
12 Presentation title - edit in Header and Footer
Thoughts contd..
Recurrent factors – learn from others
Improving staff awareness
Cleaning of equipment and the environment
Funding
Infection control team not functioning well
Outbreaks
13
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Developing a local approach
Yorkshire & Humber AMR group
HPT AMR leads, FES team, Microbiology services, NHSE
Surveillance –
• Monthly mandatory surveillance data review (MRSA, MSSA & E Coli bacteraemia +
C difficile cases)
• Monthly CPE case review (numbers, epidemiological data, linked cases)
Local Intelligence –
• Review of meetings attended and planned attendance
• Review of escalation required / report for Quality Surveillance Groups
Patient Journey –
• Working together in geographies
• Cross boundary
14
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Infection Prevention & Control
Patient
journey
Local
intelligence
15
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Patient
journey
Surveillance Local
intelligence
surveillance
16
Antibiotic guardian roadshow: Tackling antimicrobial resistance locally
21.9.2016
Infection prevention and control
Is a much better option than the
pre antibiotic era solutions!
Thankyou for Listening
Heather Edmonds
Head of Medicines optimisation
Leeds North CCG
 Show you the range of website and data
available
 The data they provide
 How to use the data locally to influence local
decisions and guidance.
 PHE Fingertips portal
http://fingertips.phe.org.uk/profile/amr-local-indicators
 Open prescribing http://www.openprescribing.net/
 Antibiotic quality premium monitoring
dashboard
https://www.england.nhs.uk/resources/resources-for-
ccgs/ccg-out-tool/ccg-ois/anti-dash/
 NHSBSA information portal
http://www.nhsbsa.nhs.uk/3607.aspx (password required)
 PHE Second Generation Surveillance System
https://sgss.phe.org.uk/Security/Login (password required)
 English surveillance programme for
antimicrobial utilisation and resistance
(ESPAUR) report
https://www.gov.uk/government/publications/english-
surveillance-programme-antimicrobial-utilisation-and-
resistance-espaur-report
 HCAI Data Capture System
https://hcaidcs.phe.org.uk/WebPages/GeneralHomePage.asp
x
 PrescQIPP - https://www.prescqipp.info/datahub
 NHS E Medicines Optimisation dashboard -
https://www.england.nhs.uk/ourwork/pe/mo-dash/
Antibiotic reports
 Antibiotics in
uncomplicated UTIs
 Minocycline ADQ/1000
patients (KTT11)
 Broad-spectrum antibiotics
(KTT9)
 Co-amoxiclav,
cephalosporins &
quinolones (KTT9)
CCG comparison Practice comparison
CCG AREA England CCG (%) AREA (%) England (%)
0.28 0.31 0.30 5.95 6.04 8.48
ANTIBIOTICS
Antibacterial items per STAR PU
Number of prescription items for antibacterial drugs (BNF 5.1) per oral antibacterial (BNF 5.1sub-set)
ITEM based STAR-PU
Co-amoxiclav, Cephalosporins and Quinolones % items
Number of prescription items for Co-amoxiclav, Cephalosporins and Quinolones as a percentage of
the total number of prescription items for selected antibacterial drugs (sub-set of BNF 5.1)
0.0
0.1
0.2
0.3
0.4
0.5
Numberofantibacterialitems
perSTAR-PU
Clinical Commissioning Group
All CCGs CCGs in West Yorkshire Area
NHS Leeds North CCG England (AVG)
West Yorkshire Area (AVG)
0
2
4
6
8
10
12
14
16
PercentageofitemsforCo-
amoxiclav,Cephalosporinsand
Quinolones
Clinical Commissioning Group
All CCGs CCGs in West Yorkshire Area
NHS Leeds North CCG England (AVG)
West Yorkshire Area (AVG)
Any questions?
Tackling AMR: Engaging with
Patients and the Public
AntibioticGuardianRoadshow
21st September2016
Aliya Rajah
Professional Training and Public
Engagement Coordinator
Antimicrobial Resistance Programme
Public Health England
Aliya.rajah@phe.gov.uk
Twitter - @AliyaRa5
#AntibioticGuardian
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) Chaintarli
42 Tackling AMR: Engaging with Patients and the Public
Antibiotic resistance is poorly communicated and widely
misunderstood by UK public
“the body becomes resistant to antibiotics”
“If my symptoms have gone, I no longer
need to take antibiotics”
“It’s not my problem”
People have a better understanding when
AMR is presented in a way that is relatable
to them
“By getting antibiotics from the doctor, I
haven’t wasted their time”
43 Tackling AMR: Engaging with Patients and the Public
Every infection prevented
means less antibiotics
are used
AMR
44 Tackling AMR: Engaging with Patients and the Public
45 Tackling AMR: Engaging with Patients and the Public
2016 theme: chain of infection
Timeline of English Antibiotic
Awareness campaigns
46 Tackling AMR: Engaging with Patients and the Public
1999:Andybiotic –
“Don’t wear me out”
• Press and magazines
• GP surgeries –
leaflets and postcards
• GP non-prescription
pads
• 1999, 2000, 2003,
2006
Educating the public: the value of awareness campaigns
Dr Diane Ashiru-Oredope
47 Tackling AMR: Engaging with Patients and the Public
Sent to all GP surgeries and
independent pharmacies
48 Tackling AMR: Engaging with Patients and the Public
Developing plans for EAAD 2014
• In previous years EAAD plans included creating educational materials
which healthcare professionals could use as part of local awareness
campaigns.
• Developed EAAD in 2014
• campaign that would be available all year round
• awareness raising  engagement
• commitment from healthcare professionals and the public
• First year that the lead organisation aimed to directly engage the public
• Campaign developed by PHE in collaboration with all the UK devolved
administrations and also professional organisations
• Planning group is a multi-disciplinary group with public and third-sector
representation from human and animal health sector across the UK
49 Tackling AMR: Engaging with Patients and 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/
Tackling AMR: Engaging with Patients and the PublicCombating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope
EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope50 Tackling AMR: Engaging with Patients and the Public
Video created with TV doctor
Educates on antibiotic resistance; suggests three steps that public can
take to help and a call to become an antibiotic guardian. Available for
download
51 Tackling AMR: Engaging with Patients and the Public
Tackling AMR: Engaging with Patients and the PublicCombating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope
EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope52 Tackling AMR: Engaging with Patients and the Public
Current website
Public Information should reflect One Health agenda –
VMD, Bella Moss
53 Tackling AMR: Engaging with Patients and the Public
Tackling AMR: Engaging with
Patients and the Public
EAAD &Antibiotic Guardian: children
centres; hospitals; community pharmacies
University College London Hospitals
Awareness and engagement in Hospitals, community pharmacies,
universities, organisations in all UK Countries
Tackling AMR: Engaging with Patients and the Public
Engagement via social media – e.g pictures tweeted with
#AntibioticGuardian
Tackling AMR: Engaging with Patients and the Public
Antibiotic Guardian demographics
31 March 2016:
31, 105 AGs
30 August 2016
57 Tackling AMR: Engaging with Patients and the Public
AG pledges from across the world
As of 09 May 2016,
there were 31,440
Antibiotic Guardian
pledges; with at least
one pledge from 77
countries across the
world.
There were five or
more pledges from
24 countries
including South
Africa, USA, India,
Nigeria, Australia,
several countries in
Europe
Tackling AMR: Engaging with Patients and the Public58 Tackling AMR: Engaging with Patients and the Public
1) Healthcare Students – seeking Antibiotic Guardian
champions in healthcare schools
2) Young families for children and families
• Developing “Junior Antibiotic Guardian” through the use of digital
badges. This is in collaboration with PHE nursing directorate,
eBug and Makewaves (https://www.makewav.es/).
3) The Public through Community Pharmacy
New Antibiotic Guardian
Resources for 2016/17
59 Tackling AMR: Engaging with Patients and the Public
Educating children – e-bug led by PHE
Primary Care Unit (Prof Cliodna McNulty)
Europe wide resource, led by Public Health England
e-Bug has
been
translated
into 22
different
languages,
including
most
European
languages,
Turkish
and Arabic
Free educational resource for classroom and home use and makes learning about micro-
organisms, the spread, prevention and treatment of infection fun and accessible for children and
young adults/students
AMR Public Involvement Forum
• Engage with the public via strategic partners and other voluntary
organisations, PHE colleagues, lay members
• Representation from
• animal health, respiratory conditions, faith organisation, BME organisation,
home hygiene, various Healthwatch
• Raise awareness of the importance of AMR
• Encourage organisations to engage with the public to raise awareness
of AMR, especially during WAAW, IIPW
• Using resources and expertise to produce a public engagement toolkit
to support local Public Health England centres and Health Protection
teams
61 Tackling AMR: Engaging with Patients and the Public
Local
engagement
62 Tackling AMR: Engaging with Patients and the Public
Conclusion
• Improving professional education, training and public engagement is
one of the seven key areas of the 5 year UK AMR strategy
• England has participated in EAAD activities since 2008, awareness
was increased but no evidence of increased knowledge and behaviour
change
• For the first time, using behaviour change strategies, the Antibiotic
Guardian campaign has shown evidence of moving from increasing
AWARENESS to ENGAGMENT and commitment from healthcare
professionals and the public
• Evaluation of the Antibiotic Guardian campaign highlighted that it is
an effective for increasing knowledge and changing behaviour (self
reported) particularly among members of public
63 Tackling AMR: Engaging with Patients and the Public
Acknowledgements
British Society for Antimicrobial Chemotherapy for the funding the initial website
development in 2014 and continued active support
Pharma Mix for implementing the design and development of AG website of
www.AntibioticGuardian.com
Inkling London www.inklinglondon.com, for providing marketing and
behavioural insights on the pledges during development
Members of the core EAAD-AG planning group are acknowledged for their
contribution in the planning of the AG campaign
Organisations and individuals who have actively participated in the wider
planning and delivery of the campaign are also acknowledged and can be
found listed in the web appendix methods
64 Tackling AMR: Engaging with Patients and the Public
You are invited to become an Antibiotic Guardian today
(available via mobiles)
Tackling AMR: Engaging with Patients and the Public
Aliya Rajah
Professional Training and Public Engagement Coordinator
Antimicrobial Resistance Programme
Public Health England
aliya.rajah@phe.gov.uk
Twitter - @AliyaRa5
#AntibioticGuardian
66 Tackling AMR: Engaging with Patients and the Public
Question and answers from the floor
#antibioticguardian
Lunch and networking
#antibioticguardian
Welcome back
Dr Diane Ashiru-Oredope, Pharmacist Lead,
Public Health England
#antibioticguardian
Antimicrobial Stewardship - national
update on CQUIN and QP
Stuart Brown
Project Lead – AMR and HCAI
NHS Improvement
21st September 2016
Plan
• Background
• AMR CQUIN
• Quality Premium
• It is growing and spreading according to WHO
figures
– 5 of 6 regions show >50% resistance to 3rd gen
cephalosporins & fluoroquinolones in E.coli
– ALL SIX regions have >50% resistance in Kleb
pneumonia to 3rd gen cephalosporins & 2/5 show AMR
to carbapenems
• All antibiotics will be become resistant in time
• Antimicrobial resistance is generally irreversible
• AMR is directly linked to use at national level
• The antibiotic pipeline is dripping at best
Global AMR in 2014
UK Five Year AMR Strategy
Commissioning for Quality
and Innovation (CQUIN)
• CQUIN framework supports improvements
in the quality of hospital services and the
creation of new, improved patterns of care.
• National & local indicators
– 4 or 5 national priorities each year. Worth 2.5%
of income
– 2016-7 Clinical: Sepsis (2nd year), AMR,
Physical health of patient with severe mental
health
Commissioning for Quality and
Innovation (CQUIN) 2016-17
The CQUIN scheme is intended to deliver clinical quality
improvements and drive transformational change. These
will impact on reducing inequalities in access to services,
the experiences of using them and the outcomes
achieved
Part A – Reduction in antibiotic consumption per
1,000 admissions
Part B – Empiric review of antibiotic prescriptions
76
Part A – 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
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
– Q2 Perform an antibiotic review for at least 50% of cases in the sample
– Q3 Perform an antibiotic review for at least 75% of cases in the sample
– Q4 Perform an antibiotic review for at least 90% of cases in the sample
78
AMR-CQUIN – what & why?
Requires 1% (DDD per admission) vs 2013-4
baseline for:
• Total (IP & OP): +6% over 4 years nationally
• Carbapenems: +36% & KPC outbreaks
• Piperacillin-tazo: +55% & K.pneum-R +36%
E.coli +31%
• 90%+ documentation of empiric antibiotics review
by day 3 (Q1 25%, Q2 50%, Q3 75%, Q4 90%): Only 10% of
Trusts could provide data though mandatory
Hospitals AMS Teams to use ££ to improve IT, staffing,
fund more expensive antibiotics or tests.
Leadership
Can we (AMS team) achieve this on our
own?
• 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?
• 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
Start Smart – Then Focus
82
Progress So Far (as of August 2016)
• Part A – Antibiotic consumption per 1,000 admissions
– 115 of 155 Trusts have submitted consumption data for 2014/15
and 2015/16
– A number of Trusts (n=86) have also submitted data for 2013/14
– 105 Trusts have submitted data for Q1 2016/17
• Part B Empiric review of antibiotic prescriptions
– 119 of 155 Trusts have submitted data via the PHE AMS online
submission tool
– Preliminary data indicates that 80.84% of prescriptions have
evidence of review within 72 hours (range 22-100%).
• All data submitted will be available on AMR Fingertips
October 2016
Quality Premium
2015/16 and 2016/17
Improved antibiotic prescribing in
primary and secondary care
The ‘quality premium’ is intended to reward
clinical commissioning groups (CCGs)
for improvements in the quality of the
services that they commission and for
associated improvements in health
outcomes and reductions in inequalities in
access and in health outcomes
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
NHS England Antibiotic Quality
Premium Dashboard
NHS England Antibiotic Quality Premium
Dashboard 2015-16
Antimicrobial resistance (AMR) Improving
antibiotic prescribing in primary care
Quality Premium Guidance for 2016/17
The two parts of the quality premium have specific thresholds as
follows:
• 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
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
Antimicrobial resistance (AMR)
Improving antibiotic prescribing in
primary care
Quality Premium Guidance for 2016/17
Current Performance
93
Future Work
• Joining Sepsis and AMR work
• Continue to reduce inappropriate antibiotic use
• Reductions in Gram negative bacteraemias
Philip HOWARD
Consultant Antimicrobial Pharmacist,
LTHT AMS Co-lead
NHS Improvement AMR project Lead (part-time)
philip.howard2@nhs.net
@AntibioticLeeds @ LTHTAntibiotic
Antimicrobial Resistance CQUIN
1800 in-patient beds over 3 sites
Secondary care population of Leeds 900k & tertiary care to 2.5m
for northern Yorkshire & Humber
St James’s: Acute Medicine, CF, ID, Cancer (surgery & tx),
Transplant, ED
LGI: Reg trauma, Neuro, Cardio-vascular, Paeds + CF, ED
Chapel Allerton: Elective ortho, rehab, rheum /dermatology
Leeds Teaching Hospitals approach
• AMR-CQUIN requires a 1%  per admission against 2013-
4 baseline for:
• total (IP & OP), carbapenems and pip-tazo
• 90%+ documentation of empiric antibiotics by day 3
by Q4 (Q1 =25%+, Q2 = 50%+ and Q3 = 75%+)
• LTHT target is 1% total (already 9% lower than
FY20134), 1% carbapenem (8% lower than FY1314)and
16% pip-tazo (based on growth since FY1314).
• Day 3 – could do better. Was 72% from monthly PPS
• Worth £1m OR £250k per element
AMR-CQUIN
• Reasonably mature AMS programme ~7 years
• lean! (1.3wte/2000beds for micro & pharmacy). Monthly reports.
• Antimicrobial treatment & prophylaxis guidelines are mainstay of ASP.
• >16k hits per month (no App), 100+ guidelines (diagnosis & tx)
• Monthly mini PPS since 2008:
• >90% for indication & duration
• Since Jul-15: guideline compliance >90%, D3 review outcome ~70%.
• Benchmark consumption using Rx-info Define:
• higher CDI risk antibiotics; < peers (DDD/1000 beds), avg for total AB
and slightly higher for IV antibiotics
• Trust AMS audit programme: monthly mini PPS (pharmacy) & annual
specialty audit.
Where we were
LTHT feasibility of achieving CQUINs
Antibacterial usage was growing after our early AMS years gain – less focus?
Getting ideas
What’s my biggest challenge? Total, carbapenems or pip-tazo?
What guidelines recommend pip-tazo (or carbapenems)?
• Are there alternatives? Identify a lead for each to review.  LTHT: HAP,
cIAI, CVC, CF, CA-urosepsis >65yr diagnosis, sepsis (?no PsA), SBP?,
• 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%  Q1 63%
• Do we act on results within 24 hours? LTH 50%  Q1 83%
• Can we use diagnostic tests to delay or avoid starting or stopping
antibiotics earlier? CRP in ED, procalcitonin, etc
Can we (AMS team) achieve this on our own?
• 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?
• They came asking for a monthly update – income
stream.
• Supplied activity data
• AMSG developed an action plan for Trust
Leadership
Which CSU has the biggest share
& growth of target antibiotics?
CardioResp (Carbapenems
Oncology (PipTaz)
Oncology (Carbapenem)
AcuteMed - PipTaz
CR
ACC
Onc (total)
AMS
NS
UC
TRS
UC
AMNS
AM
GOOD
Room for improvement
Rx-info developed scatter
plots based on this so
bought Refine £6k
CSUs with biggest growth per admission
& share of target ABs
Antibiotic CSU Share (% of all
CSUs)
Growth (DDD/adm)
FY1516 vs FY1314
Piperacillin-tazo Oncology 27% 30%
Acute Med 15% 24%
Adult Critical Care 15% 11%
Cardio-Resp 13% 12%
Abdo Med Surgery 9% 20%
Neurosciences 7% 60%
Urgent care 5% 45%
Carbapenems Cardio-resp 44% 21%
Oncology 18% 12%
Total Oncology 14% 16%
Acute Medicine 8% 14%
Tighten up our protected (restricted) antibiotics
• Already had a system that used micro / ID authorisation codes
PLUS order forms. Eg PPH2109A02
• Replaced with pharmacist writing code on order form and
copied onto JAC “patient notes”
• Band 3 pharmacy business support runs a SQL report on
“restricted antibiotics” & checks telepath for missing codes
• Email micro / ID where codes are missing or expired to
follow up
• Now much improved = less carbapenems
Date Drug Name Time Pack Size Packs Dose
Units
Value Cost Centre Iss
Type
User Patient Name Hosp No Indication Note
Status
When note added Note added by
POSACONAZOLE 100 mg Gastro-
Resistant Tablets
15/09/2016 POSACONAZOLE 100 mg Gastro-
Resistant Tablets
14:25 96 Tablet
Pack
1 0 £2,865.42 J***** R.M. DR
(PAEDIATRIC
HAEMATOLOGY)
ONEST
OP
EPS01 4113656
TIGECYCLINE 50 mg Dry Powder
for Infusion
15/09/2016 TIGECYCLINE 50 mg Dry Powder for
Infusion
21:42 10 Dry
Powder for
Infusion Pack
0 2 £77.54 ALD******** M.A. MR
(HEPATOLOGY)
INP AL04 3919168
Antimicrobial stewardship extract
Restricted antimicrobials - date range: 15-Sep-2016 to 16-Sep-2016
Auth Code
Business case to fund initiatives
Summary of funding received for AMR-CQUIN from Aug-16 Amount
Procalcitonin £ 55,462
Day 3 review data collection (AMR 50 pts /mth and Sepsis 30/mth) Band 6 nurse
Penicillin allergy testing £ 10,000
AMR-CQUIN Antibiotic Guardian campaign £ 5,000
Alternative antibiotics £ 150,000
Refine software £ 6,000
Must be invoiced each month
One side of A4 justifying need for funding – spent £6k
• Updating guidelines where piperacillin-tazo recommended as 1st line
• Hospital acquired pneumonia – little Pseudomonas (Amox + Temo)
• Severe sepsis thro ED – only 2/68 cases have Pseudomonas
• Uncomplicated intra-abdo infections = only 4 day course (NEJM)
• Urosepsis in >80yr – new guideline BUT aztreonam shortage
• Improve culture taking (currently 73-81% BC where required)
• Acting on C&S results more quickly (currently 50-83% in 24hr)
• Improving review of empiric antibiotic within 1st 3 days (STOP, de-
escalate, IVOS, change AB, OPAT) – currently 61-82% continue IV
•  IVOS (LOS, ££, Nursing time, phlebitis, patients prefer it, less
C.diff as usually narrower spectrum / shorter)
• Targeted use of procalcitonin in ITU ( LOS by 1.8 days) & medical
admissions (AB by 3.8 days & LOS by 3 days)
What is AMSG (IAPG) doing to reduce pip-tazo use?
Ward HCAI / AMS health check
May-16 Day 3 audit results
(Womens, Children on old Rx, UC no AB, Head &
Neck – no D3 reviews)
Update e-Whiteboard to highlight IV AB – for nursing
safety huddle & Dr Board Rounds
AB
Change to IV or PO in
orange circle
Day 3 review tool
• Combination of our IVOS and Dundee
(Pulcini) D3 review
• Trial in Acute Medicine and Abdo
Medicine & Surgery of small sticker
• Nurse puts sticker in medical notes on
day 3 for ward round
• Didn’t make much difference, so
version 2 being designed
Complete daily review of antibiotics.
IV to oral switch – day 3 sticker over D5-7?
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
• Got protocols for ED & AMU from Winchester &
Sepsis from Central Manchester.
• Got agreement for pathology and a great cost
~£6/test
• Micro / clinician leads amending protocols for
starting in Oct-16 (respiratory season)
• CASPUR (Cost effectiveness and Antibiotic
Stewardship of serum Procalcitonin UK Report)
• prospectively 1-2 months or ~ 70-100 patients.
• kordo.saeed@hhft.nhs.uk
Procalcitonin
Communications
campaign
• Base around Antibiotic Guardian
campaign
• Link to Leeds Citywide AMS campaign
• So far – screensavers, spoke to key
groups (CDs, HoN), monthly AMS report
for CSUs, pharmacy newsletters
• To come – stands, Start of the Week (for
procalcitonin launch), Grand Round
debate on 16th Nov 2016, all IPC Link
Nurse events
@LTHTAntibiotics
• Review diagnosis as new information arrives
• Bodansky 2012: only 55% of 100 consecutive MAU admissions had
clear infection diagnosis at discharge
• Review all IV AB daily: benefit & harm
• Check for results daily on ward / board round
• Culture of challenge “do they really or still need
antibiotics?” rather than “just 1 more day”
• Review need for catheters regularly (prevent HCAIs)
• Become an Antibiotic Guardian
• Any other ideas?
What can doctors do to help?
• Review all patients on IV Abs at safety
huddle
• Drive IV to oral switch.
• Eating & on IV AB = IVOS or OPAT review
• Charts by beds on ward rounds
• Avoid missed doses
• Become an Antibiotic Guardian
• Other ideas?
What can nursing do to help?
• Check AB prescribing vs guidelines
• Check/update IV AB column on eWhiteboard
• Check pts on IV AB daily
• Drive IV to oral switch & OPAT
• Thoughts on protocol for IVOS? Common in USA
• Check micro results
• Follow up “protected” antibiotics
• Become an Antibiotic Guardian
• Other ideas?
What can pharmacy do to help?
Challenges
Aztreonam shortage
• Biggest user in UK (9178 DDD/1000
beds vs 1034 avg)
• Restricted to 5 pts/day (27%)
• Restricting to CF mainly
• Alternatives: IV cipro except pip-
tazo for >65yr upper UTI.
• Impact on pip-taz = 4.6%DDD/adm
• Micro reluctant to use
gentamicin as AKI risk
Lack of AMS staff - vacancies
Summary of antibiotic use & prescribing standards for Aug-16
AB usage per admission to
YTD FY1617 vs FY1314 (AMR-
CQUIN period) - target -1%
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)
Total AB (IP+OP) -11% 0% -37% 8% -11% -16% -53% -34% 2% 43% -17% -47% -18%
Carbapenem -16% -25% -48% -19% 9% 0% -56% -51% 895% 64% -61% -24% -85%
Pipercillin-Tazobactam 13% 13% -27% 16% 31% 48% -59% -24% 225% 52% 22% -9% -94%
Day 3 review (target 90%+) 63% 23% 92% 73% 93% n/a 100% n/a 60% 53% 71% 0% n/a
AMR-CQUIN performance             
Other AB usage per
admission to YTD FY1617 vs
FY1314 (AMR-CQUIN period)
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)
IV AB 6% 16% -28% 30% 17% -27% -29% -16% 30% 30% 5% 16% 15%
4C AB (cef/FQ/clind/CoAmox) -9% 0% -14% 5% -16% 5% -63% -22% 38% 42% -29% -44% -1%
Higher risk Cdiff (4C+Carb+PipTaz) -8% 0% -32% 6% -7% 9% -63% -25% 45% 46% -27% -43% -3%
Antimicrobial Prescribing
Standards
LTH
ABDO
MED
SURG
ADULT
CRITICAL
CARE
ACUTE
MEDICINE
CARDIO-
RESPIRAT
ORY
CENTRE
FOR
NEUROS
CIENCES
CHAPEL
ALLERTO
N
CHILDRE
N'S
HEAD &
NECK
LEEDS
CANCER
CENTRE
TRAUMA &
RELATED
SERVICES
URGENT
CARE
WOMEN'S
Overall AB Rx Std 83% 74% 96% 86% 85% 82% 95% 95% 71% 75% 84% 64% 97%
No on Abs 372 49 15 61 52 16 12 41 8 62 48 2 6
No of Abs Rxd 471 56 25 71 90 16 13 65 8 65 54 2 6
No on Abs % 31% 28% 32% 29% 33% 16% 20% 34% 44% 50% 37% 9% 16%
% with indication 96% 96% 100% 99% 99% 88% 100% 94% 75% 97% 94% 100% 83%
% Abs with duration or review 93% 82% 96% 92% 94% 100% 100% 95% 88% 95% 93% 100% 67%
Following guidelines 97% 95% 96% 99% 98% 81% 100% 100% 100% 98% 98% 100% 100%
% D3 review completed 63% 55% 67% 49% 74% 67% #DIV/0! #DIV/0! #DIV/0! 83% 50% #DIV/0! #DIV/0!
% allergy completed 97% 95% 100% 95% 95% 100% 100% 98% 100% 99% 91% 100% 100%
% daily review codes completed 78% 68% 80% 80% 86% 75% 100% 100% 88% 75% 43% 100% 100%
% MRSA screening boxes completed 58% 60% 94% 29% 43% 78% 100% 100% 28% 23% 55% 61% 100%
% of Abs IV 59% 59% 96% 42% 52% 50% 77% 66% 38% 63% 69% 0% 50%
% of IV Abs given for >48hr 62% 55% 75% 50% 70% 75% 70% 67% 33% 54% 68% #DIV/0! 0%
Day 3 r/v STOP 5% 6% 0% 6% 0% 0% no Abs n/a not done 0% 20% no D3 no D3
Day 3 r/v IVOS 5% 0% 0% 0% 14% 0% no Abs n/a not done 3% 15% no D3 no D3
Day 3 oral to IV switch 0% 0% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3
Day 3 r/v change AB 2% 18% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3
Day 3 r/v CONT 88% 76% 100% 94% 86% 100% no Abs n/a not done 97% 65% no D3 no D3
Do you know your AMS performance?
• users like smiley faces – easy to understand
• Total: FY1516 vs FY1314: -9% (DDD/Adm) To Aug-16: -11%
• Carbapenems: FY1516 vs FY1314: -8% (DDD/Adm) To Aug-16: -16%
• Pip-tazo: FY1516 vs FY1314: +16% (DDD/Adm). +5% (+2% azt shortage) to
Jul-16 but +13% to Aug-16: (+8% accounting for aztreonam shortage)
• Day 3 review: Q1 69% (from PPS), Q2 so far 62% (from PPS)
Performance so far
AMR-CQUIN Summary position to Aug-16
• On target : Total -11%, Carbapenem -16%, Day 3 review 69% Q1
• Off target: Pip-tazo +13% (as Apr-Aug FY1314 vs FY1617)
Summary of AMR-CQUIN to Aug-16
DDD/1000 adm (except ACC /
Thea = DDD)
Growth FY1516 vs FY1314
CSU Total Carbapenem Pip-Tazo
Performan
ce
Total Carbapenem Pip-Tazo
Performan
ce
Total Carbapenem Pip-Tazo
Performan
ce
24 Urgent Care CSU -15% 36% 45%  -47% -24% -9%  -52% -55% -21% 
22 Cardio-Respiratory CSU -26% 22% 17%  -11% 9% 31%  -25% 26% 20% 
32 Abdominal Med-Surg CSU 9% -27% 21%  0% -25% 13%  -1% -33% 8% 
18 Acute Medicine CSU 15% -19% 27%  8% -19% 16%  9% -25% 10% 
16 Leeds Cancer Centre 16% 15% 30%  43% 64% 52%  37% 34% 44% 
14 Childrens CSU -21% -39% -22%  -34% -51% -24%  -32% -47% -22% 
36 Trauma & Related CSU -2% -51% 12%  -17% -61% 22%  -15% -67% 7% 
28 Head & Neck CSU -11% -50% 69%  2% 895% 225%  -11% 96% 275% 
12 Womens CSU -15% -43% -68%  -18% -85% -94%  -22% -50% -93% 
20 CAH CSU -49% -76% -35%  -53% -56% -59%  -55% -49% -74% 
44 Theatres & Anaesthetics CSU* 4% -5% 22%  23% -76% 46%  19% -62% 60% 
34 Neurosciences CSU 2% 9% 60%  -16% 0% 48%  -10% -26% 39% 
42 Adult Critical Care* -15% -41% -5%  -37% -48% -27%  -35% -43% -25% 
Total -9% -8% 16%  -11% -16% 13%  -15% -16% 7% 
Growth YTD FY1617 vs YTD FY1314 Growth YTD 1617 vs Avg FY1314
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
• Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne,
Cheryl Mitchell, Mark Wilcox, Kelly Atack,
• Colin Richman – Rx-Info for developing new reports so quickly
Philip HOWARD
Consultant Antimicrobial Pharmacist,
LTHT AMS Co-lead
NHS Improvement AMR project Lead (part-time)
philip.howard2@nhs.net
@AntibioticLeeds @ LTHTantibiotic
AMR CQUIN – any questions?
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%)
Tackling AMR locally – workshop session
#antibioticguardian
Working with South Asian
communities
BILAL YAKUB PATEL
MEDICINES MANAGEMENT PHARMACIST
North Kirklees
• Population 190,244
• Growing South Asian population
– Batley and Dewsbury - 38% of those aged under
18 are now South Asian
• Health issues exacerbated by a lack of
understanding
Antimicrobial Prescribing
• Antibacterial prescribing rates in North Kirklees
have traditionally been much higher than the
England average
• GP practices in Dewsbury and Batley in particular
have struggled to make any impact on reducing
antimicrobial prescribing rates
• GPs working in these areas report difficulties in
managing the demand for antibiotics from the
South Asian population
APPROACH
MOSQUE PRESENTATION
OTHER AREAS OF WORK
• Push for all clinicians and surgery staff to sign
up to be Antibiotic Guardians
• Educational videos and leaflets in surgeries
• Delayed antibiotic prescription templates
being used
• Other useful resources for clinicians, surgery
staff and patients to use
RESULTS: Total Antimicrobials
ADU’s per 1000 Star PUs
LEARNING POINTS
• Engage with the community
• Build relationships and find champions
• A health message from within mosques has a
high acceptance rate amongst users and they
enjoy/appreciate the interaction
• The South-Asian communities are looking for
education on issues surrounding health.
• Success in one mosque opens many doors
WHAT NEXT?
ANY QUESTIONS?
The role of community
pharmacists in delivering
the 5 year AMR strategy.
Dr Gill Hawksworth
Visiting Fellow University of Huddersfield
Student project 2015
An Evaluation of Antimicrobial Stewardship in Community Pharmacy
• Hancock L, Mellor C, Hawksworth G. University of Huddersfield.
Huddersfield.Howard P. Leeds teaching hospitals NHS trust . Leeds.
• Results- It was found 92 (92%) members of the public selected that they would
be comfortable allowing their indication on prescriptions for antibiotics, and 83
(83%) selected that they would be comfortable with pharmacy access to
medical records.
• Conclusions-This study suggests that increased awareness is necessary of the
resources available to pharmacists, regarding antibiotic resistance initiatives and
monitoring of antimicrobial prescribing. Also, an improvement is required,
concerning patient education by community pharmacists. Finally, the public
should be appropriately educated, regarding patient confidentiality, and the
benefits of pharmacy access to patient information.
Presented as poster at FIS 2015 Glasgow and published in FIELDS U of Huddersfield
2015.
Student project-2016
Three streams of research:-
• The role of community pharmacists in delivering the
5-year antimicrobial resistance strategy- linking to the
current work programme of the NHS England
antimicrobial strategy to shape the national
strategy.Clifford E, Devine S, Mills J, Yazdani B,
Hawksworth G. University of Huddersfield .
Huddersfield Howard P. Leeds teaching hospitals NHS
trust. Leeds
• Patient’s views of community pharmacists delivering
the 5-year antimicrobial resistance strategy .
• Younger generation views-community pharmacists
delivering the 5-year antimicrobial resistance strategy.
Methodology
• Ethical approval obtained
• Questionnaires sent to community pharmacists in
Calderdale and Kirklees.
• Questionnaires requested from patients collecting
prescriptions for antibiotics at consenting community
pharmacies.
• World Antibiotic Awareness Week 16-22 November
2015 – all pharmacy students (yr1-4) U of Huddersfield
did a pledge eg 3rd students instructed on handwashing
before making their pledge. Antibiotic Public health
campaign held in University main atrium –students
from all courses invited to complete questionnaire.
The role of community pharmacists in
delivering the 5-year antimicrobial
resistance strategy .
Important results of interest-
During patient counselling , 32 (64%) explained the dose, 31 (62%) explained
about completing the course and 26 (52%) explained about the avoidance of
sharing antibiotics with friends and family. Only 17 (34%) of pharmacists rate
themselves as good antimicrobial stewards but when asked about further services,
37 (74%) pharmacists would consider point of care testing and 45 (90%)
pharmacists would consider an expansion of a vaccination programme with 38
pharmacists stating that there needs to be more of an emphasis on hand washing.
Conclusion -This study suggests community pharmacists need more training in
local antibiotic prescribing to deliver the 5-year antimicrobial strategy. Potential
practice improvements could be made by the inclusion of the indication on an
antibiotic prescription and a checklist including allergies of patients, counselling
(dose, complete the course, left-overs and common side effects) as well as general
hygiene and self-help guides for patients. The study also suggests that diagnostic
services are something community pharmacists would develop which may show
further implementation of the 5-year antimicrobial strategy.
Patient’s views of community
pharmacists delivering the 5-year
antimicrobial resistance strategy .
Important results of interest:-
One hundred (83%) of patients would be comfortable having their
indication written on their prescription but when asked about personal
conditions (HIV, chlamydia etc.), 18 (18%) changed their mind. Ninety one
patients (75%) said they knew what antimicrobial resistance was, but
confirmed their knowledge was obtained via the media although 81
patients (67%) said that they didn’t trust the media.Patients were aware
of the NHS self help guide with 92 patients (76%) in favour .
Conclusions
This study highlights the potential of development of practice around
specific counselling points on antibiotics from community pharmacists to
improve adherence to the 5-year antimicrobial strategy plan so patients
obtain relevant information and resources from trusted sources such as
the community pharmacist or GP. Further interventions such as the
indication on antibiotic prescriptions at the patient’s discretion would help
improve antibiotic monitoring and counselling.
Younger generation views-community
pharmacists delivering the 5-year
antimicrobial resistance strategy.
Important results of interest:-
From 90 questionnaires, 54.4% (n=49) students missed and/or stopped
before the antibiotic course ended, 72.2% (n=65) correctly identified
antibiotics solely effective against bacterial infections .For cold/flu
symptoms only 66.7% (n=67) students saw a pharmacist before GP but
61.1% (n=55) support the cause of infection on their prescription,
however 21 of these would feel uncomfortable for personal conditions
such as chlamydia, HIV and thrush. Handwashing was important for 70.9%
(n=61) who used good hand washing technique.
Conclusion :-
Students’ knowledge on antimicrobial resistance needs improving, many
students were not taking their antibiotics correctly. Community
pharmacists could increasing compliance of antibiotic use with further
counselling, signposting to informative websites, and provision of leaflets
on hand washing technique .However many students are unwilling to see
a pharmacist before a GP.
Publications and future work
Posters accepted:-
• FIS 2016 Edinburgh 2016
• UKCPA Manchester-November 2016
Ongoing AMR research at University of Huddersfield
2017.
We acknowledge ongoing support from Phil Howard.
Concluding comments
Dr Diane Ashiru-Oredope, Pharmacist Lead,
Public Health England
#antibioticguardian

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Antibiotic Guardian Leeds Workshop 2016

  • 1. Welcome to the Antibiotic Guardian Leeds Workshop #antibioticguardian
  • 2. Introduction Dr Diane Ashiru-Oredope, Pharmacist Lead, AMR Programme, Public Health England & Department of Health Expert Advisory Committee on AMR & HCAI (ARHAI) #antibioticguardian
  • 3. Strengthening infection prevention and control practices Suzanne Calvert – Senior Health Protection Practitioner Yorkshire and the Humber PHE 21st September 2016 Antibiotic Guardian Roadshow: tackling antimicrobial resistance locally
  • 4. Introduction UK Five year Antimicrobial resistance strategy 2013-2018 number of hard-to-treat infections continues to grow…increasingly difficult to control infection in routine medical care settings … antibiotic resistance cannot be eradicated, it can be managed to limit the threat to, and minimise the impact ‘the medicine cabinet is empty for some’ ‘Everyone has a responsibility and a role to play in making this happen’ * 4 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 5. UK AMR strategy 2013 – 2018 WHO global action plan 2014 European Press release 2016 Tackling drug-resistant infections Globally – O’Neill May 2016 5 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016 European, International resources
  • 6. Key considerations 6 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016 “ The basics of public health – clean water, good sanitation and hygiene, infection prevention and control and surveillance – ..critical for reducing the impact of antimicrobial resistance and infectious disease control’ Infection Prevention and Control needs to be embedded as a priority for health systems at all levels. A return to the attitudes pre-antibiotic era, when infection prevention was a priority, cures were limited. Top-down priority-setting have a valuable role in bringing this issue higher up the priority
  • 7. UK 2016 Government press statement at the close of the G7 summit: ‘global health…the urgent need to tackle antimicrobial resistance’. ‘…the catastrophic consequences if we do not act – 10 million excess deaths a year by 2050. If we do nothing …. the potential end of modern medicine as we know it’. Dame Sally Davies, Chief Medical Officer for England – ‘antibiotic apocalypse’ Jane Cummins – Chief Nursing Office - prevent infections and control their spread, ….reduce the need for antibiotics and limit opportunities for antimicrobial resistant strains to develop. 7 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 8. Definitions Infection is the invasion of body tissues by disease -causing agents, their multiplication, the reaction of host tissues to these organisms and the toxins they produce Prevention action of stopping something from happening or arising Control the power to influence or direct people's behaviour a means of limiting or regulating something 8 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 9. What do the regulations say? Outcome 8: CQC`s Essential Standards for Quality and Safety on cleanliness and infection control  Must… ensure that: • service users, persons employed, others who may be at risk of exposure to a health care associated infection ‘are protected against identifiable risks of acquiring such an infection ……..’  assess the risk  appropriate standards of cleanliness and hygiene *The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 9 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 10. Infection prevention - thoughts Microbes spread from person to person – varying routes Mobile genes spread between microbial species Infection control mistakes Basic infection control precautions are key to preventing spread - opportunities Whole health economy involvement How do we assure ourselves that what should be happening is really happening? Should we have more targets? 10 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 11. IPC Opportunities 11 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 12. Contact time - opportunities ‘Staffing levels impact upon the ability of nursing and midwifery staff to provide high quality care’ NHSE: Safer Staffing: A Guide to Care Contact Time Nov.2014 ‘Unnecessary extra workload created by lack of clear systems and processes for practices and hospitals to communicate with each other regarding shared patients…’ Making time in General practice’ 2015 12 Presentation title - edit in Header and Footer
  • 13. Thoughts contd.. Recurrent factors – learn from others Improving staff awareness Cleaning of equipment and the environment Funding Infection control team not functioning well Outbreaks 13 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 14. Developing a local approach Yorkshire & Humber AMR group HPT AMR leads, FES team, Microbiology services, NHSE Surveillance – • Monthly mandatory surveillance data review (MRSA, MSSA & E Coli bacteraemia + C difficile cases) • Monthly CPE case review (numbers, epidemiological data, linked cases) Local Intelligence – • Review of meetings attended and planned attendance • Review of escalation required / report for Quality Surveillance Groups Patient Journey – • Working together in geographies • Cross boundary 14 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016
  • 15. Infection Prevention & Control Patient journey Local intelligence 15 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016 Patient journey Surveillance Local intelligence surveillance
  • 16. 16 Antibiotic guardian roadshow: Tackling antimicrobial resistance locally 21.9.2016 Infection prevention and control Is a much better option than the pre antibiotic era solutions! Thankyou for Listening
  • 17. Heather Edmonds Head of Medicines optimisation Leeds North CCG
  • 18.  Show you the range of website and data available  The data they provide  How to use the data locally to influence local decisions and guidance.
  • 19.  PHE Fingertips portal http://fingertips.phe.org.uk/profile/amr-local-indicators  Open prescribing http://www.openprescribing.net/  Antibiotic quality premium monitoring dashboard https://www.england.nhs.uk/resources/resources-for- ccgs/ccg-out-tool/ccg-ois/anti-dash/  NHSBSA information portal http://www.nhsbsa.nhs.uk/3607.aspx (password required)  PHE Second Generation Surveillance System https://sgss.phe.org.uk/Security/Login (password required)
  • 20.  English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report https://www.gov.uk/government/publications/english- surveillance-programme-antimicrobial-utilisation-and- resistance-espaur-report  HCAI Data Capture System https://hcaidcs.phe.org.uk/WebPages/GeneralHomePage.asp x  PrescQIPP - https://www.prescqipp.info/datahub  NHS E Medicines Optimisation dashboard - https://www.england.nhs.uk/ourwork/pe/mo-dash/
  • 21.
  • 22.
  • 23.
  • 24. Antibiotic reports  Antibiotics in uncomplicated UTIs  Minocycline ADQ/1000 patients (KTT11)  Broad-spectrum antibiotics (KTT9)  Co-amoxiclav, cephalosporins & quinolones (KTT9)
  • 25.
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  • 27.
  • 28.
  • 30.
  • 31.
  • 32. CCG AREA England CCG (%) AREA (%) England (%) 0.28 0.31 0.30 5.95 6.04 8.48 ANTIBIOTICS Antibacterial items per STAR PU Number of prescription items for antibacterial drugs (BNF 5.1) per oral antibacterial (BNF 5.1sub-set) ITEM based STAR-PU Co-amoxiclav, Cephalosporins and Quinolones % items Number of prescription items for Co-amoxiclav, Cephalosporins and Quinolones as a percentage of the total number of prescription items for selected antibacterial drugs (sub-set of BNF 5.1) 0.0 0.1 0.2 0.3 0.4 0.5 Numberofantibacterialitems perSTAR-PU Clinical Commissioning Group All CCGs CCGs in West Yorkshire Area NHS Leeds North CCG England (AVG) West Yorkshire Area (AVG) 0 2 4 6 8 10 12 14 16 PercentageofitemsforCo- amoxiclav,Cephalosporinsand Quinolones Clinical Commissioning Group All CCGs CCGs in West Yorkshire Area NHS Leeds North CCG England (AVG) West Yorkshire Area (AVG)
  • 33.
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  • 36.
  • 37.
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  • 39.
  • 41. Tackling AMR: Engaging with Patients and the Public AntibioticGuardianRoadshow 21st September2016 Aliya Rajah Professional Training and Public Engagement Coordinator Antimicrobial Resistance Programme Public Health England Aliya.rajah@phe.gov.uk Twitter - @AliyaRa5 #AntibioticGuardian
  • 42. 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) Chaintarli 42 Tackling AMR: Engaging with Patients and the Public
  • 43. Antibiotic resistance is poorly communicated and widely misunderstood by UK public “the body becomes resistant to antibiotics” “If my symptoms have gone, I no longer need to take antibiotics” “It’s not my problem” People have a better understanding when AMR is presented in a way that is relatable to them “By getting antibiotics from the doctor, I haven’t wasted their time” 43 Tackling AMR: Engaging with Patients and the Public
  • 44. Every infection prevented means less antibiotics are used AMR 44 Tackling AMR: Engaging with Patients and the Public
  • 45. 45 Tackling AMR: Engaging with Patients and the Public 2016 theme: chain of infection
  • 46. Timeline of English Antibiotic Awareness campaigns 46 Tackling AMR: Engaging with Patients and the Public
  • 47. 1999:Andybiotic – “Don’t wear me out” • Press and magazines • GP surgeries – leaflets and postcards • GP non-prescription pads • 1999, 2000, 2003, 2006 Educating the public: the value of awareness campaigns Dr Diane Ashiru-Oredope 47 Tackling AMR: Engaging with Patients and the Public Sent to all GP surgeries and independent pharmacies
  • 48. 48 Tackling AMR: Engaging with Patients and the Public
  • 49. Developing plans for EAAD 2014 • In previous years EAAD plans included creating educational materials which healthcare professionals could use as part of local awareness campaigns. • Developed EAAD in 2014 • campaign that would be available all year round • awareness raising  engagement • commitment from healthcare professionals and the public • First year that the lead organisation aimed to directly engage the public • Campaign developed by PHE in collaboration with all the UK devolved administrations and also professional organisations • Planning group is a multi-disciplinary group with public and third-sector representation from human and animal health sector across the UK 49 Tackling AMR: Engaging with Patients and the Public
  • 50. 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/ Tackling AMR: Engaging with Patients and the PublicCombating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope50 Tackling AMR: Engaging with Patients and the Public
  • 51. Video created with TV doctor Educates on antibiotic resistance; suggests three steps that public can take to help and a call to become an antibiotic guardian. Available for download 51 Tackling AMR: Engaging with Patients and the Public
  • 52. Tackling AMR: Engaging with Patients and the PublicCombating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope52 Tackling AMR: Engaging with Patients and the Public Current website
  • 53. Public Information should reflect One Health agenda – VMD, Bella Moss 53 Tackling AMR: Engaging with Patients and the Public
  • 54. Tackling AMR: Engaging with Patients and the Public
  • 55. EAAD &Antibiotic Guardian: children centres; hospitals; community pharmacies University College London Hospitals Awareness and engagement in Hospitals, community pharmacies, universities, organisations in all UK Countries Tackling AMR: Engaging with Patients and the Public
  • 56. Engagement via social media – e.g pictures tweeted with #AntibioticGuardian Tackling AMR: Engaging with Patients and the Public
  • 57. Antibiotic Guardian demographics 31 March 2016: 31, 105 AGs 30 August 2016 57 Tackling AMR: Engaging with Patients and the Public
  • 58. AG pledges from across the world As of 09 May 2016, there were 31,440 Antibiotic Guardian pledges; with at least one pledge from 77 countries across the world. There were five or more pledges from 24 countries including South Africa, USA, India, Nigeria, Australia, several countries in Europe Tackling AMR: Engaging with Patients and the Public58 Tackling AMR: Engaging with Patients and the Public
  • 59. 1) Healthcare Students – seeking Antibiotic Guardian champions in healthcare schools 2) Young families for children and families • Developing “Junior Antibiotic Guardian” through the use of digital badges. This is in collaboration with PHE nursing directorate, eBug and Makewaves (https://www.makewav.es/). 3) The Public through Community Pharmacy New Antibiotic Guardian Resources for 2016/17 59 Tackling AMR: Engaging with Patients and the Public
  • 60. Educating children – e-bug led by PHE Primary Care Unit (Prof Cliodna McNulty) Europe wide resource, led by Public Health England e-Bug has been translated into 22 different languages, including most European languages, Turkish and Arabic Free educational resource for classroom and home use and makes learning about micro- organisms, the spread, prevention and treatment of infection fun and accessible for children and young adults/students
  • 61. AMR Public Involvement Forum • Engage with the public via strategic partners and other voluntary organisations, PHE colleagues, lay members • Representation from • animal health, respiratory conditions, faith organisation, BME organisation, home hygiene, various Healthwatch • Raise awareness of the importance of AMR • Encourage organisations to engage with the public to raise awareness of AMR, especially during WAAW, IIPW • Using resources and expertise to produce a public engagement toolkit to support local Public Health England centres and Health Protection teams 61 Tackling AMR: Engaging with Patients and the Public
  • 62. Local engagement 62 Tackling AMR: Engaging with Patients and the Public
  • 63. Conclusion • Improving professional education, training and public engagement is one of the seven key areas of the 5 year UK AMR strategy • England has participated in EAAD activities since 2008, awareness was increased but no evidence of increased knowledge and behaviour change • For the first time, using behaviour change strategies, the Antibiotic Guardian campaign has shown evidence of moving from increasing AWARENESS to ENGAGMENT and commitment from healthcare professionals and the public • Evaluation of the Antibiotic Guardian campaign highlighted that it is an effective for increasing knowledge and changing behaviour (self reported) particularly among members of public 63 Tackling AMR: Engaging with Patients and the Public
  • 64. Acknowledgements British Society for Antimicrobial Chemotherapy for the funding the initial website development in 2014 and continued active support Pharma Mix for implementing the design and development of AG website of www.AntibioticGuardian.com Inkling London www.inklinglondon.com, for providing marketing and behavioural insights on the pledges during development Members of the core EAAD-AG planning group are acknowledged for their contribution in the planning of the AG campaign Organisations and individuals who have actively participated in the wider planning and delivery of the campaign are also acknowledged and can be found listed in the web appendix methods 64 Tackling AMR: Engaging with Patients and the Public
  • 65. You are invited to become an Antibiotic Guardian today (available via mobiles) Tackling AMR: Engaging with Patients and the Public
  • 66. Aliya Rajah Professional Training and Public Engagement Coordinator Antimicrobial Resistance Programme Public Health England aliya.rajah@phe.gov.uk Twitter - @AliyaRa5 #AntibioticGuardian 66 Tackling AMR: Engaging with Patients and the Public
  • 67. Question and answers from the floor #antibioticguardian
  • 69. Welcome back Dr Diane Ashiru-Oredope, Pharmacist Lead, Public Health England #antibioticguardian
  • 70. Antimicrobial Stewardship - national update on CQUIN and QP Stuart Brown Project Lead – AMR and HCAI NHS Improvement 21st September 2016
  • 71. Plan • Background • AMR CQUIN • Quality Premium
  • 72. • It is growing and spreading according to WHO figures – 5 of 6 regions show >50% resistance to 3rd gen cephalosporins & fluoroquinolones in E.coli – ALL SIX regions have >50% resistance in Kleb pneumonia to 3rd gen cephalosporins & 2/5 show AMR to carbapenems • All antibiotics will be become resistant in time • Antimicrobial resistance is generally irreversible • AMR is directly linked to use at national level • The antibiotic pipeline is dripping at best Global AMR in 2014
  • 73. UK Five Year AMR Strategy
  • 74. Commissioning for Quality and Innovation (CQUIN) • CQUIN framework supports improvements in the quality of hospital services and the creation of new, improved patterns of care. • National & local indicators – 4 or 5 national priorities each year. Worth 2.5% of income – 2016-7 Clinical: Sepsis (2nd year), AMR, Physical health of patient with severe mental health
  • 75. Commissioning for Quality and Innovation (CQUIN) 2016-17 The CQUIN scheme is intended to deliver clinical quality improvements and drive transformational change. These will impact on reducing inequalities in access to services, the experiences of using them and the outcomes achieved
  • 76. Part A – Reduction in antibiotic consumption per 1,000 admissions Part B – Empiric review of antibiotic prescriptions 76
  • 77. Part A – 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
  • 78. 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 – Q2 Perform an antibiotic review for at least 50% of cases in the sample – Q3 Perform an antibiotic review for at least 75% of cases in the sample – Q4 Perform an antibiotic review for at least 90% of cases in the sample 78
  • 79. AMR-CQUIN – what & why? Requires 1% (DDD per admission) vs 2013-4 baseline for: • Total (IP & OP): +6% over 4 years nationally • Carbapenems: +36% & KPC outbreaks • Piperacillin-tazo: +55% & K.pneum-R +36% E.coli +31% • 90%+ documentation of empiric antibiotics review by day 3 (Q1 25%, Q2 50%, Q3 75%, Q4 90%): Only 10% of Trusts could provide data though mandatory Hospitals AMS Teams to use ££ to improve IT, staffing, fund more expensive antibiotics or tests.
  • 80. Leadership Can we (AMS team) achieve this on our own? • 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? • Ask! They will be asking you for a monthly update – income stream
  • 81. 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
  • 82. Start Smart – Then Focus 82
  • 83. Progress So Far (as of August 2016) • Part A – Antibiotic consumption per 1,000 admissions – 115 of 155 Trusts have submitted consumption data for 2014/15 and 2015/16 – A number of Trusts (n=86) have also submitted data for 2013/14 – 105 Trusts have submitted data for Q1 2016/17 • Part B Empiric review of antibiotic prescriptions – 119 of 155 Trusts have submitted data via the PHE AMS online submission tool – Preliminary data indicates that 80.84% of prescriptions have evidence of review within 72 hours (range 22-100%). • All data submitted will be available on AMR Fingertips October 2016
  • 85. Improved antibiotic prescribing in primary and secondary care The ‘quality premium’ is intended to reward clinical commissioning groups (CCGs) for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reductions in inequalities in access and in health outcomes 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
  • 86. NHS England Antibiotic Quality Premium Dashboard
  • 87. NHS England Antibiotic Quality Premium Dashboard 2015-16
  • 88.
  • 89.
  • 90. Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care Quality Premium Guidance for 2016/17 The two parts of the quality premium have specific thresholds as follows: • 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
  • 91. 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
  • 92. Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care Quality Premium Guidance for 2016/17
  • 94. Future Work • Joining Sepsis and AMR work • Continue to reduce inappropriate antibiotic use • Reductions in Gram negative bacteraemias
  • 95. Philip HOWARD Consultant Antimicrobial Pharmacist, LTHT AMS Co-lead NHS Improvement AMR project Lead (part-time) philip.howard2@nhs.net @AntibioticLeeds @ LTHTAntibiotic Antimicrobial Resistance CQUIN
  • 96. 1800 in-patient beds over 3 sites Secondary care population of Leeds 900k & tertiary care to 2.5m for northern Yorkshire & Humber St James’s: Acute Medicine, CF, ID, Cancer (surgery & tx), Transplant, ED LGI: Reg trauma, Neuro, Cardio-vascular, Paeds + CF, ED Chapel Allerton: Elective ortho, rehab, rheum /dermatology Leeds Teaching Hospitals approach
  • 97. • AMR-CQUIN requires a 1%  per admission against 2013- 4 baseline for: • total (IP & OP), carbapenems and pip-tazo • 90%+ documentation of empiric antibiotics by day 3 by Q4 (Q1 =25%+, Q2 = 50%+ and Q3 = 75%+) • LTHT target is 1% total (already 9% lower than FY20134), 1% carbapenem (8% lower than FY1314)and 16% pip-tazo (based on growth since FY1314). • Day 3 – could do better. Was 72% from monthly PPS • Worth £1m OR £250k per element AMR-CQUIN
  • 98. • Reasonably mature AMS programme ~7 years • lean! (1.3wte/2000beds for micro & pharmacy). Monthly reports. • Antimicrobial treatment & prophylaxis guidelines are mainstay of ASP. • >16k hits per month (no App), 100+ guidelines (diagnosis & tx) • Monthly mini PPS since 2008: • >90% for indication & duration • Since Jul-15: guideline compliance >90%, D3 review outcome ~70%. • Benchmark consumption using Rx-info Define: • higher CDI risk antibiotics; < peers (DDD/1000 beds), avg for total AB and slightly higher for IV antibiotics • Trust AMS audit programme: monthly mini PPS (pharmacy) & annual specialty audit. Where we were
  • 99. LTHT feasibility of achieving CQUINs Antibacterial usage was growing after our early AMS years gain – less focus?
  • 100.
  • 101. Getting ideas What’s my biggest challenge? Total, carbapenems or pip-tazo? What guidelines recommend pip-tazo (or carbapenems)? • Are there alternatives? Identify a lead for each to review.  LTHT: HAP, cIAI, CVC, CF, CA-urosepsis >65yr diagnosis, sepsis (?no PsA), SBP?, • 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%  Q1 63% • Do we act on results within 24 hours? LTH 50%  Q1 83% • Can we use diagnostic tests to delay or avoid starting or stopping antibiotics earlier? CRP in ED, procalcitonin, etc
  • 102. Can we (AMS team) achieve this on our own? • 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? • They came asking for a monthly update – income stream. • Supplied activity data • AMSG developed an action plan for Trust Leadership
  • 103. Which CSU has the biggest share & growth of target antibiotics? CardioResp (Carbapenems Oncology (PipTaz) Oncology (Carbapenem) AcuteMed - PipTaz CR ACC Onc (total) AMS NS UC TRS UC AMNS AM GOOD Room for improvement Rx-info developed scatter plots based on this so bought Refine £6k
  • 104. CSUs with biggest growth per admission & share of target ABs Antibiotic CSU Share (% of all CSUs) Growth (DDD/adm) FY1516 vs FY1314 Piperacillin-tazo Oncology 27% 30% Acute Med 15% 24% Adult Critical Care 15% 11% Cardio-Resp 13% 12% Abdo Med Surgery 9% 20% Neurosciences 7% 60% Urgent care 5% 45% Carbapenems Cardio-resp 44% 21% Oncology 18% 12% Total Oncology 14% 16% Acute Medicine 8% 14%
  • 105. Tighten up our protected (restricted) antibiotics • Already had a system that used micro / ID authorisation codes PLUS order forms. Eg PPH2109A02 • Replaced with pharmacist writing code on order form and copied onto JAC “patient notes” • Band 3 pharmacy business support runs a SQL report on “restricted antibiotics” & checks telepath for missing codes • Email micro / ID where codes are missing or expired to follow up • Now much improved = less carbapenems Date Drug Name Time Pack Size Packs Dose Units Value Cost Centre Iss Type User Patient Name Hosp No Indication Note Status When note added Note added by POSACONAZOLE 100 mg Gastro- Resistant Tablets 15/09/2016 POSACONAZOLE 100 mg Gastro- Resistant Tablets 14:25 96 Tablet Pack 1 0 £2,865.42 J***** R.M. DR (PAEDIATRIC HAEMATOLOGY) ONEST OP EPS01 4113656 TIGECYCLINE 50 mg Dry Powder for Infusion 15/09/2016 TIGECYCLINE 50 mg Dry Powder for Infusion 21:42 10 Dry Powder for Infusion Pack 0 2 £77.54 ALD******** M.A. MR (HEPATOLOGY) INP AL04 3919168 Antimicrobial stewardship extract Restricted antimicrobials - date range: 15-Sep-2016 to 16-Sep-2016 Auth Code
  • 106. Business case to fund initiatives Summary of funding received for AMR-CQUIN from Aug-16 Amount Procalcitonin £ 55,462 Day 3 review data collection (AMR 50 pts /mth and Sepsis 30/mth) Band 6 nurse Penicillin allergy testing £ 10,000 AMR-CQUIN Antibiotic Guardian campaign £ 5,000 Alternative antibiotics £ 150,000 Refine software £ 6,000 Must be invoiced each month One side of A4 justifying need for funding – spent £6k
  • 107. • Updating guidelines where piperacillin-tazo recommended as 1st line • Hospital acquired pneumonia – little Pseudomonas (Amox + Temo) • Severe sepsis thro ED – only 2/68 cases have Pseudomonas • Uncomplicated intra-abdo infections = only 4 day course (NEJM) • Urosepsis in >80yr – new guideline BUT aztreonam shortage • Improve culture taking (currently 73-81% BC where required) • Acting on C&S results more quickly (currently 50-83% in 24hr) • Improving review of empiric antibiotic within 1st 3 days (STOP, de- escalate, IVOS, change AB, OPAT) – currently 61-82% continue IV •  IVOS (LOS, ££, Nursing time, phlebitis, patients prefer it, less C.diff as usually narrower spectrum / shorter) • Targeted use of procalcitonin in ITU ( LOS by 1.8 days) & medical admissions (AB by 3.8 days & LOS by 3 days) What is AMSG (IAPG) doing to reduce pip-tazo use?
  • 108. Ward HCAI / AMS health check
  • 109. May-16 Day 3 audit results (Womens, Children on old Rx, UC no AB, Head & Neck – no D3 reviews)
  • 110. Update e-Whiteboard to highlight IV AB – for nursing safety huddle & Dr Board Rounds AB Change to IV or PO in orange circle
  • 111.
  • 112. Day 3 review tool • Combination of our IVOS and Dundee (Pulcini) D3 review • Trial in Acute Medicine and Abdo Medicine & Surgery of small sticker • Nurse puts sticker in medical notes on day 3 for ward round • Didn’t make much difference, so version 2 being designed
  • 113. Complete daily review of antibiotics. IV to oral switch – day 3 sticker over D5-7? Day 3 review of antibiotics Micro results checked  Imaging  Patient eating? IVOS  OPAT  New diagnosis: Next review date:
  • 114. 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
  • 115. 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
  • 116. • Got protocols for ED & AMU from Winchester & Sepsis from Central Manchester. • Got agreement for pathology and a great cost ~£6/test • Micro / clinician leads amending protocols for starting in Oct-16 (respiratory season) • CASPUR (Cost effectiveness and Antibiotic Stewardship of serum Procalcitonin UK Report) • prospectively 1-2 months or ~ 70-100 patients. • kordo.saeed@hhft.nhs.uk Procalcitonin
  • 117. Communications campaign • Base around Antibiotic Guardian campaign • Link to Leeds Citywide AMS campaign • So far – screensavers, spoke to key groups (CDs, HoN), monthly AMS report for CSUs, pharmacy newsletters • To come – stands, Start of the Week (for procalcitonin launch), Grand Round debate on 16th Nov 2016, all IPC Link Nurse events
  • 119. • Review diagnosis as new information arrives • Bodansky 2012: only 55% of 100 consecutive MAU admissions had clear infection diagnosis at discharge • Review all IV AB daily: benefit & harm • Check for results daily on ward / board round • Culture of challenge “do they really or still need antibiotics?” rather than “just 1 more day” • Review need for catheters regularly (prevent HCAIs) • Become an Antibiotic Guardian • Any other ideas? What can doctors do to help?
  • 120. • Review all patients on IV Abs at safety huddle • Drive IV to oral switch. • Eating & on IV AB = IVOS or OPAT review • Charts by beds on ward rounds • Avoid missed doses • Become an Antibiotic Guardian • Other ideas? What can nursing do to help?
  • 121. • Check AB prescribing vs guidelines • Check/update IV AB column on eWhiteboard • Check pts on IV AB daily • Drive IV to oral switch & OPAT • Thoughts on protocol for IVOS? Common in USA • Check micro results • Follow up “protected” antibiotics • Become an Antibiotic Guardian • Other ideas? What can pharmacy do to help?
  • 122. Challenges Aztreonam shortage • Biggest user in UK (9178 DDD/1000 beds vs 1034 avg) • Restricted to 5 pts/day (27%) • Restricting to CF mainly • Alternatives: IV cipro except pip- tazo for >65yr upper UTI. • Impact on pip-taz = 4.6%DDD/adm • Micro reluctant to use gentamicin as AKI risk Lack of AMS staff - vacancies
  • 123. Summary of antibiotic use & prescribing standards for Aug-16 AB usage per admission to YTD FY1617 vs FY1314 (AMR- CQUIN period) - target -1% 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) Total AB (IP+OP) -11% 0% -37% 8% -11% -16% -53% -34% 2% 43% -17% -47% -18% Carbapenem -16% -25% -48% -19% 9% 0% -56% -51% 895% 64% -61% -24% -85% Pipercillin-Tazobactam 13% 13% -27% 16% 31% 48% -59% -24% 225% 52% 22% -9% -94% Day 3 review (target 90%+) 63% 23% 92% 73% 93% n/a 100% n/a 60% 53% 71% 0% n/a AMR-CQUIN performance              Other AB usage per admission to YTD FY1617 vs FY1314 (AMR-CQUIN period) 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) IV AB 6% 16% -28% 30% 17% -27% -29% -16% 30% 30% 5% 16% 15% 4C AB (cef/FQ/clind/CoAmox) -9% 0% -14% 5% -16% 5% -63% -22% 38% 42% -29% -44% -1% Higher risk Cdiff (4C+Carb+PipTaz) -8% 0% -32% 6% -7% 9% -63% -25% 45% 46% -27% -43% -3% Antimicrobial Prescribing Standards LTH ABDO MED SURG ADULT CRITICAL CARE ACUTE MEDICINE CARDIO- RESPIRAT ORY CENTRE FOR NEUROS CIENCES CHAPEL ALLERTO N CHILDRE N'S HEAD & NECK LEEDS CANCER CENTRE TRAUMA & RELATED SERVICES URGENT CARE WOMEN'S Overall AB Rx Std 83% 74% 96% 86% 85% 82% 95% 95% 71% 75% 84% 64% 97% No on Abs 372 49 15 61 52 16 12 41 8 62 48 2 6 No of Abs Rxd 471 56 25 71 90 16 13 65 8 65 54 2 6 No on Abs % 31% 28% 32% 29% 33% 16% 20% 34% 44% 50% 37% 9% 16% % with indication 96% 96% 100% 99% 99% 88% 100% 94% 75% 97% 94% 100% 83% % Abs with duration or review 93% 82% 96% 92% 94% 100% 100% 95% 88% 95% 93% 100% 67% Following guidelines 97% 95% 96% 99% 98% 81% 100% 100% 100% 98% 98% 100% 100% % D3 review completed 63% 55% 67% 49% 74% 67% #DIV/0! #DIV/0! #DIV/0! 83% 50% #DIV/0! #DIV/0! % allergy completed 97% 95% 100% 95% 95% 100% 100% 98% 100% 99% 91% 100% 100% % daily review codes completed 78% 68% 80% 80% 86% 75% 100% 100% 88% 75% 43% 100% 100% % MRSA screening boxes completed 58% 60% 94% 29% 43% 78% 100% 100% 28% 23% 55% 61% 100% % of Abs IV 59% 59% 96% 42% 52% 50% 77% 66% 38% 63% 69% 0% 50% % of IV Abs given for >48hr 62% 55% 75% 50% 70% 75% 70% 67% 33% 54% 68% #DIV/0! 0% Day 3 r/v STOP 5% 6% 0% 6% 0% 0% no Abs n/a not done 0% 20% no D3 no D3 Day 3 r/v IVOS 5% 0% 0% 0% 14% 0% no Abs n/a not done 3% 15% no D3 no D3 Day 3 oral to IV switch 0% 0% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3 Day 3 r/v change AB 2% 18% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3 Day 3 r/v CONT 88% 76% 100% 94% 86% 100% no Abs n/a not done 97% 65% no D3 no D3 Do you know your AMS performance? • users like smiley faces – easy to understand
  • 124. • Total: FY1516 vs FY1314: -9% (DDD/Adm) To Aug-16: -11% • Carbapenems: FY1516 vs FY1314: -8% (DDD/Adm) To Aug-16: -16% • Pip-tazo: FY1516 vs FY1314: +16% (DDD/Adm). +5% (+2% azt shortage) to Jul-16 but +13% to Aug-16: (+8% accounting for aztreonam shortage) • Day 3 review: Q1 69% (from PPS), Q2 so far 62% (from PPS) Performance so far
  • 125. AMR-CQUIN Summary position to Aug-16 • On target : Total -11%, Carbapenem -16%, Day 3 review 69% Q1 • Off target: Pip-tazo +13% (as Apr-Aug FY1314 vs FY1617) Summary of AMR-CQUIN to Aug-16 DDD/1000 adm (except ACC / Thea = DDD) Growth FY1516 vs FY1314 CSU Total Carbapenem Pip-Tazo Performan ce Total Carbapenem Pip-Tazo Performan ce Total Carbapenem Pip-Tazo Performan ce 24 Urgent Care CSU -15% 36% 45%  -47% -24% -9%  -52% -55% -21%  22 Cardio-Respiratory CSU -26% 22% 17%  -11% 9% 31%  -25% 26% 20%  32 Abdominal Med-Surg CSU 9% -27% 21%  0% -25% 13%  -1% -33% 8%  18 Acute Medicine CSU 15% -19% 27%  8% -19% 16%  9% -25% 10%  16 Leeds Cancer Centre 16% 15% 30%  43% 64% 52%  37% 34% 44%  14 Childrens CSU -21% -39% -22%  -34% -51% -24%  -32% -47% -22%  36 Trauma & Related CSU -2% -51% 12%  -17% -61% 22%  -15% -67% 7%  28 Head & Neck CSU -11% -50% 69%  2% 895% 225%  -11% 96% 275%  12 Womens CSU -15% -43% -68%  -18% -85% -94%  -22% -50% -93%  20 CAH CSU -49% -76% -35%  -53% -56% -59%  -55% -49% -74%  44 Theatres & Anaesthetics CSU* 4% -5% 22%  23% -76% 46%  19% -62% 60%  34 Neurosciences CSU 2% 9% 60%  -16% 0% 48%  -10% -26% 39%  42 Adult Critical Care* -15% -41% -5%  -37% -48% -27%  -35% -43% -25%  Total -9% -8% 16%  -11% -16% 13%  -15% -16% 7%  Growth YTD FY1617 vs YTD FY1314 Growth YTD 1617 vs Avg FY1314
  • 126. 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
  • 127. Thank you to lots of people • Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne, Cheryl Mitchell, Mark Wilcox, Kelly Atack, • Colin Richman – Rx-Info for developing new reports so quickly
  • 128. Philip HOWARD Consultant Antimicrobial Pharmacist, LTHT AMS Co-lead NHS Improvement AMR project Lead (part-time) philip.howard2@nhs.net @AntibioticLeeds @ LTHTantibiotic AMR CQUIN – any questions?
  • 129. 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%)
  • 130. Tackling AMR locally – workshop session #antibioticguardian
  • 131. Working with South Asian communities BILAL YAKUB PATEL MEDICINES MANAGEMENT PHARMACIST
  • 132. North Kirklees • Population 190,244 • Growing South Asian population – Batley and Dewsbury - 38% of those aged under 18 are now South Asian • Health issues exacerbated by a lack of understanding
  • 133. Antimicrobial Prescribing • Antibacterial prescribing rates in North Kirklees have traditionally been much higher than the England average • GP practices in Dewsbury and Batley in particular have struggled to make any impact on reducing antimicrobial prescribing rates • GPs working in these areas report difficulties in managing the demand for antibiotics from the South Asian population
  • 136. OTHER AREAS OF WORK • Push for all clinicians and surgery staff to sign up to be Antibiotic Guardians • Educational videos and leaflets in surgeries • Delayed antibiotic prescription templates being used • Other useful resources for clinicians, surgery staff and patients to use
  • 138. LEARNING POINTS • Engage with the community • Build relationships and find champions • A health message from within mosques has a high acceptance rate amongst users and they enjoy/appreciate the interaction • The South-Asian communities are looking for education on issues surrounding health. • Success in one mosque opens many doors
  • 141. The role of community pharmacists in delivering the 5 year AMR strategy. Dr Gill Hawksworth Visiting Fellow University of Huddersfield
  • 142. Student project 2015 An Evaluation of Antimicrobial Stewardship in Community Pharmacy • Hancock L, Mellor C, Hawksworth G. University of Huddersfield. Huddersfield.Howard P. Leeds teaching hospitals NHS trust . Leeds. • Results- It was found 92 (92%) members of the public selected that they would be comfortable allowing their indication on prescriptions for antibiotics, and 83 (83%) selected that they would be comfortable with pharmacy access to medical records. • Conclusions-This study suggests that increased awareness is necessary of the resources available to pharmacists, regarding antibiotic resistance initiatives and monitoring of antimicrobial prescribing. Also, an improvement is required, concerning patient education by community pharmacists. Finally, the public should be appropriately educated, regarding patient confidentiality, and the benefits of pharmacy access to patient information. Presented as poster at FIS 2015 Glasgow and published in FIELDS U of Huddersfield 2015.
  • 143. Student project-2016 Three streams of research:- • The role of community pharmacists in delivering the 5-year antimicrobial resistance strategy- linking to the current work programme of the NHS England antimicrobial strategy to shape the national strategy.Clifford E, Devine S, Mills J, Yazdani B, Hawksworth G. University of Huddersfield . Huddersfield Howard P. Leeds teaching hospitals NHS trust. Leeds • Patient’s views of community pharmacists delivering the 5-year antimicrobial resistance strategy . • Younger generation views-community pharmacists delivering the 5-year antimicrobial resistance strategy.
  • 144. Methodology • Ethical approval obtained • Questionnaires sent to community pharmacists in Calderdale and Kirklees. • Questionnaires requested from patients collecting prescriptions for antibiotics at consenting community pharmacies. • World Antibiotic Awareness Week 16-22 November 2015 – all pharmacy students (yr1-4) U of Huddersfield did a pledge eg 3rd students instructed on handwashing before making their pledge. Antibiotic Public health campaign held in University main atrium –students from all courses invited to complete questionnaire.
  • 145. The role of community pharmacists in delivering the 5-year antimicrobial resistance strategy . Important results of interest- During patient counselling , 32 (64%) explained the dose, 31 (62%) explained about completing the course and 26 (52%) explained about the avoidance of sharing antibiotics with friends and family. Only 17 (34%) of pharmacists rate themselves as good antimicrobial stewards but when asked about further services, 37 (74%) pharmacists would consider point of care testing and 45 (90%) pharmacists would consider an expansion of a vaccination programme with 38 pharmacists stating that there needs to be more of an emphasis on hand washing. Conclusion -This study suggests community pharmacists need more training in local antibiotic prescribing to deliver the 5-year antimicrobial strategy. Potential practice improvements could be made by the inclusion of the indication on an antibiotic prescription and a checklist including allergies of patients, counselling (dose, complete the course, left-overs and common side effects) as well as general hygiene and self-help guides for patients. The study also suggests that diagnostic services are something community pharmacists would develop which may show further implementation of the 5-year antimicrobial strategy.
  • 146. Patient’s views of community pharmacists delivering the 5-year antimicrobial resistance strategy . Important results of interest:- One hundred (83%) of patients would be comfortable having their indication written on their prescription but when asked about personal conditions (HIV, chlamydia etc.), 18 (18%) changed their mind. Ninety one patients (75%) said they knew what antimicrobial resistance was, but confirmed their knowledge was obtained via the media although 81 patients (67%) said that they didn’t trust the media.Patients were aware of the NHS self help guide with 92 patients (76%) in favour . Conclusions This study highlights the potential of development of practice around specific counselling points on antibiotics from community pharmacists to improve adherence to the 5-year antimicrobial strategy plan so patients obtain relevant information and resources from trusted sources such as the community pharmacist or GP. Further interventions such as the indication on antibiotic prescriptions at the patient’s discretion would help improve antibiotic monitoring and counselling.
  • 147. Younger generation views-community pharmacists delivering the 5-year antimicrobial resistance strategy. Important results of interest:- From 90 questionnaires, 54.4% (n=49) students missed and/or stopped before the antibiotic course ended, 72.2% (n=65) correctly identified antibiotics solely effective against bacterial infections .For cold/flu symptoms only 66.7% (n=67) students saw a pharmacist before GP but 61.1% (n=55) support the cause of infection on their prescription, however 21 of these would feel uncomfortable for personal conditions such as chlamydia, HIV and thrush. Handwashing was important for 70.9% (n=61) who used good hand washing technique. Conclusion :- Students’ knowledge on antimicrobial resistance needs improving, many students were not taking their antibiotics correctly. Community pharmacists could increasing compliance of antibiotic use with further counselling, signposting to informative websites, and provision of leaflets on hand washing technique .However many students are unwilling to see a pharmacist before a GP.
  • 148. Publications and future work Posters accepted:- • FIS 2016 Edinburgh 2016 • UKCPA Manchester-November 2016 Ongoing AMR research at University of Huddersfield 2017. We acknowledge ongoing support from Phil Howard.
  • 149. Concluding comments Dr Diane Ashiru-Oredope, Pharmacist Lead, Public Health England #antibioticguardian