Antibiotic Guardian Bristol Workshop

Welcome to the Antibiotic
Guardian Bristol Workshop
#antibioticguardian

Chairs opening comments and
welcome
Dr Chaamala Klinger, Consultant in
Communicable Disease Control,
Public Health England
#antibioticguardian

National actions to tackle antimicrobial
resistance (AMR)
AntibioticGuardianRoadshow
08February2016
Dr Diane Ashiru-Oredope
Pharmacist Lead;
Antimicrobial Resistance Programme
Twitter - @DrDianeAshiru
#AntibioticGuardian

The future if we do not act now
4
By 2050: more deaths from
resistant infections compared to
e.g. cancer
http://amr-review.org/
Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

AMR andAntibiotic Use
5 Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

TacklingAMR:
• The government
• Professional bodies/organisations/Public health agencies and leads
• Healthcare professionals – human and animal health
• The public
• Pharmaceutical companies
Antimicrobial Resistance
Dr Diane Ashiru-Oredope6 AMR; WLMHT Physical Health Conference Dr Diane Ashiru-Oredope
EVERYONE HAS A ROLE:

Global action onAMR
• WHA 2014 resolution
• WHO Global AMR Action Plan 2015 – framework for
action
• Global Health Security Agenda: AMR action package
- mechanism and collaboration to accelerate
implementation
• United Nations Declaration – September 2016 (193
countries)
http://www.un.org/pga/71/2016/09/21/press-release-hl-meeting-on-antimicrobial-resistance/

UK 5-yearAMR Strategy 2013-18:
Seven key areas for action
PHE
Human health
DH – High Level Steering Group (cross government)
Defra
Animal health
DH
1. Improving infection prevention and control
2. Optimising prescribing practice
3. Improving professional education, training
and public engagement
4. Better access to and use of surveillance
data
• Improving the evidence
base through research
• Developing new drugs,
vaccines and other
diagnostics and treatments
• Strengthening UK and
international collaboration
Impact of EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope & Ms Katerina (Aikaterini) ChaintarliEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope
Antimicrobial Resistance Dr Diane Ashiru-Oredope8 Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

Non-susceptibility (%) among (a) E. coli, (b) Klebsiella spp. and (c) Enterobacter spp. from
bacteraemias in England, Wales and Northern Ireland, as reported to PHE-LabBase.
Livermore D M et al. J. Antimicrob. Chemother.
2013;jac.dkt212
© The Author 2013. Published by Oxford University Press on behalf of the British Society for
Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com
Cephalosporins, diamonds;
ciprofloxacin, squares;
gentamicin, triangles Antimicrobial Use
is a driver for
resistance

AMR: individual risk
Risk of resistance persists for at least 12 months in
individuals after each intake of an antibiotic
Increased risk of
resistant organism
Antibiotic in past
2 months
Antibiotic in past
12 months
UTI
5 studies: n = 14,348 2.5 times 1.33 times
RTI
7 studies: n = 2,605 2.4 times 2.4 times
A meta analysis of English Primary Care
Costello et al. BMJ. (2010) 340:c2096.
10 Antimicrobial Resistance Dr Diane Ashiru-Oredope10 Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

11 Antimicrobial Resistance Dr Diane Ashiru-Oredope
CPEs: 2013 vs 2015

2013 vs 2015
12
Antimicrobial Resistance Dr Diane Ashiru-Oredope

England:AMR andAMU surveillance

National Surveillance:Antibiotic use and
resistance in England 2015

Better access to and use of data
In April 2015 PHE launched a series of AMR local indicators for England on the
Fingertips data portal.2 Data for more than 70 indicators are now available
across three NHS geographies: acute trusts, clinical commisioning groups
(CCGs) and GP practices.

Other clinicalsyndromes:
E.coliUTI
ESPAUR 2010-2014: Year 2 Report
ImprovedAMR surveillance and drug-bug
outputs
Secular trends:
Bloodstream E. coli AMR
Increased coverage from NHS
laboratories from 30% to 98%
Increased daily reporting from
10% to 82%
Increased automated reporting
from 0% to 78%

Developed Enhanced Surveillance for
Emerging Critical Resistance
CPE* in the UK, 2000-2014 Developed Enhanced
Surveillance
Develop
toolkits for
healthcare
settings*Carbapenemase Producing
Enterobacteriaceae
17
Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

ImprovedAMU surveillance
ESPAUR can now track antibiotic prescribing from each healthcare sector.
PHE has worked with NHS England and NHS Improvement to implement the
Antibiotic Prescribing Quality Measures advised by the Department of
Health (DH) expert advisory committee on Antimicrobial Resistance and
Healthcare-Associated Infections (ARHAI) into incentives for CCGs and
acute trusts.
2015

Antibiotic use compared across the UK
health administrations
Antibiotic items per
1000 population per
day
(community only)
DDD per 1000 population per day
(hospital and community)
Total
Antibiotics
Piperacillin/t
azobactam
Carbapenem
s
England 1.79 21.90 0.11 0.08
Scotland 2.00 25.90 0.07 0.05
Wales 2.19 24.27 0.12 0.09

England:AMU surveillance, impact of QP

Antimicrobial resistance (AMR) Improving
antibiotic prescribing in primary care
QualityPremiumGuidancefor2016/17
Slide courtesy Elizabeth Beech

Have you viewed the AMR
indicators in the last six months
www.slido.com
Event code – AGBristol

Improved antimicrobial stewardship

NationalAntimicrobial Stewardship Toolkits: led by
PHE in collaboration with several organisations
27 Future Antimicrobial Usage Surveillance HIS Foundation Course 2017 Dr Diane Ashiru-Oredope

2014 and 2015: assessment of AMS activities and implementation of national AMS
toolkits in primary and secondary care – TARGET and Start Smart then Focus
(SSTF) respectively – Published in JAC
2015/16: Assessing the implementation of recommended antimicrobial stewardship
interventions in community healthcare trusts (77% response rate)

Community Health Trusts – guidelines and
policies

developed an antimicrobial stewardship surveillance system including tools to
support stewardship audits in acute trusts and these are being used as part
of the CQUIN (Commissioning for Quality and Innovation) in 2016/17.

Antimicrobial Stewardship Surveillance:
CQUIN - data collection and submission
tools
ESPAUR and AMS Tools PHE CSPHDG Professional meeting Dr Diane Ashiru-Oredope31 Antimicrobial Resistance and Stewardship Dr Diane Ashiru-Oredope

Dental antimicrobial stewardship toolkit has been developed and rolled out by
the dental subgroup of ESPAUR in collaboration with Faculty of General
Dental Practice and British Dental Association
https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit:
• Resources
• Guidance
• Education and training tools
• Audit tool and action planning

Improved public and professional
engagement
Antibiotic Guardian’ (AG) campaign from awareness to engagement and
changes in public and professional behaviour around antibiotic use.
Process and outcome evaluations:
• showed the wide reach of the campaign success in increasing commitment
to tackling AMR in both healthcare professionals and members of the public
• increased self-reported knowledge and changed self-reported behaviour,
particularly among people with prior AMR awareness

Improved public and professional
engagement
Worked with Health Education England to scope and develop implementation
options related to education and training of healthcare professionals for
antimicrobial prescribing and stewardship competencies in undergraduate
and postgraduate education and for continuing professional development.
August 2016

4. Improved public and professional
engagement
The PHE Primary Care Unit has continued to work with schools to provide
education about the spread, prevention and treatment of infection through
the ongoing development and delivery e-Bug, a free educational resource
for use in the classroom and at home.

New work on fungal resistance,
surveillance and stewardship
ESPAUR have also increased outputs to look at fungal resistance, antifungal
consumption and stewardship as this is an area of emerging concern

ImprovedAntimicrobial Stewardship:Antifungal
Stewardship
There was a 30% response rate to the antifungal survey from acute trusts.
Although only a minority of trusts conducts AFS programmes, nearly half
include AFS as part of routine antimicrobial stewardship activities. Cost and
clinical need are the main drivers for AFS..

National point prevalence survey on
healthcare-associated infections and
antimicrobial use in acute hospitals

National incentives for infections/AMR
2015-2017
• Quality Premium for improved antibiotic prescribing in primary care 2015-
16 and 2016-17
• Sepsis CQUIN 2015-16 & 2016-17 - systematic screening for sepsis and
timely treatment
• AMR CQUIN 2016-17 - Reduced antibiotic consumption in acute trusts &
improved stewardship review 2016-17
Coming up in 2017
• CQUIN 2017-19 - Reducing the impact of serious infection
• Quality Premium 2017-19 - Reducing Gram Negative Bloodstream
Infections (GNBSIs) and inappropriate antibiotic prescribing in at risk groups
41 Future Antimicrobial Usage Surveillance HIS Foundation Course 2017 Dr Diane Ashiru-Oredope

The rest of the day: Local
actions to tackle AMR

Developed by Public Health England
National Awards
June 2017, London
Categories include:
Staff engagement: How have staff promoted Antibiotic Guardian and stewardship within their
organisation?
Community: How has your organisation worked within the community to highlight Antibiotic Guardian?
Prescribing: How has your organisation tackled prescription and prescribing antibiotics effectively?
Innovation: Tell us how you have demonstrated innovation to address Antimicrobial Resistance?
Antibiotic Stewardship: How have you improved or measured antibiotic usage in your area or
community?
AMS Research: How have you demonstrated development of research to support Antimicrobial
Stewardship?
Young People and Family Antibiotic Guardian champions
Healthcare Students
For details of how to apply please visit
www.antibioticguardian.com

Antimicrobial Resistance Dr Diane Ashiru-Oredope
You are invited to become an Antibiotic
Guardian today (available via mobiles)

Antibiotic Guardian Roadshow:
tackling antimicrobial resistance
in the South West
Chaam Klinger
CCDC

Overview
Take home messages
Priorities from UK AMR strategy
Examples of work in the South West
46

Past model
47
HCAI Infection
prevention
and control
Antimicrobial
stewardship/
prescribing

Current thinking onAMR
IPC
AMSHCAI
48
Reduce the
burden of
infection
Reduce use
of
antimicrobials

UKAMR Strategy: 7 key areas for action
50 ABG Roadshow
Improve IPC
Optimise
prescribing
Improve
education
Develop new
drugs/diagnostics
Better access
to and use of
surveillance
data
Identification and
prioritisation of
AMR research
needs
Strengthen
international
collaboration
Professional
and public

Improve IPC
51 ABG Roadshow
Improve
IPC
Optimise
prescribing
Improve
education
Develop
new
drugs/diagn
ostics
Better
access to
and use of
surveillance
data
Identification
and
prioritisation
of AMR
research
needs
Strengthen
international
collaboration
Developed by Grace Magani, HPP

Optimise prescribing
53 From Liz Jones, North Somerset CCG
Optimise
prescribi
ng
Improve
IPC
Improv
e
educati
onDevelop
new
drugs/dia
gnostics
Better
access to
and use of
surveillanc
e data
Identificatio
n and
prioritisation
of AMR
research
needs
Strengthen
internation
al
collaboratio
n

54
From Liz Jones, North Somerset CCG

55
From Liz Jones, North Somerset CCG

Research
56 ABG Roadshow
Identification
and
prioritisation of
AMR reseach
needs
Optimise
prescribing
Improve
education
Develop new
drugs/diagnostics
Better
access to
and use of
surveillance
data
Improve IPC
Strengthen
international
collaboration

AMR Force
Work towards decreasing antibiotic use while improving animal health
Research questions:
• Can we use medicine audits to encourage responsible medicine use by
veterinarians?
• Can we impact the way veterinarians prescribe medicines?
• Can we assist in developing medicines use policy with policy-makers,
veterinarians and farmers (using participatory or other approaches)?
• Does reducing antimicrobial use impact patterns of resistance?
• How do microbes and AMR genes cycle in the environment?
57

AMR Force
Collaborations
Social
sceinces
Animal
welfare
Policy
making
Bristol
Bridge
58

bridgethegapsbetweenthephysicalsciences/
engineering,andantimicrobialresistance(AMR).
59
Physical
scientists
Engineers
Mathematicians
Life scientists
Clinicians
Veterinary
scientists
Collaboration

1.New tools and techniques for assays, screening and diagnostics, and novel
antimicrobial compounds
2.Innovative antimicrobials, smart surfaces and wound dressings to prevent
infection, and new drug delivery methods
3.Developing AMR surveillance and intervention techniques.
60

Aim: Develop an AMR stewardship policy to‘reduce and rationalise
antimicrobial use without compromising animal health and welfare’
61
Participatory Policy Making by Dairy Producers to Reduce
Anti-Microbial use on Farms, L. van Dijk et al
Project
team
Dairy
producers
Veterinary
advisors
Retail
represen
-tatives
Milk
buyers
Researchers
Regional
workshops

Antimicrobial stewardship policy
Policy principle Policy measure
1: Disease reduction
strategies
All producers work with their veterinarians to assess and address disease
risk regularly.
2: Ensuring correct
use of medicines
On all farms, all staff engaged in using antibiotic use them responsibly or
are adequately supervised by staff who are able to do so.
3: Avoiding
prophylactic use
All producers use animal production practices that reduce, and, where
possible, eliminate the need for AMtherapies. On all farms, the use of
antibiotics to prevent disease is minimalized.
4: Encouraging
quality data
recording and use
On all farms, unified data is collected and used to benchmark and compare
medicine use within and between farms to work towards further reductions
in AM use.
62

Fig.3.Participants’responsetothequestionabout theimportance of theroleoftheproducer
and theveterinarianinthefight against anti-microbialresistance.
63
Participatory Policy Making by Dairy Producers to Reduce
Anti-Microbial use on Farms, L. van Dijk et al

64
Improve
education
Optimise
prescribing
Identification
and
prioratisation of
AMR research
needs
Develop new
drugs/diagnostics
Better
access to
and use of
surveillance
data
Improve IPC
Strengthen
international
collaboration

65 Issy Tucker, Wiltshire Council

66 Presentation title - edit in Header and Footer
My design is about
only using
antibiotics when
the doctor says you
really need them.
Don’t use them
when you only
have a cold”

67 Issy Tucker, Wiltshire Council

STP andAMR
• Using existing resources differently
• Opportunity to change the way to work within health and social care
• AMR has been recognised as a priority within local STPs
• e.g. BNSSG
• Key performance indicator added to BNSSG Local Authority Sexual Health
Contracts
“All patients with gonorrhoea positive specimens have a culture sent for AMR”.
69

Partners in CARG
NHS
England
CCG
Acute trusts
Community
health trusts
Animal
Health
Dentists
Community
Pharmacists
Research
70

CARG work streams
• Education and Engagement with the Public
• Education and Engagement with Healthcare
Workers & Vets
• Comprehensive Stewardship Programme for All
Sectors

The role of the community pharmacy
Nick Kaye, Board Member South West, Member of Cornwall and Isle
of Scilly LPC and Chair of the Peninsula LPF
#antibioticguardian

Antimicrobial resistance
surveillance
Dr Charles Beck, Consultant Epidemiologist & Honorary Senior Lecturer,
Field Epidemiology Service, National Infection Service

Objectives
• To summarise key AMR information sources
• To describe aspects of how to interpret AMR data and associated
limitations
• To briefly summarise planned developments on AMR surveillance
75 Antibiotic Guardian Roadshow (Bristol), February 2017

Context
• UK five year AMR strategy 2013-18 and action plan published September
2013; PHE responsible for leading on human health aspects
• Key area 5 – better access to and use of surveillance data
• Focus has been on mandatory HCAI organisms, but ESBLs and CPE +
CROs are an international concern
• Field Epidemiology Service (FES) has key role in surveillance of infectious
diseases and management of incidents and outbreaks including AMR
• FES has a national role in enhancing surveillance of AMR

Surveillance
Cornerstone to epidemiology of AMR and intervention effectiveness
1. Second Generation Surveillance System (SGSS)
• Selected drug/bug combinations reported quarterly
2. Enhanced surveillance system for Carbapenamase-producing
Gram-negative bacteria (CPOs)
3. English Surveillance Programme for Antimicrobials Usage and
Resistance (ESPAUR)
4. Mandatory HCAI surveillance (Data Capture System)
5. AMR indicator set via Fingertips
6. International datasets and other publications

1. Second Generation Surveillance System
• SGSS - receives automated submission of isolate data from NHS
laboratories and some private labs, including:
• Notifiable and ‘significant’ infections (CDR data feed)
• All positive isolates (AMR data feed)
• Web-enabled interface including analytical tools
• 100% NHS microbiology laboratories reporting CDR and 95%
submitting AMR data to PHE

AMR Quarterly Surveillance Workbooks

2. ERS for enhanced surveillance of CPOs
• Revised enhanced reporting system launched July 2016
• Three main functions:
• a system for laboratories to request full characterisation of Gram-
negative bacteria where expression of an acquired carbapenemase
is suspected;
• a system to report locally-confirmed carbapenemase producers and;
• a system for NHS Trusts to submit enhanced surveillance data.
• ERS is the only method of capturing results of local molecular tests
for antimicrobial resistance mechanisms to provide local and national
intelligence to help understand the epidemiology of these important
pathogens
• ERS collects information on patient demographics, submitting
laboratory (including specimen) details, healthcare setting and risk
factors

ERS for enhanced surveillance of CPOs
* = Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit; (Source: ESPAUR report 2016)
Numbers of isolates confirmed as carbapenemase-producing Enterobacteriaceae by
AMRHAI*

ERS monthly report

3. English Surveillance Programme for
Antimicrobials Usage and Resistance (ESPAUR)
ESPAUR was established by PHE in 2013
in response to the cross-government UK
five-year antimicrobial resistance (AMR)
strategy.
The aims of ESPAUR are to:
• develop, maintain and disseminate
robust data relevant to antimicrobial use
(AMU), AMR and antimicrobial
stewardship (AMS)
• enable optimum use of this data across
healthcare settings
• measure the impact of AMU and AMS
on AMR and patient safety

ESPAUR - key facts (2016 report)
1. The number of people affected by antibiotic-resistant Gram-negative infections
continues to increase
2. The incidence of antibiotic-resistant Gram-negative bloodstream infections is higher in
the very young and the elderly, reflecting the higher rate of infection in these age
groups
3. Antibiotic use has reduced significantly across the whole healthcare system for the first
time
4. Antimicrobial stewardship continues to be embedded and improving in both general
practice and hospitals, although further work is needed in community health trusts
5. A new antimicrobial stewardship toolkit has been launched for dental practices
6. By November 2016, more than 33,000 people had become Antibiotic Guardians and
had pledged an action to reduce the unnecessary use of antibiotics
7. Professional organisations and stakeholders are engaging with PHE to raise
awareness, educate and deliver aspects of the UK AMR strategy

4. Mandatory HCAI surveillance
• Quarterly report – includes absolute case
counts, funnel plots, P-charts
• Monthly report – includes
• Infections include:
 MRSA
 MSSA
 Clostridium difficile
 Escherichia coli bacteraemia
• Apportionment by acute Trust or CCG for
MRSA, MSSA, C. difficile
• Hospital onset for E. coli bacteraemia

5. Fingertips
http://fingertips.phe.org.uk/profile/amr-local-indicators

Source: European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in
Europe 2015. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-
Net). Stockholm: ECDC; 2017.

Limitations
• Case definitions
• Diagnostic variation
• Antimicrobial panel variation
• Speciation variation
• Standard microbial investigations
• No linkage to clinical or prescribing data
• Voluntary reporting (some organisms)
• Epidemiological biases e.g. ascertainment bias
• No data from negative samples to inform testing denominators

Areas for development
• Continued development of surveillance arrangements for AMR
• Improvement of quality and standardisation of routine antibiotic testing and
interpretation
• Publication of locally relevant data; automated reporting
• Improving epidemiological understanding of risk factors e.g. role of UTI as
primary focus of E. coli bacteraemia
• Impact of improved resistance data informing antimicrobial stewardship and
prescribing practice, for example:
• Change in prescribing rates
• Alterations in drug use
• Effect on resistance patterns
• Change in outcomes
• Whole genome sequencing – surveillance, outbreak investigation and
infection control

Source: Aanensen et al. Whole-Genome Sequencing for Routine Pathogen Surveillance in Public Health: a Population
Snapshot of Invasive Staphylococcus aureus in Europe. mBio 7(3):e00444-16. doi:10.1128/mBio.00444-16.
Phylogenetic reconstruction
of S. aureus clonal complex
5 (CC5). Branch colour
indicates MSSA (green) or
MRSA (red). Clusters are
shaded grey. Symbols at the
tips indicate the geographic
origins of these isolates

Source: Aanensen et al. Whole-Genome Sequencing for Routine Pathogen Surveillance in Public Health: a Population
Snapshot of Invasive Staphylococcus aureus in Europe. mBio 7(3):e00444-16. doi:10.1128/mBio.00444-16.
Phylogenetic reconstruction of S. aureus CC22.
Branch colour indicates MSSA (green) or MRSA
(red). The epidemic MRSA-15 cluster is shaded grey.
Symbols at the tips of the branches indicate the
geographic origins of these isolates. A cluster
consisting of isolates from Berlin indicating the
possible point of epidemic MRSA-15 introduction into
Germany from the UK is shaded a darker grey. The
position of an isolate from Lisbon is shown indicating
the possible location of its entry into Portugal.

Conclusion
• AMR surveillance is rapidly improving
• We need to improve data quality
• Goal to make data readily available at lowest appropriate level of
granularity in a timely manner
• We need to work together to review and understand local data and
to develop whole system approaches to interventions

Acknowledgements
• Janet McCulloch, Specialist Nurse, National Infection Service, Field
Epidemiology Service South West
• Madeleine McMahon, Epidemiology and Information Analyst,
National Infection Service, Field Epidemiology Service South West
• Professor Alasdair McGowan, Lead Public Health Microbiologist
South West, PHE and Consultant in Infection, North Bristol NHS
Trust

Liz Cross, Nurse Practitioner, CLARHC fellow NIHR East of England
Attenborough Surgery
Bushey, Hertfordshire
Winner of NHS Innovation Challenge Prize (acorn category) 2015/16

 78.5% antibiotics are prescribed in primary care
 Over half of antibiotics prescribed in Primary Care are
for respiratory tract infections (RTI)
 97% of patients who ask for antibiotics are prescribed
them

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

 There is strong evidence that primary care CRP
testing for RTI reduces antibiotic prescribing and
enables patient education and the consultation
discussion.6 Especially:
.
(i) where there is a high degree of diagnostic uncertainty
(ii) for patients who are very worried and/or demanding antibiotics
(iii) to differentiate the seriously ill from the non-seriously ill.

 Is the infection bacterial or viral?
 If its bacterial, what type of bacterial is
causing the infection?
 Are the bacteria causing the infection
resistant to the available abx?
 Are the bacteria that are causing the infection
susceptible to the existing drugs?
The Review on Antimicrobial
Resistance, Jim O'Neil, October
2015

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

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

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

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

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

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

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

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

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

 8 GP practices (>10,000 list size and
medium/high abx prescribers)
◦ 5 sites using CRP point of care testing
◦ 3 sites using standard practice
◦ Nov 2016- Jan 2017
KPIs
Does CRP POCT reduce abx prescriptions?
Does CRP POCT reduced unscheduled re-attendance
within 28 days?

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

Question and answers from the floor
#antibioticguardian

Lunch and networking
#antibioticguardian

Welcome back
Dr Diane Ashiru-Oredope, Pharmacist Lead,
#antibioticguardian

AMR-CQUIN
parts a and b
objectives: How
are we doing?
Philip Howard
Consultant Pharmacist
AMR Project Lead
Twitter: @AntibioticLeeds
philip.howard2@nhs.net
#AMRCQUIN

• Hospital antibiotic use per admission
• Total +6%
• Piperacillin-tazobactam +56%
• Carbapenems +36%
AMR in England (2011-2014)
 Use =  AMR
Piperacillin-tazo +31% Pip-tazo +36.3%
7.4% last year
OECD. Antimicrobial Resistance in G7 Countries and Beyond. Available from:
https://www.oecd.org/els/health-systems/antimicrobial-resistance.htm. Last accessed
October 2016
AMR: antimicrobial resistance
PHE October 2015. Guidance: Health matters: antimicrobial resistance. Available from:
https://www.gov.uk/government/publications/health-matters-antimicrobial-resistance/health-
matters-antimicrobial-resistance#the-scale-of-the-problem. Last accessed October 2016
PHE. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) Report
2014. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_R
eport_2014__3_.pdf. Last accessed October 2016

Good Progress on Reducing Antibiotic (AB)
Use in Primary Care Across UK: 2011-2015
AB use in primary care (excluding dental)
Items/1000/day 2011 2012 2013 2014 2015 Change last year
Scotland 2.14 2.21 2.09 2.05 2.00 -2.4%
England 1.92 2.01 1.92 1.92 1.79 -6.8%
Northern Ireland 2.90 3.06 2.88 2.84 2.76 -2.8%
Wales 2.32 2.45 2.33 2.30 2.19 -4.8%
NHS National Services Scotland. Antimicrobial use and resistance in humans 2015 publication report. Available from:
https://isdscotland.scot.nhs.uk/Health-Topics/Prescribing-and-Medicines/Publications/2016-08-30/AMR_2016.xlsx. Last accessed
October 2016.
Use of broad AB (CDI associated) in primary care (excluding dental)
Items/100,000/day 2011 2012 2013 2014 2015 Change last year
Scotland 22.90 20.50 17.90 17.00 16.00 -5.9%
England 24.90 23.50 22.10 21.40 18.60 -13.1%
Northern Ireland 36.10 37.00 34.70 34.60 32.20 -6.9%
Wales 34.60 31.70 28.70 26.20 22.30 -14.9%

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5 national priorities each year. Worth 2.5% of income
• 2016-17 Clinical: sepsis (2nd year), AMR, physical health of
patients with severe mental health issues
• 2017-19 Clinical: serious infections (merger of sepsis &
AMR)
AMR: antimicrobial resistance
NHS England. Commissioning for Quality and Innovation (CQUIN). Guidance for 2016/17. March 2016. Available from:
https://www.england.nhs.uk/wp-content/uploads/2016/03/cquin-guidance-16-17-v3.pdf. Last accessed October 2016.

Overall 5.3% in IV AB/1000
adm from Apr-15 to Mar-16
(info from Rx-Info Define software)
CEM audit of IV AB in 60 min:
• 2011 = 27% (IQR 17-37%)
• 2013 = 32% (IQR 20-44%)
CQUIN Sepsis – IV AB in 60 min
2015-16 Q2 = 49%, Q3 = 58%, Q4 = 72%
61% of red flags required Abs
Day 3 review in 2016-17 CQUIN
AB: antibiotic; CEM: College of Emergency Medicine; CQUIN: Commissioning for Quality and Innovation; ED: emergency department;
IV: intravenous
Has sepsis CQUIN  ED IV AB use

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
NHS England. Commissioning for Quality and Innovation (CQUIN). Guidance for 2016/17. March 2016. Available from:
https://www.england.nhs.uk/wp-content/uploads/2016/03/cquin-guidance-16-17-v3.pdf. Last accessed October 2016.

AMR-CQUIN – What & Why?
Requires 1% (DDD per admission) vs 2013-14 baseline for:
• Total (IP & OP): +6% over 4 years nationally
• Carbapenems: +36% & KPC outbreaks
• Piperacillin-tazo: +55% & K. pneumoniae-R +36% E. coli-R +31%
• 90%+ documentation of empirical antibiotics review by day 3
(Q1 25%, Q2 50%, Q3 75%, Q4 90%):
• Only 10% of Trusts could provide data though mandatory (Llewellyn 2015)
Hospitals AMS Teams to use ££ to improve IT, staffing, and fund more
expensive antibiotics or tests.
AMR: antimicrobial resistance; AMS: antimicrobial stewardship; CQUIN: Commissioning for Quality and Innovation; DDD: defined daily
dose; IP: inpatient; KPC: Klebsiella pneumoniae Carbapenemase; OP: outpatient

Broad spectrum drives AMR. Selection risks
associated with major antimicrobial classes
MRSA VRE ESBL MDR
Pseudomonas
C.diff
Carbape
nemases
Carbapenems
Piperacillin – tazo
3rdG Cefalosporin
Quinolones
Tigecycline
Antibiotic Chemotherapy 7th edition. Ed Davey P, Irving W, Thwaites G, Wilcox MH Oxford University Press 2015
De-escalation of empiric antibiotics in severe sepsis or
septic shock: A meta-analysis Ying Guo 2016 Heart & Lung:
De-escalation in only 35-45%
No difference in mortality RR = 0.74, 95% CI 0.54-1.03

Carbapenem & piperacillin-tazobactam
usage & resistance (from ESPAUR 2016)
135
y = 60793x - 3394.8
R² = 0.9064
0
500
1000
1500
2000
0.05 0.055 0.06 0.065 0.07 0.075 0.08 0.085
CPEisolates/yr
Carbapenem DDD/1000 DID
Carbapenem use & resistance 2010-15
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
2011 2012 2013 2014 2015
E.coli-R pip-taz K.pneum-R pip-taz
Pip-taz DDD/1000adm

136
Change in Total AB DDDs /
1000 Total Admissions (inc.
Day Case) (%)
Large acute trust
(33)
Acute teaching
trust (25)
Medium acute
trust (33)
Acute specialist
trust - Inc
Children (3)
Small acute
trust (21)
Feb 2014 to Jan 2015 5.19 4.90 2.59 1.66 0.83
Feb 2015 to Jan 2016 -4.45 -1.75 -1.44 -4.59 -6.18
% growth since 2013-4 0.74 3.15 1.15 -2.93 -5.35
Total AB
target
reduction
= 1.6%
growth
since
FY1314

137
Change in DDDs / 1000 Total
Admissions (inc. Day Case) (%)
Large acute
trust (33)
Small acute
trust (21)
Medium
acute trust
(33)
Acute
teaching
trust (25)
Acute specialist
trust - Inc
Children (3)
Feb 2014 to Jan 2015 9.0 7.8 6.7 2.6 -10.4
Feb 2015 to Jan 2016 -1.7 -0.7 -1.3 -6.0 -9.2
Carbapenem % Increase since FY1314 7.3 7.1 5.4 -3.5 -19.7
Carbapene
m target
reduction =
2.3%
growth
since
FY1314

138
Large acute
trust (33)
Acute teaching
trust (25)
Small acute
trust (21)
Medium acute
trust (33)
Acute specialist trust -
Inc Children (3)
FY 2014 14.1 11.7 8.2 7.8 3.0
FY 2015 -1.1 2.3 1.5 2.6 5.4
Pip-taz % growth since FY1314 12.9 14.0 9.7 10.4 8.3
Pip-tazo
target
reduction
= 12%
growth
since
FY1314

Public Health England. 2015. Start Smart – Then Focus. Antimicrobial Stewardship Toolkit for English Hospitals.
Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF
Start Smart – Then Focus

New Evidence for AMS Teams
Schuts meta-analysis: strong evidence1
•  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) – meta-analysis of AMS on AMR
• AMR G+ve -43% (MRSA -49%), G-ve -28% (CRE -48%)
AMR: antimicrobial resistance; CRE: Carbapenem-resistant Enterobacteriaceae; C&S: culturing and samples; IV: intravenous; LOS: length
of stay; MRSA: methicillin-resistant Staphylococcus aureus; TDM: therapeutic drug monitoring
Schuts EC, et al. Lancet Infect Dis 2016; 16(7): 847-56.

How to achieve the CQUIN
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.
• Who uses most? Growing? Bought Rx-Info Refine software
• Does my restricted / protected antibiotic policy really work?
Can I reduce my total consumption?
• Do we over-treat? Is it sepsis driven? LTH+37% IV AB in 2 years 
• Is our prevalence high to peers? LTH <30% 
• Is our Day 3 review outcome data good (vs peers)? LTH 70% continue in
notes & 85% on Rx 
• Do we send appropriate samples before AB? LTH 81% 
• Do we act on results within 24 hours? LTH 50% 
• Can we use diagnostic tests to delay or avoid starting or stopping
antibiotics earlier? CRP in ED, procalcitonin, etc
AB: antibiotics; CQUIN: Commissioning for Quality and Innovation; CRP: C-reactive protein; ED: emergency department; LTH: Leeds Teaching
Hospital

NHS Scotland: Use of pip-taz, carbapenems
and carbapenem sparing agents in acute hospitals*
(aztreonam, fosfomycin, pivmecillinam, temocillin)
* Excludes NHS Highland
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
DDDsper100,000popperday
Year/Qtr
Carbapenems Pip-Tazo Carbapenem Sparing Agents
“but they cost so much more than cheap mero or pip-taz”
New antibacterials also offer options: e.g. ceftobiprole, ceftolozane-tazobactam
Malcolm W. Antibiotic use in hospitals in Scotland. 2015. Available from:
https://www.scottishmedicines.org.uk/files/sapg/Presentation_1_-
_National_surveillance_data_on_hospital_antibiotic_prescribing_in_Scotland_-_Mr_William_Malcolm.pdf. Last accessed October 2016.

NHS Scotland: Use of carbapenems,
carbapenem sparing agents and pip-tazo
in Jul-Sep 2015 in acute hospitals by NHS board*
* Excludes NHS Highland
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
DDDsper100,000popperday
Carbapenems Carbapenem Sparing Pip-Tazo
Malcolm W. Antibiotic use in hospitals in Scotland. 2015. Available from:
https://www.scottishmedicines.org.uk/files/sapg/Presentation_1_-
_National_surveillance_data_on_hospital_antibiotic_prescribing_in_Scotland_-_Mr_William_Malcolm.pdf. Last accessed October 2016.

Impact on local AMR by switching to temocillin for HAP
and upper UTI in a DGH
2012/13 2014/2015 Trend
N° of E. coli BSI 210 216 ↑
% Resistant to TZP 17 8 ↓
% Resistant to temocillin 3 2 =
% Resistant to ciprofloxacin 26 18 ↓
% Resistant to 3GC 17 13 ↓
N° of K. pneumoniae BSI 28 34 ↑
% Resistant to TZP 29 9 ↓
% Resistant to temocillin 11 3 ↓
% Resistant to 3GC 25 18 ↓
% Resistant to ciprofloxacin 18 9 ↓
H. Habayab Poster 1219 ECCMID 2016

What to use for empiric antibiotic treatment?
ESPAUR 2016 report
 Over use of pip-tazo 
AMR in E.coli & K.pneum
 Carbapenems – save
for last line
 ESPAUR 2016 report
recommending
combination alternatives
with  AMR Eg.
Gentamicin OR amikacin
PLUS co-amoxiclav OR
ciprofloxacin OR 3rd G
Cephs

Replacing pip-tazo with aminoglycoside plus co-
amoxiclav or other combination
40%

Daily meropenem stewardship programme
West Hertfordshire Hospitals NHS Trust (Vaghela & Kandil)
Started Mar-16 Feb-16 March 16 April 16 May 16
Patients on mero 56 22 31 17
Mero DDD/adm 98 67 56 26
Penicillin allergic pt 6 (27 %) 10 (29 %) 4 (23%)
Escalation from pip-tazo 6 (27 %) 11 (23 %) 9 (53 %)
Patients on Rx >10 days 5 (23 %)
(13-19 days)
4 (13 %)
(11-14 days)
2 (11.7 %)
(12-13 days)
Micro approved courses 18 (82 %) 20 (64 %) 14 (82 %)
courses stopped 2 (D5) 3 (d5 & d10) 0
appropriateness of Rx 91% 90.3% 100%
Usage of meropenem in hospital had doubled from January
to February 2016 (49 to 98 DDD/1000 admissions)

Impact of the interventions made by the antimicrobial
stewardship team (AST)
West Hertfordshire Hospitals NHS Trust (Vaghela & Kandil)
 Guidelines compliance
 88.5% were compliant
De-escalation and IV PO switch:
7% de-escalated, 5% switched to PO
Recommendation of stop (57% of courses)
Re-admission within 28 days with the same
infection episode
6/92 were re-admitted within 28 days
2-elective surgery, 4-unrelated issues
 Antimicrobial consumption :
 Pip-taz ↓ 23%, Total ↓ 7%
4050
4100
4150
4200
4250
4300
4350
4400
4450
4500
Base line after AMS
intervention
Total
antibiotic
consumption/
1000
admissions
0
50
100
150
200
250
300
Base line after AMS
intervention
Tazocin
consumption/1000
admissions

HAPPI audits (Hospital Antibiotic Prudent Prescribing Indicators)
University Hospital Southampton NHS Foundation Trust
Dr Kieran Hand and Dr Hayley Wickens
Audit standards
1. Indication / provisional
diagnosis documented on start
date
2. Antibiotic choice according to
guideline (or justified off-
guideline choice)
3. Appropriate dose prescribed
4. Reviewed at 48-72 hours with
documented treatment plan
5. Total course length ≤ 7 days (or
justified)
5 patients selected at random, per
ward per month (target 250
patients per month)
Improvement in all stds except D3 review

• NICE Drug Allergy guidance
– 10-20% claim beta-lactam allergy – probably ~1%
– Test if allergic to 2 AB classes or need for beta-lactam
– Allergy information on ALL Rx & correspondence
• Risk factor for C.diff (23%), MRSA (14%), VRE (30%)
• Higher mortality & ITU admission? Higher costs
• Alternatives have more ADR: CV deaths with macrolides,
quinolones – liver, CV, skin, tendons
• Increasing Strep pneum resistance to macrolides /
doxycycline
• Need to routinely reverse inappropriate allergy labels –
part of medicines optimisation review (65% switch rate
in USA study – Sigona JAmPharmAssoc 2016)
Penicillin allergy label & AMR
Reddy 2013 J of Allergy Clin Immunol, Schembi BMJ 2013, Ray NEJM 2012, MHRA
Charneski 2011 Pharmacotherapy 31(8)742, Macy 2014 JAllergyClinImmunol

Antimicrobial Drug charts to drive daily
review
IV to Oral Switch (IVOS) & Day 3 review
Get nurses to drive IVOS at safety huddle. 
nursing time, & ££

Day 3 Review Tool
• Combination of our IVOS and Dundee
(Pulcini) D3 review
• Nurse puts sticker in medical notes on
day 3 for ward round
• Didn’t make much difference, so
version 2 being designed

Procalcitonin Guided Antibiotic Therapy
respiratory
illness &
setting
Cold / flu
Primary
care
Bronchitis
Emergency
Dept
Pneumonia
Hospital
Sepis
ITU
Mortality <<1% <1% to 3% 5% to 20% 30% to 70%
AB initiation 75% 40% 14% 0%
AB duration 12 to 5 days 10 to 6 days
AB exposure 75% 40% 64% 40%
LOS –3.8 days -2 days
Christ-Crain Lancet 04, Christ-CrainAJRCCM 06 & 08, Stolz CHEST 07, Nobre, AJRCCM 07, Briel Arch
Int Med 08, Schütz JAMA 09, Stolz ERJ 2010, Bouadma, Lancet 2010, NICE DG18 2015Thanks to Susan Hopkins
NICE AMS: RCTs needed to see if PCT for respiratory infections is
clinically and cost-effective. Centres currently using procalcitonin
to participate in research and data collection.
CASPUR (Cost effectiveness and Antibiotic Stewardship of serum
Procalcitonin United Kingdom Report) Kordo Saeed

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
AMS: antimicrobial stewardship; AMR: antimicrobial resistance; CQUIN: Commissioning for Quality and Innovation

How are we doing at my Trust?
Part 4a Target reduction Position to Jan-17 vs FY1314
Total Allowed 7.5% growth -9.2% (0.7%)
Carbapenem Allowed 7.5% growth -7.6% (0.9%)
Pip-tazo 16.6%!
+5.3% (10.3%)
Allowing for aztreonam
shortage +0.7% (14.9%)
• Temocillin for HAP since Dec-16
• Procalcitonin from mid Feb-17
• Temocillin for >65y UUTI Mar-17
• Still not embedded robust D3
review – 73% continue on IV AB
despite 63% eating! OPAT growing

Single information source – PHE AMR
Fingertips

How are you using PHE AMR data?

Total antibacterials: % change
since FY1314 (last 12mth to Jan-17)
Trusts (dots) below the
0% growth line are
currently meeting the
AMR-CQUIN target
Rx-Info national data

Carbapenems: % change since FY1314
vs use (last 12mth to Jan-17)
Trusts (dots) below the 0% growth line are
currently meeting the AMR-CQUIN target

Piperacillin-tazo: % change since
FY1314 vs last 12mth to Jan-17
Trusts (dots) below
the 0% growth line
are currently
meeting the AMR-
CQUIN target

AMR-CQUIN Rolling Year % Change
to Jan-17 (Rx-Info 90% of ATs)
+2.6% Pip-tazo vs FY1314
-3.7% carbapenem vs FY1314
-5.5% vs prev 4Q
-0.12% total vs FY1314
-0.6% vs prev 4Q
Pip-tazo
DDDs /
1000 adm
GrowthFY1617
vsFY1314
GrowthFY1617
vsFY1415
GrowthFY1617
vsFY1516
Carbapenem
DDDs / 1000
Adm
GrowthFY1617
vsFY1314
GrowthFY1617
vsFY1415
GrowthFY1617
vsFY1516
J01 Total AB
(IP+OP) DDD
/ 1000 adm
GrowthFY1617
vsFY1314
GrowthFY1617
vsFY1415
GrowthFY1617
vsFY1516
Q1 +8.7% +3.5% -3.2% Q1 -1.0% -6.2% -5.6% Q1 0.7% -2.3% -0.3%
Q2 +5.2% -1.8% -2.9% Q2 -4.8% -9.2% -3.8% Q2 -0.2% -2.7% -1.2%
Q3 -0.6% -13.4% -12.3% Q3 -11.4% -17.2% -12.0% Q3 -3.7% -9.3% -4.4%
-8.5% Pip-tazo vs prev 4Q

Day 3 review & outcomes
Documented day 3 review
• Q1 target 25%: median 81.6%
• Q2 target 50%: median 86.6% (38% - 100%). 1
failed & 26 no submission
Outcomes data of day 3 review
(n=111 trusts ) entered voluntary data
• Continue 63%
• Stop 10%
• IVOS 16%
• switch AB 12%
• OPAT 0.5%

Future Challenges
• Reduce healthcare
associated Gram-negative
bloodstream infections in
England by 50% by 2020
• Reduce inappropriate
antibiotic prescribing by
50%, with the aim of being a
world leader in reducing
prescribing by 2020.
Government response to the Review on Antimicrobial Resistance. September 2016. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/553471/Gov_response_AMR_Review.pdf. Last
accessed October 2016.

Bug 30 day mortality
rate (2014/5)
MRSA 28.2%
MSSA 19.5%
E.coli 15.9%
C.difficile 16.2%
MRSA
MSSA
E.coli
C.diff

Reducing harm from Serious infections
CQUIN – 2017-9
2a. Sepsis screening: <50%, 50-90%, >90%
2b. AB within 60 mins in ED & IP: <50%, 50-90%, >90%
2c. Antibiotic review within D3 in sepsis patients.
30pts/month. Who review by; %BC and outcome. Q1
25%, Q2 50%, Q3 75% and Q4 >90%
2d. Based on whether above or below median value
FY1314 for 2016 data. Above median = 2% reduction
OR below median = 1% reduction for total /
carbapenem and pip-tazo based on 2016 consumption.

Is there any difference in median
value between hospital types?
Median 105.6 65.5 59.4 62 116.8
Only carbapenems: acute teaching
trusts and acute specialist trusts are
much higher.

Quality Premium – bloodstream infections
Part a) reduction in the number of Gram negative blood stream infections
across the whole health economy.
• 10% reduction (or greater) in all E coli BSI reported at CCG level based on
2016 performance data
• collection and reporting of a core primary care data set for all E coli BSI in
Q2-4 2017/18 via PHE DCS reporting system for E coli BSI
Part b) reduction of inappropriate antibiotic prescribing for UTI in primary
care.
• a 10% reduction (or greater) in the Trimethoprim: Nitrofurantoin prescribing
ratio based on CCG baseline data (June15-May16) for 2017/18.
• a 10% reduction (or greater) in the number of trimethoprim items prescribed
to patients aged 70 years or greater on baseline data (June15-May16).
Part C) sustained reduction of inappropriate prescribing in primary care
• items per STAR-PU must be equal to or below England 2013/14 mean
performance value of 1.161 items per STAR-PU.

Summary: To meet the challenge of AMR
(2016-17 AMR & Sepsis CQUINs & 2017-19
Serious Infections CQUINs)
• Design systems to force better prescribing e.g. Day 3 review for de-
escalation AND IV to oral switch
• Review guidelines containing piperacillin-tazobactam and
meropenem. Ensure they are followed through audit & feedback
• Quality improvement, not annual audit of AMS
• Merge sepsis and AMR CQUIN – start smart then focus
• Protected (restricted) antibiotic systems need to work
• Monitor & benchmark antibiotic usage
• Regular but varied communication on progress
• Local education & training at ward level
• Strong and effective multidisciplinary leadership (champions) at all
levels

Thank you to lots of people
• Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason
Dunne, Cheryl Mitchell, Mark Wilcox
• West Hertfordshire Hospitals NHS Trust: Dr Hala Kandil
• NHS Improvement / NHS England: Elizabeth Beech, Stuart Brown,
Matthew Fogarty, Lauren Mosley, Mike Durkin, Celia Ingham-Clarke
• PHE: Diane Ashiru-Oredope, Susan Hopkins, Cliodna McNulty, Duncan
Selby
• Dept of Health: Dame Sally Davies
• NHS Scotland: William Malcolm, Jacqui Sneddon, Alison Coburn, Dilip
Nathwani, Andrew Seaton, Susan Paton
• UKCPA PIN: Orla Geoghegan, Mark Gilchrist, Hani Habayeb, Kieran
Hand, Hayley Wickens
• ESCMID ESGAP: Celine Pulcini, Stephan Harbarth
• International Society of Chemo: Gabriel Levy Hara, Ian Gould
• SIDP (USA): Debbie Goff for “protected antibiotics”

Carbapenem & piperacillin-tazobactam
usage & resistance (from ESPAUR 2016)
177
y = 60793x - 3394.8
R² = 0.9064
0
500
1000
1500
2000
0.05 0.055 0.06 0.065 0.07 0.075 0.08 0.085
CPEisolates/yr
Carbapenem DDD/1000 DID
Carbapenem use & resistance 2010-15
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
2011 2012 2013 2014 2015
E.coli-R pip-taz K.pneum-R pip-taz
Pip-taz DDD/1000adm

178
Change in Total AB DDDs /
1000 Total Admissions (inc.
Day Case) (%)
Large acute trust
(33)
Acute teaching
trust (25)
Medium acute
trust (33)
Acute specialist
trust - Inc
Children (3)
Small acute
trust (21)
Feb 2014 to Jan 2015 5.19 4.90 2.59 1.66 0.83
Feb 2015 to Jan 2016 -4.45 -1.75 -1.44 -4.59 -6.18
% growth since 2013-4 0.74 3.15 1.15 -2.93 -5.35
Total AB
target
reduction
= 1.6%
growth
since
FY1314

179
Large acute
trust (33)
Small acute
trust (21)
Medium
acute trust
(33)
Acute
teaching
trust (25)
Acute specialist
trust - Inc
Children (3)
Feb 2014 to Jan 2015 9.0 7.8 6.7 2.6 -10.4
Feb 2015 to Jan 2016 -1.7 -0.7 -1.3 -6.0 -9.2
Carbapenem % Increase since FY1314 7.3 7.1 5.4 -3.5 -19.7
Carbapene
m target
reduction =
2.3%
growth
since
FY1314

180
Large acute
trust (33)
Acute teaching
trust (25)
Small acute
trust (21)
Medium acute
trust (33)
Acute specialist trust -
Inc Children (3)
FY 2014 14.1 11.7 8.2 7.8 3.0
FY 2015 -1.1 2.3 1.5 2.6 5.4
Pip-taz % growth since FY1314 12.9 14.0 9.7 10.4 8.3
Pip-tazo
target
reduction
= 12%
growth
since
FY1314

AMR-CQUIN by financial year as
DDD/1000 admission (Rx-Info Define data)
Pip-taz
Total J01
Carbapenem 
FY1617 (red) is only 10
months data for April to
Jan only (10 months
rate).
-6.4% vs FY1314
+2.6% vs FY1314
-1.4% vs FY1314
-8.5% vs FY1516

Is there any difference in median
value between hospital types?
Median 105.6 65.5 59.4 62 116.8
Only carbapenems where acute teaching
trusts and acute specialist trusts are much
higher.

Thank you to lots of people
• Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason
Dunne, Cheryl Mitchell, Mark Wilcox
• West Hertfordshire Hospitals NHS Trust: Dr Hala Kandil
• NHS England: Elizabeth Beech, Stuart Brown, Matthew Fogarty,
Lauren Mosley, Mike Durkin, Celia Ingham-Clarke
• PHE: Diane Ashiru-Oredope, Susan Hopkins, Cliodna McNulty, Duncan
Selby
• Dept of Health: Dame Sally Davies
• NHS Scotland: William Malcolm, Jacqui Sneddon, Alison Coburn, Dilip
Nathwani, Andrew Seaton, Susan Paton
• UKCPA PIN: Orla Geoghegan, Mark Gilchrist, Hani Habayeb, Kieran
Hand, Hayley Wickens
• ESCMID ESGAP: Celine Pulcini, Stephan Harbarth
• International Society of Chemo: Gabriel Levy Hara, Ian Gould
• SIDP (USA): Debbie Goff for “protected antibiotics”

Tackling AMR: Engaging with Patients and the Public - The TARGET
Antibiotics Toolkit
Dr Cliodna McNulty. Head, Public Health England Primary
Care Unit & Consultant Medical Microbiologist, and Honorary
Visiting Professor Cardiff University
#antibioticguardian

Professor Cliodna McNulty
Head, PHE Primary Care Unit
and PHE TARGET clinical lead
Engaging with patients and the public –
The TARGET antibiotics toolkit

211
Many thanks to:
The TARGET and e-Bug team at the PHE PCU:
All those involved in TARGET materials especially:
the RCGP, BSAC, RPS, DH, behavioural team at PHE,
Ruth Dale, RCN, ARHAI, Nick Francis, Phil Howard
Elizabeth Beech and Diane Ashiru-Oredope
The GPs and patients involved in evaluation and interviews
The IPSOS Mori team
I have no conflicts of interest

212
What will I cover:
 Why GP staff prescribe
 Surveys around public attitudes to & use of antibiotics
 How can we improve responsible antibiotic use –
informed by cognitive theory
 Discuss how we can implement the leaflets
 Action plan

213
Why do GP staff prescribe antibiotics?
 Relief of symptoms
 Worry about complications/more serious illness
 Patient pressure

Cochrane reviews Otitis media: Venekamp et al (2015); Sore throat: Spinks et al. 2013;
Sinusitis: Leminengre M et al. (2012); bronchitis: Smith et al. (2014)
Antibiotic use and symptoms vs natural
history (NICE CG69, Cochrane reviews)
Total
Duration
untreated
Beneficial
effect from
antibiotics
NNT for one
additional
patient to
benefit
NNT for one
additional
adverse
effect
Otitis media 4 -12 days 8-12 hours 18 9
Sore throat 8 days 12-18 hours 6-20 15
Sinusitis 12-15 days 24 hours 18 8
Bronchitis 20-22 days 11-24 hours 10-22 24

In a practice of 7000,
a 10% reduction in antibiotic
prescribing for RTI might expect:
1 additional pneumonia
each year
1 additional peritonsilar
abscess each 10 years
BMJ 2016 Gulliford http://www.bmj.com/content/354/bmj.i4245
Complications: High vs low
prescribing practices

Antibiotics and complications
● Serious complications rare after URTI,
● sore throat and otitis media NNT>4000
● Pneumonia more common after LRTI
– Age >65 years: NNT 39
– Age < 65 years: NNT >100

58% had RTI in last 6 months
What did they do?
60% took OTC(50%) or alternative medicine(21%) for symptoms
37% took extra rest
20% Contacted or visited GP surgery
6% asked pharmacy for advice
1.4% used NHS direct
0.4% took left-over antibiotics
0% visited NHS walk in centre
1,767 ≥15y in England
McNulty, Nichols, French, Joshi & Butler. British Journal of General Practice, 2013 e429)
The Patient Perspective:
why do patients visit their doctor?

The Patient Perspective:
They visited their GP if they were worried
53% Expected antibiotics 22% Other treatment for symptoms
24% Advice about self-care 12% Rule out more serious illness
7% Information about illness duration 6% A sick/fit note for work
3% For referral to hospital/specialist 3% For Tamiflu
200 What did they expect?
McNulty, Nichols, French, Joshi & Butler. British Journal of General Practice, 2013 e429)
51% Symptoms severe
47% Symptoms not improved after several days
14% family or friends suggestion
11% Other health problem
9% I usually visit GP with these symptoms
5% Worried will infect others who may get very ill
93% who asked, got an antibiotic

NIHR TARGET Alastair Hay et al.
219 http://www.bristol.ac.uk/primaryhealthcare/researchthemes/target/resources/ Hay et al
Mismatch between doctors concerns and parents/carers concerns
Parents want reassurance and advice: How to treat symptoms, how to
manage the impact on their family (disrupted sleep, eating pattern) what
to look out for so child does not get seriously ill

The Patient Perspective: A 2014 survey
showed patients trust GPs and nurses’ advice
It’s worth sharing information about the need or
not for antibiotics in consultations, and self care
McNulty, et al BMJ open

Percentage of public in favour of
delayed antibiotic prescriptions
McNulty, Butler, et al Ipsos Mori 2014
So a thorough explanation of rationale and how to collect the
prescription may be needed for some patients

223 McNulty, Lecky, Hawking, Nichols, Roberts, Butler FIS 2014
77%
40%
26%
17%
14%
11%
7%
4%
4%
4%
1%
2%
3%
Bacterial infections
Viral infections
Fungal infections
Anti-inflammatory
Colds or flu
Allergic reactions
Pain
Hay feaver
Asthma
Headaches
Other
Don't know
None of these
Which of the following conditions, if any, do you think can be
effectively treated by antibiotics? 1,625 respondents Jan 2014
Misconceptions about antibiotics
Correct
answer?

224 McNulty, Lecky, Hawking, Nichols, Roberts, Butler FIS 2014
Please tell me to what extent you agree
or disagree? 1,625 respondents Jan 2014
McNulty, Lecky, Hawking, Nichols, Roberts, Butler FIS 2014
Lack of knowledge about antibiotic resistance True
statement?

How can we fit together this evidence and change behaviour during
consultation with patients to improve antibiotic prescribing?
Evidence
Practice
Patient
GP
Possible Answers

The TARGETAntibiotics Toolkit
227 www.RCGP.org.uk/TARGETantibiotics

228
CAPABILITY
Pyschological or physical ability
to enact behaviour
Responsible
antibiotic use
COM-B – Addressing capability

Reducing complication risk
Empowering clinicians to give
● Careful clinical assessment, including targeting
treatment to those most at risk (clinical tools)
● Back-up / delayed antibiotics
● Safety netting including patient information leaflets

FeverPAIN score for sore throat
https://ctu1.phc.ox.ac.uk/feverpain/index.php

Increasing capability: Patient and staff
Knowledge & skills
www.rcgp.org.uk/TARGETantibiotics
Read codes: Delayed:8CAk, Leaflet: 8CE
“Usually lasts” section
educates patients
about when to consult
Safety netting
Back-up prescription
Information about
antibiotics & resistance
TARGET Treating your infection leaflet
All sections can be
personalised and
added to by the GP

Operated by
E-Bug / TARGET pictorial TYI leaflet

Possible urinary symptoms The outcome Recommended care Types of urinary tract infection (UTI)
Self-care to help yourself
get better more quickly
When should you get help?
Contact your GP practice or contact NHS 111
(England), NHS 24 (Scotland dial 111), or NHS
direct (Wales dial 0845 4647)
Options to help prevent a UTI Antibiotic resistance
Urinary tract infection U I information leaflet
For women outside care homes with suspected uncomplicated urinary tract infections (UTIs) or uncomplicated recurrent UTIs
Frequency: Passing urine (wee) more often than usual
Dysuria: Burning pain whenpassing urine
Urgency: Feeling the need to pass urine immediately
Haematuria: Blood in your urine
Nocturia: Needing to pass urine in the night
Suprapubic pain: Pain in your lower tummy
Other things to consider
Recent sexual history
 Some sexually transmitted infections (STIs) can have
symptoms similar to those of a UTI.
 Inflammation due to sexual activity can feel
similar to the symptoms of a UTI.
Kidneys (make urine)
Infection in the upper urinary tract
 Pyelonephritis (pie-lo-nef-right-is)
Bladder (stores urine)
Infection in the lower urinary tract
 Cystitis (sis-tight-is)
UTIs are caused by bacteria getting into your urethra
or bladder, usually from your gut. Infections may
occur in different parts of the urinary tract.
Urethra (takes urine out of the body)
Infection or inflammation in the urethra
 Urethritis (your-ith-right-is)
 Drink enough fluids to stop you
feeling thirsty. Aim to drink 6 to
8 glasses including water,
decaffeinated and sugar-free
drinks.
 Take paracetamol or
ibuprofen at regular
intervals for pain relief, if
you’ve had no previous
side effects.
 You could try taking cranberry
capsules or cystitis sachets.
These are effective for some
women. There is currently little
evidence to support their use.
 Consider the risk factors in the
‘Options to help prevent UTI’
column to reduce future UTIs.
The following symptoms are possible
signs of serious infection and should be
assessed urgently.
Phone for advice if you are not sure how
urgent the symptoms are.
1. You have shivering, chills and muscle pain.
2. You feel confused, or are very drowsy.
3. You have not passed urine all day.
4. You are vomiting.
5. You see blood in your urine.
6. Your temperature is above 38◦
C or less
than 36◦
C.
7. You have kidney pain in your back just
under the ribs.
8. Your symptoms get worse.
9. Your symptoms are not starting to
improve a little within 48 hours of taking
antibiotics.
It may help you to consider these risk factors.
Stop the spread of bacteria from your gut into your
bladder. Wipe from front (vagina) to back (bottom) when you
go to the toilet.
Avoid waiting to pass urine. Pass urine as soon as you need
a wee.
Go for a wee after having sex to flush out any bacteria that
may be near the opening to the urethra.
Wash the external vagina area with water before and
after sex to wash away any bacteria that may be near the
opening to the urethra.
Drink enough fluids to make sure you wee regularly
throughout the day, especially during hot weather.
If you have a recurrent UTI, also consider the following.
Cranberry products: Some women find these effective,
but there is currently little evidence to support this.
After the menopause: You could consider topical
hormonal treatment, for example, vaginal creams.
Common side effects to taking antibiotics
include thrush, rashes, vomiting and diarrhoea.
Antibiotics may not always be needed, only
take them after advice from a health
professional. This way they are more likely to
work if you have a UTI in the future.
Antibiotics taken by mouth, for any reason,
affect our gut bacteria. These bacteria become
resistant to antibiotics we take.
Antibiotic resistance means that the antibiotics
cannot kill that bacteria.
The gut bacteria that cause UTIs are twice as
likely to be resistant to antibiotics for at least 6
months after you have taken any antibiotic.
th anuary
Mild, or 1 to 2, symptoms or
vaginal discharge (or both)
 Antibiotics less likely to help.
 Usually lasts 5 to 7 days.
Self-care and pain relief. Symptoms
are likely to get better on their own.
Antibiotic prescription
 Immediate treatment with
antibiotics, plus self-care.
Delayed or backup prescription.
Start antibiotics if symptoms:
 get worse
 do not get a little better with self-
care after 24 to 48 hours.
Severe, or 3 or more, symptoms
and no vaginal discharge
Antibiotics are likely to help, symptoms
 should start to improve within 48 hours
 usually last 3 days.
Leaflet endorsed by:
Leaflet developed in
Outcome and
plan can be
personalised
Possible urinary
symptoms &
other things for
GP & patient to
consider
Picture helps patients
understand cause
Self-care &
safety netting
advice
How to
prevent UTIs
Flow chart
helps patient
understand
antibiotics and
resistance
TARGET Urinary Tract Infection Information leaflet
For Women outside care homes with suspected UTIs or uncomplicated recurrent UTIs

www.e-Bug.eu
Operated by

e-Bug Resources
4-7 yrs
• Online Science
Show
7-11 yrs
• Junior school
lesson plan
• Student website
11-15 yrs
• Senior school
lesson plan
• Student website
15-18 yrs
• Young adult
lesson plan
• Peer education
resources
• Student website
Launched in 2011 Launched in 2009 Launched in 2009 Launched 2014/15
Operated by

236
CAPABILITY
Responsible
antibiotic use
COM-B – Addressing motivation
MOTIVATION
Reflective and automatic
mechanisms that activate or
inhibit behaviour
Your personal attitudes
and social norms

Trimethoprim resistance in GP urines by age group (Welsh data)
Resistance in primary care

Motivation: Importance of the
team approach
238
Whole practice team
invited to TARGET
workshops

Motivation:Audit materials – audit self-care
advice, back-up antibiotics, leaflets
TARGET website templates for:
● Sore Throat Audit
● Acute cough
● UTI Audit
● Sinusitis
● Otitis externa
A self assessment checklist
www.RCGP.org.uk/TARGETantibiotics/

240
COM-B – Addressing opportunity
CAPABILITY
Responsible
antibiotic useMOTIVATION
Physical and social
environment that enables
behaviourOPPORTUNITY

Opportunity:
availability of patient leaflets
241
I
“Actually being able to pass
them a piece of paper.
Instead of passing them a
prescription but it’s something
to take away. It’s good. I
think it’s helpful because it
looks official as well”- GP
“Having hard copies of the
leaflets would be a good
idea ..GPs are so busy &
they've got so much going
on in their heads, it's only
the keen ones that will use it
and remember ..having it
..to hand visually on the desk
will help.” - Stakeholder 9“Here’s the problem,
it’s not a click away”
- GP
An evaluation of TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics
Toolkit ; LF Jones, MKD Hawking , R Owens, D Lecky, N Francis, M Gal, CC Butler, CAM McNulty,

Opportunity: availability of resources for
clinical and waiting areas
Posters for Display
Videos for patient waiting areas
www.rcgp.org.uk/TARGETantibiotics

243 Francis et al BMJ 2010, Cals et al BMJ 2009;338:1374,
Booklet toshare withpatients
Antibiotic prescription20%v40%
Intentiontoreconsult 55%v76%
I M P A C3 T
CRP and communication skills
Antibiotics in usual care 68%
communication 33%
CRP 39%
Both 23%
Opportunity: availability of GP based
interventions

Not one single thing works –
addressing patients and the
public directly is a very
important part of the solution
245www.RCGP.org.uk/TARGETantibiotics

How could your practice use sore throat
scores & back-up antibiotic prescriptions?
McNulty, Butler, et al Ipsos Mori 2014
1. Use the Centor or Fever pain scoring system
2. Use patient leaflets
3. Use back-up/ delayed antibiotic prescribing
4. Set up computer reminders for leaflets and back-up
antibiotics – who can do this?
5. Use delayed date on electronic prescription
6. Use electronic prescribing “token” and get patient to
pick up later from the surgery
7. Agree who will put up posters in the surgery
Action plan:
how to reduce antibiotics in acute sore throat?

247
www.RCGP.org.uk/TARGETantibiotics
www.TARGET-webinars.com
TARGET webinars:
• Finding data, and doing audits
• Assessing the need for antibiotics
• Managing patient expectations
• Back-up antibiotic prescriptions
• Prescribing in UTI
• Antibiotics for children
• The common practice approach
All webinars still available,
includes reflection & CPD
Increasing capability:
knowledge and skills

248 McNulty, Nichols, French, Joshi, Butler BJGP 2013

BANES – engaging with schools and combining flu campaign and
Antibiotic Awareness
Elizabeth Beech, Prescribing Advisory and National Project Lead.
Healthcare Acquired Infection and Antimicrobial Resistance, NHS
Improvement
#antibioticguardian

How local networks are enabling
Antimicrobial Stewardship activity in
Bath & North East Somerset
Schools & Vaccination
Elizabeth Beech 8th February 2017
Pharmacist - NHS Bath and North East Somerset CCG
National Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS Improvement
elizabeth.beech@nhs.net @elizbeech

Maximising flu vaccination to reduce unnecessary
antibiotic use

Maximising vaccination
• Every contact counts – childhood immunisation sticker
• Book bagging in Key Stage 1
• 40% uptake vs 33% national
• Men ACWY reminder in A levels results
• Pharmacist at the University Freshers Week stall
• 52% uptake vs 35% national
• Flu Myth Busters for health & social care workforce 2016
• School Nurses flu vaccinating 2016 70% uptake vs 55% national

Bath & North East Somerset (B&NES) Primary
School AMR Poster campaign for EAAD 2016
• Launched in World Antibiotic Awareness Week 2016
• Offer to all B&NES Primary Schools (50+) Year 3
• Lesson plans including e-Bug resources were delivered during WAAW
• Posters submitted for judging and prizes awarded to children & schools
• Display of posters in community settings – GP Practices, Community
Pharmacies, local Hospital, Leisure centres, libraries
• Communications campaign – Get a conversation going! Collect and share
photos on social media #AntibioticGuardian Please join in
• 4 key messages

Hand washing
prevents
infection

Many common winter
infections such as ear
ache, sore throats,
coughs and colds are
caused by viruses
Antibiotics do not work
for viruses and can give
you side effects like
diarrhoea and vomiting

Using a tissue
when coughing
and sneezing can
prevent sharing
your infection –
Catch it, Bin it, Kill
it

Vaccination
prevents infection,
particularly flu
vaccination

Bath & North East Somerset 2015
22% of the whole population
26% of children aged up to10 years

Workshop session - Local AMR Plans – what is required, how can we
improve?
#antibioticguardian

Concluding comments
Dr Diane Ashiru-Oredope, Pharmacist Lead,
#antibioticguardian

Antibiotic Guardian Bristol Workshop

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