Antimicrobial Stewardship

 

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Welcome to the Antimicrobial Stewardship (AMS) Hub, hosted as part of a PrescQIPP collaboration with NHS Improvement to support CCG Antimicrobial Stewardship activity in particular delivery of the Quality Premium. This work has been led by Elizabeth Beech, Healthcare Acquired Infection and Antimicrobial Resistance Project Lead, Patient Safety Domain, NHS Improvement, who is responsible or the range of content available on this AMS Hub.

nhs improvement logoIn the sliders below you will find a selection of resources and links to help you better understand and navigate this key area of work for commissioners and providers alike.

 

The Role of NHS England in Antimicrobial Resistance Prevention

NHS England has seconded three healthcare associated infection (HCAI) and AMR project leads to work for the rest of the 2014/15 financial year. The project leads will provide specialist clinical advice on AMR and HCAI to support commissioners, strengthen existing clinical networks and collaboration with partner organisations.

Who is Who

Elizabeth Beech - Primary Care (elizabeth.beech@nhs.net)
Stuart Brown - Secondary Care (stuart.brown3@nhs.net)
Phil Howard - Community Pharmacy (philip.howard2@nhs.net)

Infection Prevention and Control and Antimicrobial Stewardship

Healthcare workers have a vital role in preserving the power of antimicrobials. Antibiotic prescribing and antibiotic resistance are inextricably linked. Overuse and incorrect use of antibiotics are major drivers of resistance. Inadequate hygiene and infection prevention and control measures help to spread infections.

The more we can do to prevent infections and control their spread, the more we will reduce the need for antibiotics and limit opportunities for antimicrobial resistant strains to develop. Where infections do occur we need to diagnose them quickly and use the antibiotics we have appropriately.

In December, 2010, National Health Service (NHS) England introduced national mandatory screening of all admissions for meticillin-resistant Staphylococcus aureus (MRSA). Public Health England published guidance on The Implementation of modified admission MRSA screening guidance for NHS (2014). This article reports an assessment of the effectiveness and cost-effectiveness of the 2010 policy, from a regional or national health-care decision makers' perspective, compared with alternative screening strategies. A review of the national MRSA screening programme has been published.

ECDC Evidence Brief – Update on the spread of carbapenemase-producing Enterobacteriacea in Europe.

What's New?

The articles below show new content added to the AMS Hub. 

Infection Prevention & Control Event - 12th July

Knowlex are offering free places to NHS staff at their Infection Prevention & Control event in Leeds on 12th July. This is a repeat of the event that sold out in London in February 2017, and will be covering the NHS CQUIN and Quality Premium initiatives to reduce both sepsis and healthcare acquired gram-negative blood stream infections. 

Book a free place or learn more about the event here and use DISCOUNT CODE: LEE17DPN or email delegates@knowlex.co.uk 

If you have any questions please call 0161 696 4868.

Antibiotics in pregnancy - PHE guidelines updated

Following publication of new evidence of increased risk of spontaneous abortion associated with use of antibiotics in pregnancy Flory TM, Sheehy O, Berard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017 May; 1(189):625-633.

PHE have reviewed the new evidence and updated their guidelines - Management of infection guidance for primary care for consultation and local adaptation to include changes to pages 5 and 17.

If you have any queries about this update please contact Sarah.Alton@phe.gov.uk

Preventing healthcare associated gram-negative bloodstream infections

NHS Improvement Preventing healthcare associated gram-negative bloodstream infections associated gram-negative bloodstream infections: an improvement resource May 2017.

New Health Education England Resources Slider

New resources and links have been added to the Health Education England Resources slider at the bottom of the Key Reports and Links section.

New Challenges in Antibiotic Resistance: Gram Negative Bacteria Course starting on FutureLearn 8th May 2017

Identify, diagnose and treat gram negative bacterial infections.

Gram negative bacteria (GNB) are a group of bacteria that can cause infection and toxic reaction in patients, yet are difficult to differentiate and treat with antibiotics due to their structure.

This online course - led by experts from the British Society for Antimicrobial Chemotherapy (BSAC) - looks at this challenge. You’ll explore the microbiology of gram-negative bacteria, and find out how to identify, classify, diagnose and treat GNB infections.

You’ll also look at occurrences of GNB and antibiotic resistance worldwide, and understand the impact they have on health and economic outcomes.

Click here for more details.

Useful AMS Data Sources

AMS Visualisations by PrescQIPP to Support the AMS Quality Premium Activities

In the visualisation linked below, you'll find our interpretation of the reports that we have been producing over the last two years as part of our collaboration with NHS E around Antimicrobial Stewardship. Please note that this is fully public domain data, from the NHS BSA Information Services Portal, and that is commonly used within the public domain - future visualisations will be restricted at the usual levels.

Antibacterial data monthly commissioner & practice level reporting against commissioner Improvement Assessment Framework AMR indicators & Quality Premium targets. Also provides specific antibacterial trend analysis.

 

An Introduction to the Quality Premium

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 reducing inequalities. There are new Quality Premium AMR CCG targets for 2017-19, and the guidance sets out the measures for 2017-18 and the levels of improvement for CCGs to achieve in order to qualify for the quality premium.

For more information please visit the NHS England webpage here.

NHS England Quality Premium 2017-19: Reducing Gram Negative Bloodstream Infections (GNBSIs) and inappropriate antibiotic prescribing in at risk groups – updated targets, early performance, and trimethoprim age banded GP practice data now published. 

CCG targets to reduce use of trimethoprim in people aged 70+ years by 10% have been updated for all CCGs and recalculated on the same baseline data set; this has happened due to rapid system improvements in the identification of patient age for prescription items. Subsequently patient identifiers are now available for 90% of all dispensed prescriptions, compared to 74% when the 10% reduction targets were published. Use of this more accurate data provides CCGs greater certainty of both reduction targets and performance against those targets. The process by which the baseline data has been adjusted, and the 10% reduction targets calculated, will be published in the updated annex part b.

Some CCGs have boundary changes, GP practice movement and name changes from 1st April 2017 and the antibiotic prescribing  targets in part b have been updated in this annex v7. Similar changes to the E.coli BSI targets in part a will be made when PHE have updated their baseline data set, and an amended annex will be uploaded to the NHSE QP website at a later date.

Publication of GP practice level data for the number of trimethoprim items for people aged 70+ years has been calculated for 12 months to Dec 2016 and is accessible via the NHSBSA website. This is an interim solution until the NHSBSA publish the ePACT2 Antimicrobial Stewardship dashboard in June 2017 (April 2017 data) - the NHSBSA will be contacting all CCGs/CSUs to request a nominated AMS lead to allow early access to the AMS dashboard while ePACT2 is rolled out in 2017.

In collaboration with NHS Improvement, the ePACT2 Antimicrobial Stewardship Dashboard is being developed to support the national Antimicrobial Resistance Strategy. The Government is committed to lead the international fight against AMR setting out new ambitions to do this. Following the O’Neill Review of AMR, the Government set the following ambitions:

  • 50% reduction of preventable Gram-negative bloodstream infections (GNBSIs) by 2020/21 – the SRO is Dr Ruth May NHS Improvement
  • 50% reduction of the number of inappropriate antimicrobial prescriptions by 2020 – the SRO is Dr Keith Ridge NHS England

The Antimicrobial Stewardship Dashboard will support delivery of both of these ambitions, providing prescribing data to support local stewardship activity and reporting, and linking to relevant AMR resources such as the PHE AMR Portal and NICE guidelines.

The 2016/17 Antibiotic quality premium monitoring dashboard format will be updated for the 2017/18 AMR Quality Premium, with publication monthly on the NHS England website.

NHS England have published the newly updated CCG improvement and assessment framework 2016/17, this contains the below:

  • Two new indicators under the Better Health Section
  • Anti-microbial resistance: Appropriate prescribing of antibiotics in primary care
  • Anti-microbial resistance: Appropriate prescribing of broad spectrum antibiotics in primary care.

CCGs are expected to demonstrate appropriate use of antibiotics and CCG performance against both indicators is reported in the Antibiotic quality premium monitoring dashboard.

NHS Improvement Preventing healthcare associated Gram-negative bloodstream infections associated Gram-negative bloodstream infections: an improvement resource May 2017.

New MOOC starting on FutureLearn 8th May 2017 - Challenges in Antibiotic Resistance: Gram Negative Bacteria

Identify, diagnose and treat gram negative bacterial infections. Gram negative bacteria (GNB) are a group of bacteria that can cause infection and toxic reaction in patients, yet are difficult to differentiate and treat with antibiotics due to their structure.

This online course - led by experts from the British Society for Antimicrobial Chemotherapy (BSAC) - looks at this challenge. You’ll explore the microbiology of gram-negative bacteria, and find out how to identify, classify, diagnose and treat GNB infections. You’ll also look at occurrences of GNB and antibiotic resistance worldwide, and understand the impact they have on health and economic outcomes.

The Commissioning for Quality and Innovation (CQUINs)

There is a 2016/17 Antimicrobial Resistance CQUIN which has a stated Goal: Reduction in antibiotic consumption and encouraging focus on antimicrobial stewardship and ensuring antibiotic review within 72 hours based on the Rationale: Reducing consumption of antibiotics and optimising prescribing practice by reducing the indiscriminate or inappropriate use of antibiotics which is a key driver in the spread of antibiotic resistance.

To share examples of antimicrobial CQUINs developed for local use please contact elizabeth.beech@nhs.net

Bristol CCG CQUIN for community services provider

This is a NHS Bristol CCG CQUIN that was agreed with its community services provider (Bristol Community Health) in 2015/16. Bristol Community Health provides a range of services in the Bristol area (Community Matrons, District Nursing etc.) but notably also an Urgent Care Centre/Walk in Centre. Prescribing by Bristol Community Health is attributed to Bristol CCG, rather than to BCH itself as an independent sector healthcare provider. BCH prescribing therefore affects Bristol CCG’s Quality Premium achievement. Please he CQUIN is attached.

Please direct queries to jon.hayhurst@bristolccg.nhs.uk 

    BCH CQUIN – Quality Premium

Infographics

Share your Innovation, Audits and Education

As this page develops we will start to showcase great examples of work that has been done locally.

To share innovation and successful antimicrobial stewardship activities, audit programmes and educational resources here please contact elizabeth.beech@nhs.net

PrescQIPP Innovation Awards

PrescQIPP Annual Event 2016

For a second year we have a broad, yet dedicated category for projects that specifically focus and deliver outcomes around the critical area of patient safety.

Whilst we’ll be delighted to hear about any successful, innovative projects with a specific focus on safety, we’ll be paying a particular interest to any projects that align with helping achieve national objectives around medicines safety (i.e. reducing medication errors, Antimicrobial Stewardship, Acute Kidney Injury (AKI), acutely ill and/or frail elderly and HCAI.

Submission deadline: Friday, 9th September 2016

Find out more information on the Innovation Awards 2016 and details on how to enter!

For inspiration please take a look at the Innovation Award Winner for 2015 - At Scale Antimicrobal Stewardship In Primary Care and all other sumbissions for the Innovation Awards 2015.

Behaviour Change and Public Education

  • NICE have published a draft guideline Antimicrobial Resistance - Changing Risk-Related Behaviours in the General Population: Draft Guideline Consultation - This guideline covers interventions to change people’s behaviour to help reduce antimicrobial resistance and stop the spread of resistant microbes. Consultation closes 20 October 2015
  • The Wellcome Trust have published an excellent research based report into consumers attitudes to AMR and antibiotic use - Exploring the Consumer Perspective on Antimicrobial Resistance June 2015
  • Antibiotic Guardian NHS England is a proud supporter of European Antibiotic Awareness Day (EAAD). EAAD is held annually on 18 November as a European-wide event to raise awareness on how to use antibiotics in a responsible way that will help keep them effective for the future. European Antibiotic Awareness Day and Antibiotic Guardian resources can be found here and will be updated to support 2015 activity when available
  • Public Health England have commissioned roadshows on Antibiotic Guardianship that aim to deliver guidance, information and resources to health professionals. Resources to engage, promote and share Antibiotic Guardianship within the attendees’ organisation and with their stakeholders will be provided to delegates. The link for registration for these roadshows is here
  • e-Bug schools resource produced by Public Health England. This is an exciting, fun and free health education resource for teachers and school aged children. The resources make learning about microbes, antibiotic resistance, and the spread, treatment and prevention of infection fun and accessible for all. The e-Bug lesson plans can be used in biology and PSHE lessons, assemblies and health events. All lesson plans are in line with the National Curriculum and are free to download online here. We have partners in 27 countries and our resources are translated in 22 different languages. We need to teach children and young people about antibiotics as they are our future generation of users and prescribers. If we can reduce childhood infections by educating children on infections then we can reduce antibiotic use. If you would like further information on e-Bug please email e-Bug@phe.gov.uk or follow e-Bug on Twitter @eBug_UK
  • Why is Antimicrobial Stewardship Important? - This is a short cartoon video explaining why Antimicrobial Stewardship matters and may be useful for use in presentations or clinical networking events. This video is part of the Mount Sinai Hospital-University Health Network Antimicrobial Stewardship Program with support from CAHO.
  • Massive Open Online Course (MOOC) on Antimicrobial Stewardship available free here.

             Future Learn MOOC on Antimicrobial Stewardship

  • The Reducing Antimicrobial Resistance programme has been designed to support all health and social care staff – both clinical and non-clinical - in a variety of settings to understand the threats posed by antimicrobial resistance, and ways they can help to tackle this major health issue. This programme has been developed by Health Education England in collaboration with Public Health England and NHS England.
    This programme consists of a single e-learning session entitled ‘Reducing Antimicrobial Resistance: An Introduction’. It provides an overview of how to tackle antimicrobial (antibiotic) resistance, key facts about antimicrobial resistance and describes the important role everyone working in a health and social care environment has in tackling it. By the end of this session, health and social care staff will be able to:
              - Discuss why there is such a concern about misuse of antibiotics and antimicrobial resistance
              - List the key risks for development of antimicrobial resistance
              - Identify their role in tackling antimicrobial resistance
  • Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial - This is a report of the research that informed the decision to send CMO letters to the Top 20% antibiotic prescribing GP practices in January 2016.

Chief Medical Officer mailing to GP practices – January 2016

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Chief Medical Officer mailing to GP practices – April 2017

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Diagnostics

  • AMR Review: Rapid Diagnostics - Stopping unnecessary use of antibiotics. October 2015.
  • This report provides an overview of how diagnostics can play an important role in the fight against antimicrobial resistance, by reducing unnecessary use. It addresses how we can improve innovation as well as encourage the uptake of diagnostics.
  • Position Paper on Anti-Microbial Resistance Diagnostics – Centre for Evidence-Based Medicine, University of Oxford June 2015. DOI:10.13140/RG.2.1.1135.9846.
    This report highlights the considerable number of new diagnostic technologies in development to underpin the rational prescribing of antibiotics.
  • What a difference a CRP makes. A prospective observational study on how point-of-care C-reactive protein testing influences antibiotic prescription for respiratory tract infections in Swedish primary health care, Scandinavian Journal of Primary Health care, DOI: 10.3109/02813432.2015.1114348
    This study reports the prospective use of CRP point of care testing in Swedish primary care settings for patients with RTIs, and clearly documents the impact on antibiotic prescribing.
  • Tackling Drug-Resistant Infections Globally: Final report and recommendations

Antibiotic Guardian

s300 AntibioticGuardian logo gre

NHS England is a proud supporter of European Antibiotic Awareness Day (EAAD). EAAD is held annually on 18 November as a European-wide event to raise awareness on how to use antibiotics in a responsible way that will help keep them effective for the future. European Antibiotic Awareness Day and Antibiotic Guardian resources can be found here and will be updated to support 2015 activity when available.

Public Health England have commissioned roadshows on Antibiotic Guardianship that aim to deliver guidance, information and resources to health professionals. Resources to engage, promote and share Antibiotic Guardianship within the attendees’ organisation and with their stakeholders will be provided to delegates. The link for registration for these roadshows is here.

Letters to NHS, local authority and professional organisations have been sent by Public Health England, asking organisations to register their EAAD planned activities. Letters can be found here.

Additional information promoting the use of Antibiotic Guardian resources during EAAD events can be found in the accompanying documents below.

   ECDC's Short Video Pledges

   Antibiotic Guardian Bulletin - January 2016

AntibioticGuardian Social Media Resources

In the link below you will find the social media content from Public Health England.

    Social Media Content - Public Health England

 

Out of Hours and Urgent Care

This section will support the development of antibacterial prescribing comparators for use in OOH and urgent care organisations. To share innovation and successful antimicrobial stewardship activities in OOH and urgent care organisations here please contact elizabeth.beech@nhs.net

Bristol CCG CQUIN for community services provider

This is a NHS Bristol CCG CQUIN that was agreed with its community services provider (Bristol Community Health) in 2015/16. Bristol Community Health provides a range of services in the Bristol area (Community Matrons, District Nursing etc.) but notably also an Urgent Care Centre/Walk in Centre. Prescribing by Bristol Community Health is attributed to Bristol CCG, rather than to BCH itself as an independent sector healthcare provider. BCH prescribing therefore affects Bristol CCG’s Quality Premium achievement. Please he CQUIN is attached.

Please direct queries to jon.hayhurst@bristolccg.nhs.uk 

    BCH CQUIN – Quality Premium

TARGET patient information leaflets

The TARGET patient information leaflet has now been adapted for use by OOH and Community Pharmacy providers.

    Treating your infection - out of hours clinics

     Treating your infection - community pharmacies

Community and Out Patient IV Antibiotic Services

This section will link to resources to support the commissioning and use of IV antibiotics in out of hospital locations. To share innovation and successful antimicrobial stewardship activities here please contact elizabeth.beech@nhs.net 

Useful Resources

            CIVAS: Patient Preferences for and Cost Effectiveness of Community Intravenous Antibiotic Services

Key Reports and Links

AMR and AMS Publications

Please find below AMR and AMS publications that you may find useful: 

    • UK National 5 Year Antimicrobial Resistance Strategy 2013-18
    • Annual Progress Report and Implementation Plan 2014 - 
      The 7 key areas for action:
      1. Improving infection prevention and control practices
      2. Optimising prescribing practice
      3. Improving professional education, training and public engagement
      4. Developing new drugs, treatments and diagnostics
      5. Better access to and use of surveillance data
      6. Better identification and prioritisation of AMR research needs
      7. Strengthened international collaboration
    • Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections: Annual Reports - ARHAI is the expert scientific advisory committee providing independent advice to the Department of Health on antimicrobial resistance and healthcare-associated infection. The committee provides advice on policies and guidance to minimise healthcare-associated infections, and to conserve the effectiveness of antibiotics by encouraging best practice in prescribing.
    • English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2015 has been published
    • English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2014 - this reports antimicrobial resistance for drug-bug combinations and antibiotic consumption at a whole health economy level based on an NHS area team footprint using a combined unit of measurement: Defined Daily Dose per 1000 inhabitants per day. Key messages are:
      • The number of patients with bloodstream infections has increased each year from 2010 to 2013
      • There were an increased number of bloodstream infections where antibiotic resistance was identified
      • Antibiotic prescribing has increased in England year on year
      • The majority of antibiotic prescribing takes place in the community (ie general practice)
      • There is considerable variability in both antibiotic resistance and antibiotic prescribing across England; frequently areas with high prescribing also have high resistance
      • Individual healthcare organisations should use this data to benchmark their organisation
    • Review on Antimicrobial Resistance - Responding to mounting international concern about the rise of drug-resistant infections, the UK Prime Minister, The Rt Hon David Cameron MP, commissioned Jim O’Neill in July 2014 to chair this review on antimicrobial resistance. The Review has published Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations which explains why failing to tackle drug-resistant infections will cause 10 million deaths a year and cost up to US $100 trillion by 2050. Comparative Deaths 1
    • National Risk Register for Civil Emergencies 2015 - AMR has been included in the register as an emerging serious long-term issue; pandemic flu is also included in the register.
      The report states that the numbers of infections complicated by AMR are expected to increase markedly over the next 20 years. If a widespread outbreak were to occur, we could expect around 200,000 people to be affected by a bacterial blood infection that could not be treated effectively with existing drugs, and around 80,000 of these people might die. High numbers of deaths could also be expected from other forms of antimicrobial resistant infection.
    • NHS Scotland report: Antimicrobial Use and Resistance in Humans in 2014
    • Position Paper on AMR Diagnostics June 2015 This excellent report, commissioned by the Department of Health,  provides an overview of the diagnostic technologies (including c-reactive protein) that improve the appropriate prescribing of antibiotics, and reports on the evidence base.
    • Tackling Drug-Resistant Infections Globally: Final report and recommendations

Commissioning Resources and Toolkits

This section links to resources to support antimicrobial stewardship activities with commissioning pathways.

Guidelines and Resources

Please find below guidelines and resources that you may find useful: 

TARGET Antibiotics

TARGET Antibiotics is the central resource to help prescribers and commissioning organisations optimise antibiotic prescribing in primary care. It has been developed by the Public Health England (PHE) Primary Care Unit, the Royal College of General Practitioners (RCGP) and the Antimicrobial Stewardship in Primary Care Group.  Some of the resources for commissioners are provided below and an extensive toolkit of materials is available here.

    TARGET Antibiotics Toolkit - Guide to Resources

    Treating your infection

    Treating your infection - community pharmacies

    Treating your infection - out of hours clinics

Public Health England (PHE), the British Society for Antimicrobial Chemotherapy (BSAC), and primary care colleagues have developed seven free TARGET antibiotic webinars highlighting key easy actions you can take to help improve antibiotic prescribing, the patient journey and self-care, reducing future consultations. Professor Cliodna McNulty, Head of PHE Primary Care Unit will lead each session.

Webinars start Wednesday 2 November 1:30 – 2:15 p.m. Full content and reading will be available after each session.

REGISTER NOW for FREE TARGET antibiotic webinar series and gain 7 hours of CPD

Health Education England Resources