Antibiotic Guardian London Workshop

Welcome to the Antibiotic Guardian
London Work Shop

Chairs introduction
Professor Anthony Kessel
Director of International Public Health
Public Health England

Antibiotic Resistance Overview
Dr Diane Ashiru-Oredope, Pharmacist Lead,
Public Health England & Department of
Health Expert Advisory Committee on AMR
& HCAI (ARHAI)

Infection Prevention and Control
in reducing Antimicrobial
Resistance
Karen Shaw
Infection Prevention and Control Lead
Public Health England
AMR Programme

National Priorities for addressingAMR
5 Infection Prevention and Control in reducing AMR Karen Shaw
1. Improve
Infection
Prevention and
Control
practices
Every infection prevented means less
antibiotics used
Lowering the use of antibiotics lowers the
risk of resistance

12
“We need to get to a point where:
good infection prevention and
control measures to help prevent
infections occurring become the
norm in all sectors …..”
Professor Dame Sally C. Davies
Infection Prevention and Control in reducing AMR Karen Shaw

14
Competentstaff
SeniorEngagement
AsepticTechnique(ANTT)
Legislation
Microbiologyand
Laboratorysupport
Strategic Plan, Vision and Governance
CleanSafeEnvironment
Surveillanceandaudit
Technicalguidelinesand
procedures
Antimicrobialstewardship
OccupationalHealth
Infection Prevention and
Control Programme

Health and Social Care: Code of Practice 2015
15Infection Prevention and Control in reducing AMR Karen Shaw

IPC is complex

19

Stop infections at every
patient contact.

Infection
Control
in
Cambodia
Prevention
and

Why didn’t IPC work?
25
1. Lack of legislation
2. Lack of understanding and belief that ‘it’s
not my job!’
3. Lack of compliance with known standards
4. Lack of engagement
OWNERSHIP

34
Strengthen IPC
Every infection prevented conserves antibiotics
Protect patients at every intervention

London
February 24, 2016
London
February 24, 2016
AMR Action
WHO/EURO Region
Saskia Nahrgang
Programme Control of Antimicrobial Resistance
Division of Communicable Diseases and Health
Security
WHO Regional Office for Europe

London
February 24, 2016
WHO European Region

Draft Global Action Plan for AMR
European strategic action plan on
antibiotic resistance
2011–2020

London
February 24, 2016
European Commission

London
February 24, 2016
Global action plan on
antimicrobial resistance

London
February 24, 2016
Global AMR Action Plan - Strategic Objectives
1. Improve awareness and understanding
2. Strengthen knowledge and evidence
base
3. Reduce incidence of infection
4. Optimize use of antimicrobial medicines
5. Develop economic case for sustainable
investment
http://www.who.int/drugresistance/global_action_plan/en/

London
February 24, 2016
UK Strategy 2013-2018
Key area 1: improving infection prevention and
control practices
Key area 2: optimising prescribing practice
Key area 3: improving professional education,
training and public engagement
Key area 4: developing new drugs, treatments and
diagnostics
Key area 5: better access to and use of
surveillance data
Key area 6: better identification and prioritisation
of AMR research needs
Key area 7: strengthened international
collaboration

London
February 24, 2016
German strategy (DART 2020)
Six-point plan:
1. Close co-operation between ministries and with
international organizations.
2. Monitoring systems should be strengthened (…)
3. For human and veterinary medicine, the diagnosis should
be improved and the implementation of
hygiene measures will be promoted.
4. An optimization of methods in animal husbandry.
5. Education of the public as well as by physicians and
veterinarians will be intensified.
6. Emphasis on interdisciplinary projects.

London
February 24, 2016
GOOD PRACTICE
Source:
http://www.bag.admin.ch/themen/internationales/11287/15615/index.html?la
ng=
• Strengthening the One Health
approach
• Combating and preventing
infections
• Promote the responsible use of
antibiotics
• Strengthening surveillance
systems
• Support of research and
development

London
February 24, 2016
Surveillance in the EU
Antimicrobial
Resistance
Antimicrobial
Consumption
EARSS
1998
2011
ESAC
2001
2010
EARS-Net
ESAC-Net

London
February 24, 2016
Surveillance in European region
Antimicrobial
Resistance
Antimicrobial
Consumption
CAESAR
AMC
2011
2012

London
February 24, 2016
CAESAR Annual Report 2014
 Data of 5 countries (Turkey, The former
Yugoslav Republic of Macedonia, Serbia,
Belarus, Switzerland)
 EQA results 2013 (9 countries)
 Guidance for data interpretation
 Encourage implementation, maintenance and
improvement of national AMR surveillance
programs
 2015 and 2016 report will be published this
year (now incl. Russian Federation)

London
February 24, 2016
Central Asian and Eastern
European Surveillance of
Antimicrobial Resistance (CAESAR)
World Health Organization Regional Office for Europe
Expanding AMR surveillance
throughout Europe
Country Level
of
eviden
ce
No. of
labs in
network
#
isolate
s
Belarus B 10 (33%
labs)
386
FYROM B 6 (26%
labs)
189
Serbia B 14 (50%
hosp)
1465
Switzerland A 20 (70%
hosp)
7945
Turkey A 77 (?%) 10377
Source: CAESAR Report 2014
Countries submitting data to CAESAR

London
February 24, 2016
CAESAR data - Levels of evidence
• Level A
– Data is representative of target population
– Laboratory results reliable
• Level B
– Data is not representative of target population
– Laboratory results reliable
• Level C
– Data is not representative of target population
– Laboratory results not entirely reliable

London
February 24, 2016
Sharing good practice

London
February 24, 2016
Global Initiatives and
Partnership

London
February 24, 2016
Research & Innovation

London
February 24, 2016
Awareness

2008 Materials for the general public
32 countries participated
2009 Materials for primary care prescribers
2010 Materials for hospital prescribers
and hospitals
Matched Get Smart week in the U.S.
and the campaign in Canada
2011 Patient stories and Euronews movie
2012 Collaboration with WHO/Europe:
First EAAD Twitter chat
Australia becomes a partner
2013 Start work on self-medication with
antibiotics, with PGEU and CPME
2014 Revised toolkit for the general public
on self-medication with antibiotics
New Zealand becomes a partner
Global Twitter conversation and European Twitter chat
For more information: Earnshaw S, et al. Euro Surveill 2009 Jul 30;14(30): & 2014 Oct 16;19(41).
European Antibiotic Awareness Day,
2008-2014
Toolkit for primary care prescribers
Toolkit for hospital prescribers and
and hospitals
Toolkit for the general public
Revised toolkit for the general public
on self-medication with antibiotics

Images from national campaigns on
prudent use of antibiotics

London
February 24, 2016
WAAW Baseline Survey:
Russian Federation and Serbia
Russian Federation:
• 1007 online interviews
• 67% think colds and flu can be treated with
antibiotics
• > One quarter (26%) think they should stop
taking antibiotics when they feel better
rather than taking the full course as
directed.
Serbia:
• 510 face-to-face interviews
• 68% wrongly believe that colds and flu can
be treated with antibiotics.
• Only 60% heard of the term antibiotic
resistance’

13.8K+ views
16.9 M impressions
170K engagements
Global Social Channel Performance Regional Media Coverage
Global video
views
Twitter hashtag
mentions
21M+ 75.5K+ 850K+ 8K+
Global social channel
impressions
Campaign website
page views
4.5 M impressions
18K engagements
Global pieces of
coverage
993+
World Antibiotic Awareness Week Global Highlights
122+ 351+
Region of the Americas Eastern Mediterranean
Region
Africa Region
48+

European Region
339+
South East Asia Region
50+
Western Pacific
Region
83+
Interviews secured
across the globe
28
*Note: These numbers do not encompass all regions/totals

Most Viewed Materials Ever on WHO Social Media
To view click here
To view click here
To view click here
Most Watched Video on Vine
Most Liked Video on Instagram
Most Liked Infographic on Facebook

European Region
TOTAL ARTICLES: 339
Russia: 95
UK: 54
Estonia: 60
Bulgaria: 50
France: 26
Republic of Moldova: 4
Spain: 11
Uzbekistan: 8
Switzerland:6
Georgia: 4
Lithuania: 4
Germany: 3
Slovakia: 3
Serbia: 3
Italy: 3
Ireland: 2
Belgium: 1
Israel: 1
Czech Republic: 1
117
63
112
36
94
26
13
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7
No.ofkeymessagementions
Key message
Key Message Delivery
6
0
1%
1%
1%
1%
2%
2%
2%
3%
19%
47%
0% 10% 20% 30% 40% 50%
Prof Timothy Walsh
Dr Susan Hopkins
Dr. Des Walsh
Jian-Hua Liu
Laura Piddock
Jim O'Neill
Zsuzsanna Jakab
Sergey Khachatryan
Dr Keiji Fukuda
Margaret Chan
Spokesperson Inclusion
UK in the top 5

London
February 24, 2016
Awareness Raising: France
• French National Awareness Campaign
(2002-2007) aimed at the general public
and health care professionals
Reduction in the # of unnecessary
antibiotic prescriptions
Goosens H, Guillemot D, Ferech M et al. National campaigns
To improve antibiotic use. Eur J Clin Pharmacol 2006; 62: 373-9

London
February 24, 2016
Awareness campaigns: Belgium
• Simple repeated messages in Belgium
2006-07
Decreased sale of antibiotics
Goosens H, Coenen S, Costers M, et al. Achievements of the
Belgian Antibiotic Policy Coordination Committee (BAPCOC).
Euro Surveill 2008; 13: pii 19036

London
February 24, 2016
Thank you for your
attention

London
February 24, 2016
WHO Europe: Partnership

London
February 24, 2016
WHO Europe:
Acknowledgments
• Division of Communicable Disease,
Health Security & Environment
– Nedret Emiroglu
– Cristiana Salvi
– Siff Malue Nielsen
• AMR Coordination
– Danilo Lo Fo Wong
– Nienke van de Sande-Bruinsma
– Saskia Nahrgang
• Food Safety
– Hilde Kruse
• Health Systems and Public Health
– Hans Kluge
• Health Technologies and
Pharmaceuticals
– Hanne Bak Pedersen
– Guillaume Dedet
• Influenza & other Respiratory Pathogens
– Caroline Brown
– Pamela Hepple
• Vaccine Preventable Diseases &
Immunization
– Robb Butler
• Alert and Response Operations
– Ana Paula Coutinho
• WHO Country offices
• National AMR focal points!

The Governments stance
Professor John Watson, Deputy Chief
Medical Officer for the Department of
Health

Building laboratory capacity, surveillance
networks and response capacity
Dr Mike Turner, Head of Infection and
Immunobiology, Wellcome Trust

Wellcome back
& HCAI (ARHAI)

Healthy Eating: “The Route to
Health and Wellbeing”
Peter Stevenson
Compassion in World Farming

Most antibiotic use is in intensive sector
• Prophylactic use is “particularly prevalent in intensive agriculture,
where animals are kept in confined conditions”: The Review on
Antimicrobial Resistance, December 2015
• Around 90% of UK farm antibiotic use is in pigs & poultry, the two
most intensively farmed species
• WHO: growing demand for meat “especially when met by intensive
farming practices, contributes to the massive use of antibiotics in
livestock production”
• FAO: “the prevalence of resistance in the agricultural sector is
generally higher in animal species reared under intensive production
systems”

Do we need to increase food production to
meet the demands of a growing population?
• Many argue we need to increase food production by
70%
• And so, driven by that imperative, we must further
intensify agriculture including livestock sector
• And that will mean increased antibiotics use – and
increased resistance

Do we really need a major increase in production?
• Worldwide 25% of food calories are lost or wasted post
harvest or at the distribution/retail & consumer levels:
High Level Panel of Experts on Food Security and Nutrition, 2014
• 9% is used for biofuels & other industrial purposes:
Cassidy et al, 2013
• 36% of global crop calories are used as animal feed:
Cassidy et al, 2013

Dairy Eggs Chicken Pork Beef
Calorie
conversion
efficiency
(%)
40 22 12 10 3
Protein
conversion
efficiency
(%)
43 35 40 10 5
What happens to the 36% of the world’s crop calories
used as animal feed?
For every 100 calories of human-edible cereals fed to animals, just 17-
30 calories enter the human food chain as meat or milk: Lundqvist et al,
2008; UNEP, 2009
Some studies indicate the conversion rate is even lower for meat
Source: Cassidy et al, 2013

Of the 36% of the world’s crop
calories used as animal feed
Approx ¼
produces
meat & milk
Approx ¾
is wasted: it
produces no meat
& milk for human
consumption
27% of global
crop calories
wasted by being
fed to animals
9% of global
crop calories
produce meat
& milk
Waste Fruitful

Many recognise that feeding cereals to animals is wasteful
Chatham House: “staggeringly inefficient”
International Institute for
Environment and Development: “colossally inefficient”
FAO: “potential to threaten food security”
Bajželj et al, 2014
“a very inefficient use of land to produce food”

Feeding the 2.6 billion extra people anticipated by 2050

People (in billions)

People (in billions)
Extra people (in billions) that could
be fed by reducing over consumption
Based on data from UNEP, 2009; Cassidy et al, 2013;High Level
Panel of Experts of the Committee on World Security, 2014; World
Resources Institute, 2013,

The false premise that we need to hugely increase
production will drive further intensification of livestock
–and with it increased use of antibiotics

Transformation of the role of
livestock
• Research funded by the FAO examines a reduction (possibly to
zero) in use of grain as animal feed as this competes with crop
production for direct human consumption: Schader et al, 2015: two of
the authors work for FAO
• The study argues that the role of livestock “is to use resources that
cannot be otherwise used for food production”
• Pasture
• By- products
• Unavoidable food waste
• Integrated crop-livestock farming - in line with circular economy
principles. The waste products of one component serve as a
resource for the other: animals are fed on crop residues & their
manure, rather than being a pollutant, fertilises the land.

Reduction of use of grain as feed would lead to
reduced production of meat & dairy
• What would happen if we were to move to healthier diets – more
fruit, vegetables, whole grains, legumes, nuts & seeds and less red
& processed meat?
• Animals could be farmed less intensively with an end to routine
preventive use of antibiotics
• Need to “develop health-orientated systems for rearing of animals”:
The Lancet Infectious Diseases Commission, 2013

Health-
Orientated
Systems
Avoid
excessive
group size
Reduce
high
production
levels
Avoid
mixing
Avoid
over-
crowding
Reduce
stress
Good air
quality
No early
weaning
of pigs
Enable
natural
behaviours

Reduced consumption of meat & dairy would
bring many benefits
• This would bring health benefits:
• reduced use of antibiotics in livestock sector
• reduced heart disease, certain cancers, obesity, diabetes: European
Commission 2012; Friel et al, 2009; Aston et al, 2012
• consumption of red meat in Europe is on average more than twice
as much as the recommended limit: Westhoek et al, 2015
• average per capita protein intake in the EU is about 70% higher than
required: Westhoek et al, 2015

Well below 2°C
By 2050 our diets alone likely to have taken us
above the ‘well below 2°C’ target: Bajželj et al, 2014

© Chatham House: From Chatham House
presentation by Antony Froggatt “Putting
Meat on the Climate Negotiating Table”,
December 2015
Reduced meat & dairy consumption could bridge over a quarter of the gap
between emissions pledged & emissions needed to meet ‘well below 2°C’ target

Reduced consumption of meat & dairy would bring
environmental benefits
Factor affected by
reduction in meat
consumption
% reduction from current
levels
Soybean use as animal feed
(=reduced deforestation)
75%
Use and pollution of surface-
and ground-water *
20%
Cropland use 23%
Nitrogen emissions 40%
Greenhouse Gas emissions 19–42%
* In this case the figure in column 2 refers
to a 45% reduction in meat consumption.
Sources: Vanham et al, 2013; Westhoek et al, 2014 & 2015

Reduced meat & dairy consumption would bring
animal welfare benefits. It would allow a move from
industrial to high welfare systems
To this
Or these
From this

From this
To this
France
Portugal

The 50%/50g Diet
50% reduction in
meat & dairy consumption
&
50g per day per person:
max meat consumption

Two Schools of Food Policy: the
Productionist Approach
• Exemplified by Defra
• Defra’s forthcoming 25 year Plan on Food & Farming will focus on
production, competiveness & agri-tech alone and will almost
completely ignore dietary health, the environment & animal welfare
• Suggested strapline for Defra plan:

Integrated Food System: Building for the Future
Good
Healthy &
Nutritious
Food For All
Environmental
Sustainability
No Routine
Preventive
Antibiotic
Good
Animal
Welfare
Culture:
Bonding,
Richness,
Diversity

Antimicrobial stewardship: Changing risk-related
behaviours in the general population
Jacqueline Sneddon
Antimicrobial Pharmacist

Disclaimer
• I am a ‘topic expert member’ for the guideline on
‘Antimicrobial stewardship: Changing risk-
related behaviours in the general population’
• I am not a NICE employee
• NICE has not had prior sight or approval of this
presentation

The background: why NICE was
set up
• Established in 1999
• Aim: to reduce variation in the
availability and quality of
treatments and care (the so
called ‘postcode lottery’)
• To resolve uncertainty about
which medicines and
treatments work best and
which represent best value for
money for the NHS

Core principles of NICE’s work
• Based on the best evidence available
• Expert input
• Patient and carer involvement
• Independent advisory committees
• Genuine consultation
• Regular review
• Open and transparent process
• Social values and equity considerations

Antimicrobial stewardship:
Changing risk-related
behaviours in the general
population

Guideline due for publication
2016
• This is a Public Health Guideline and has
been in development for about 18 months
• Core PH committee members plus 6 topic
experts
• Limited evidence base impact of
interventions
• Public consultation on guidance:
8 September to 20 October 2015

Scope
• Interventions to change public behaviours
to reduce development of AMR and stop
spread of resistant microbes
– Includes measures to raise awareness and
knowledge about antibiotic use and AMR
– Includes measures to prevent and control
infection

Target audience
• Those with responsibility for prescribing and
dispensing antimicrobials
• Those in public health
• Those who give information and advice to the
public
• Those responsible for preventing and controlling
infections
• The public themselves – especially vulnerable
groups

Draft guideline - Seven areas of
recommendation
1. National and local information
campaigns
2. Public interventions to prevent
infection
3. Interventions to reduce inappropriate
antimicrobial demand and use
4. Childcare settings
5. Schools
6. Educational and residential settings
for young adults
7. Healthcare settings
Setting-specific
recommendations

1. National and local information
campaigns
• Raise awareness of AMR and appropriate
antimicrobial use
• Give info on preventing and controlling
infections e.g. “Now wash your hands”
• Using range of modes of delivery (verbal
advice, multimedia, written, mass media)

2. Public interventions to
prevent infection
• Advice on hand washing (including when
and how to wash hands; when hand
sanitisers are / are not appropriate)
• Food hygiene advice
• Wider aspects of infection prevention
(such as the need for vaccinations)

3. Reduce inappropriate
antimicrobial demand and use
• Educating patients and the public about the
natural course of self-limiting conditions
(including red-flag symptoms)
• Educating the public about where to seek
help/advice if/when they need it (e.g. use
pharmacies rather than A&E)
• Advising people to use prescribed antimicrobials
appropriately – complete the course, don’t
share, don’t keep

Role of community pharmacy
• Expertise of pharmacists in managing symptoms
and providing advice on medicines often under
utilised
• Accessible to all 7 days a week
• Promote as first port of call for patients with
symptoms of self-limiting infections
• Can refer to GP if required and highlight signs of
serious illness

4. Childcare settings
• Clean premises and equipment appropriately
• Provide hand washing facilities for staff and
children
• Educate children about hand washing, involving
parents and carers
• Ensure parents and carers are aware of the
importance of preventing spread of infections and
appropriate antimicrobial use to reduce AMR

5. Schools
• Take a ‘whole-school’ approach
• Provide hand washing facilities, and teach hand
washing in an age-appropriate way
• Use teaching resources such as PHE’s “e-bug”
to educate children about microbes and AMR
• Consider integration of wider messages within
curriculum as well as involving parents and
carers

E-bug resources
http://www.e-bug.eu/

6. Educational and residential
settings for young adults
• Awareness raising activities, including about
hand washing (with posters in strategic
locations) and food-safety campaigns
• Raise awareness about other aspects of
infection prevention (e.g. vaccinations)
• Help students to understand about self-care and
where to seek help

7. Healthcare settings
• Give advice about self-limiting conditions,
including natural course and where to seek help
• Consider using decision-support aids to
encourage health professionals not to prescribe
antibiotics for self-limiting conditions
• When not prescribing antibiotics, explain why,
and give written information including safety-
netting advice
• When prescribing antibiotics, explain why, and
give written information on antibiotics

Research recommendations
• Cost-effectiveness
• Multi-component interventions
• High-risk groups
• Workplaces

Overarching implementation
• Consider developing a local area
antimicrobial stewardship strategy linking
public health, local authorities, healthcare,
and social care.

Antimicrobial
stewardship:
systems and
processes for
effective
antimicrobial
medicine use
(NG15)
https://www.nice.org.uk/guidance/ng15

Scope
• Effective use of antimicrobials as part of all
publically funded health and social care
commissioned or provided by NHS
organisations, local authorities (in
England), independent organisations or
independent contractors.

Recommendations for:
• Organisations (commissioners and providers)
– Establish antimicrobial stewardship team
– Establish antimicrobial stewardship programme
– Further specific recommendations around
communication, interventions, and lab testing
• Prescribers and practitioners
– Specific guidelines for prescribing antimicrobials
• Introduction of new antimicrobials
- assessment and approval mechanisms

Keeping up to date with the
latest from NICE
• NICE Pathways - brings together all NICE
guidance, quality standards and support in
easy-to-navigate flowcharts
• Monthly newsletters
• Subscribe to awareness services
– Eyes on evidence, Medicines, Public Health

NICE guidance and BNF apps for your
iPhone or smartphone
Search over 750 pieces of
NICE guidance, including
Public health guidance.
Download it today for free
from Apple’s App Store
and Google Play.
BNF apps available free with
Athens password.

Get involved
• Join a NICE Committee- use your expertise to
support development of NICE guidance
• Comment on a Consultation- feedback on
scope and drafts of guidance and quality
standards
• Join the Fellows and Scholars programme- a
growing group of professionals benefitting from
NICE sponsorship and mentoring
• www.nice.org.uk/getinvolved

IMPLEMENTING START
SMART AND FOCUS IN
PRACTICE – A CASE
STUDY
Danielle Stacey
Lead Pharmacist - Antimicrobials
Dudley Group NHS Foundation Trust

Dudley Group NHS Foundation Trust
• Serves a population of 450,000 across Dudley and areas
of Sandwell, South Staffs and Wyre Forest
• District General
• Provides specialist
services to Black
Country and West
Midlands

Elements of Antimicrobial Stewardship
ExpertiseLeadership
Interventions Monitoring
EducationReporting

First steps
• Start Smart then Focus toolkit first published in November
2011
• Antimicrobial Steering Group established
• Online antibiotic guidelines and credit card published
• Restricted formulary introduced to reduce high-risk broad
spectrum antibiotics
• Antibiotic usage monitoring began
• Quarterly Point prevalence surveys started

Point prevalence surveys
• Quarterly data collection
• PPS benchmarked against rest of region

Issues Identified for Improvement
• Adherence to guidelines
• Elements of Start Smart and Focus
• Documentation of indication
• Documentation of duration/date for review
• High IV antibiotic usage
• Duration of antibiotic course
• Underpinning all of this: Education and Training

Antibiotic guideline adherence
• Microguide App and Webviewer
• April 2014

Reducing duration of IV and overall
course length
• New drug chart – 72 hr review banner
• Drug chart update – duration and micro approved box
added
• Further update – indication box added

Feedback of point prevalence surveys
• After new drug charts introduced, improvements in results
became static
• What will make these improve?
• Educational outreach
• Rolling programme to visit every speciality 6 monthly
• Feedback on C.diff cases and apportionment outcomes

course length

Did it make a difference?
• Documentation of duration still 55-60%
• Indication rose from 60% to 70% after first round of
feedback visits
• Up to 78% after second round of visits
• Highest result in West Midlands Region!
• C.diff cases apportioned due to lapses in Abx prescribing
• 34% cases Trust apportioned in 2014-15
• 18% cases Trust apportioned in 2015-16 so far

course length
• Improved documentation has not reduced usage

Ensuring Start Smart and Focus
• Are antimicrobial prescribing policies and guidelines being
followed?
• Barriers
• Staff time to collect data
• Ownership of results
• Feedback of results

Adherence Audits
• Mandatory audit – Trust audit programme
• Medic led
• 20 patients per speciality annually
• Each speciality produced report with recommendations
• Discussed at speciality meetings and Trust audit meeting
– see others results!!

Adherence audit results
Trust standard Target Result
Indication documented
in medical notes
100% 80%
Name documented in
medical notes
100% 77%
Duration documented
on prescription chart
100% 63%
Compliance with Trust
guidelines
90% 75%
If no: on microbiology
advice?
90% 22%
• Identified 75% compliance with guidelines due to no guidelines for some
indications – worked with specialities to produce guidelines
• 2015 re-audit – to include 48hr Review

Actions
• Trust Clinical Audit lead instructed all specialities to
develop a localised action plan including:
• Documentation of indication & stop/review dates
• Documenting conversations with microbiology
• Stewardship team to work with specialities to develop
more guidelines
• Audit “Start Smart then Focus”

Adherence re-audit 2015
Trust Standard Target 2014 Result 2015 Result
Indication
documented in
medical notes
100% 80% 92%
Duration or review
date documented
100% 63% 66%
Compliance with
Trust guidelines
100% 75% 86%
If no: on
microbiology advice?
90% 22% 43%
48-72 hour review
documented for IV
antibiotics
100% Not audited 38%
• Improvements in documentation of indication and duration and
compliance with guidelines compared with 2014
• First year of auditing 48-72 hour review

Education and Training
• Every doctor, nurse and pharmacist has antimicrobial
induction
• Mandatory training every 3 years – e-learning package
• Better training, better care – junior doctors

New initiatives
• Attending audit meetings to present results – league
tables!
• Junior doctor liaisons – feedback updates to guidelines,
problems in practice, errors
• Two way feedback
• Start Smart then Focus – peer review
• 48 hour review ward rounds and weekend planning
• Does 48-72 hour review reduce overall usage?

Summary
• Effective leadership and expertise essential
• Monitor – intervene – monitor
• Prescriber ownership is essential
• Competition helps
• Effective feedback mechanisms – two-way
• Continual education – not one-off

How local networks are enabling
antimicrobial stewardship activity in the
South West
Elizabeth Beech 24th February 2016
Pharmacist - NHS Bath and North East Somerset CCG
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS England
elizabeth.beech@nhs.net @elizbeech

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

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

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

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

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

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

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

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

The next steps
& HCAI (ARHAI)
#Antibioticguardian

Antibiotic Guardian London Workshop

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