Scottish Antimicrobial Prescribing Group Research Articles

P24 Penicillin allergy de labelling: a whole system approach

Abstract Background Approximately 10% of patients have a documented allergy to penicillin on their health records.1 However, when checked up to 95% are thought to be incorrect2 with side effects such as nausea, vomiting and gastrointestinal upset often being documented as allergy. Inappropriate and over labelling of penicillin allergy is detrimental to individuals and healthcare systems as alternatives to penicillins are associated with more complications, adverse events, financial costs and extended length of stay. Unnecessary use of penicillin alternatives also increases the risk of antimicrobial resistance development. Penicillin allergy de-labelling is a viable option for patients within primary care and acute settings where they meet specific criteria, leading to financial benefits for the health board and optimal treatment outcomes for the patient. NHS Tayside is the first and only Board in Scotland to adopt a whole system approach to de-labelling patients in both acute and community settings. Through the implementation of evidence-based, collaborative and systematic risk assessment processes, clinical teams are able to identify patients who may be eligible for the penicillin allergy de-labelling programme. Methods Within the acute sector, two pilot wards were identified. A Short Life Working Group (SLWG) was developed to oversee the de-labelling process and governance. Patients were identified by clinical teams and consent gained prior to carrying out the process. A single dose of oral flucloxacillin or amoxicillin was administered to the patient. The patient was monitored for any reaction as per Scottish Antimicrobial Prescribing Group (SAPG) algorithm.3 If the patient experienced no reaction, they were de-labelled, a request was sent to GP to remove the label and their details were added to a database held by the SLWG. A similar project was piloted in primary care across three Angus GP practices. The aim of the project is to identify a patient population that are labelled penicillin allergic but have received a subsequent prescription for a penicillin allowing a primary care SLWG to carry out a patient consultation with the aim of retrospectively de-labelling and updating the record. This will allow patients to receive optimal treatment options in the future. Results Within the acute setting, the pilot was initiated in May 2022. Since then, 44 patients have been recruited to the penicillin allergy de-labelling process with 98% having no immediate reaction and 67% of labels removed from patient care records at the 3 month follow-up stage. Within primary care across three GP practices, 163 patients were eligible for the pilot. A total of 85 patients (52%) were contacted via telephone and a consultation on allergy status carried out. Overall, 42 patients (50%) were successfully de-labelled and patient records were updated. Conclusions Following similar processes, there is potential for practitioners within the acute and community sectors to adopt this pilot as part of an integrated work plan across all wards and GP practices. By de-labelling patients within the community or acute sector, the patients’ records will be accurate and future treatment options can be optimized to ensure positive outcomes and minimize harm.

Supporting antimicrobial stewardship in Ghana: evaluation of the impact of training on knowledge and attitudes of healthcare professionals in two hospitals.

BackgroundA Commonwealth Partnership for Antimicrobial Stewardship was created between the Scottish Antimicrobial Prescribing Group (SAPG), Ghana Police Hospital and Keta Municipal Hospital. During a scoping visit, requirements for implementing antimicrobial stewardship (AMS), areas for improvement and training needs were identified.MethodsA multidisciplinary team from SAPG and health psychologists from The Change Exchange developed and delivered multi-professional evidence-based teaching incorporating behavioural science, supported by partner pharmacists in each hospital. Four sessions were delivered over 2 days to 60 participants across both sites. Before and after the sessions, participants were asked to complete a knowledge quiz and a behaviours survey. Results were analysed using t-tests.ResultsComparison of the participants’ pre- and post-test quiz scores (Keta Municipal Hospital 9.4 and 10.9, Ghana Police Hospital 9.2 and 11.1, respectively) demonstrated statistically significant improvement in knowledge of antimicrobial resistance and appropriate use of antibiotics. Comparison of survey responses before and after the education sessions indicated that the education had a positive impact on participants’ attitudes towards the issue of antimicrobial resistance, their role in AMS and confidence in using the Ghana Standard Treatment Guidelines. Participants were also more likely to question colleagues about compliance with guidelines. Forty-eight participants (80%) completed a training evaluation and all responded positively.ConclusionsThe education sessions appeared to be successful in improving knowledge and behaviours of hospital staff. Cascade of an abbreviated version of the training by partner pharmacists and AMS teams in Ghana will ensure that all staff have the opportunity to develop skills and knowledge to support AMS.

Enough is enough – is it time for the Scottish Antimicrobial Prescribing Group (SAPG) to develop the third age of antimicrobial stewardship in primary care in Scotland?

Background From 2008 the SAPG focused on ‘what to prescribe’ to tackle Clostridium difficile infection and from 2013 on ‘whether to prescribe’ to tackle unnecessary prescribing for self-limiting infections. Following these successes SAPG is now moving to the age of ‘how much to prescribe’ to ensure correct duration of therapy. We aimed to compare current prescribing practice with guidance from Public Health England (PHE)/NICE which recommends five days’ treatment for most common community respiratory infections (RTI). Methods The durations of antibiotic courses for treatment of respiratory tract infections was derived from data on dispensed prescriptions in 2018 from the Prescribing Information System, a national database of all NHS prescriptions dispensed in Scotland. Observed course durations were compared to course lengths recommended by PHE/NICE and modelling was undertaken on the impact on antibiotic use if durations were in line with guidance. Results For antibiotics recommended for RTI, the most common length of treatment used was seven days. For amoxicillin the proportion of five day prescriptions varied across health boards from 1.8% to 68.7%. Modelling estimated if 75% of seven day prescriptions for antibiotics recommended for RTI were changed to five days this would deliver a 4.1% reduction in antibiotic use. Conclusion SAPG has agreed to lead work to encourage the use of five day courses of antibiotics where indicated. Switching to five day courses would support reduction in total antibiotic use to achieve the ambitions of the UK AMR National Action Plan.

Review of antibiotic prophylaxis for the prevention of surgical site infection in low and middle income countries (LMICs)

Background The Scottish Antimicrobial Prescribing Group (SAPG) is supporting two hospitals in Ghana via a Fleming Fund healthcare partnership to develop antimicrobial stewardship. Initial intelligence gathering suggests that antibiotic prophylaxis to prevent surgical site infection (SSI) is suboptimal. To inform a quality improvement programme we have reviewed the evidence for use of surgical prophylaxis in LMICs including staff behaviours and attitudes. Methods MEDLINE, Embase, Cochrane, CINHAL and Google Scholar were searched from inception to 22 July 2019 for trials, audits, guidelines and systematic review in English. Grey literature, websites and reference lists of included studies were searched. The following data were extracted; study characteristics, interventions, outcomes and recommendations. In view of heterogeneity between studies descriptive analysis was conducted. Results Of 185 records screened, 26 studies related to SSI and timing of antibiotic prophylaxis in LMICs were included. The incidence of SSI is significantly higher in LMICs compared with high income countries, recording of infection surveillance data is poor and a lack of local guidelines for antibiotic prophylaxis. Several projects in Africa have reported reduction in SSI with single dose preoperative antibiotic use compared with post-operative prophylaxis and a reduction in cost and nurse time. Despite evidence to the contrary, many surgeons continue to use post-operative antibiotic prophylaxis. Conclusion Education to improve incidence of SSI in LMICs through appropriate antibiotic prophylaxis can be successful. Interventions must include local context and address strongly held beliefs. The establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Developing a national indicator of intravenous antibiotic use to support timely review of antibiotics in Scottish hospitals

Background To address increasing antibiotic use in acute hospitals, the Scottish Antimicrobial Prescribing Group developed a quality improvement (QI) initiative to support reliable review of patients started on intravenous (IV) antibiotics within 72 hours. This will reduce unnecessary continuation of antibiotics, ensure personalised treatment and appropriate IV to oral switch with associated benefits for patients of reduced risk of device related infections and potential for earlier discharge from hospital. Methods Using data obtained from the Hospital Medicines Utilisation Database, a national database of secondary care medicines use in Scotland, we examined trends in IV antibiotic use between 2013 and 2017. We then projected the current trend forward to 2021 to inform development of national indicator to optimise IV antibiotic use. Results In 2017, IV antibiotics accounted for 32.9% of all antibiotic use in Scottish hospitals. Annual IV antibiotic use (defined daily doses per 1000 population per day) increased by 20.5% between 2013 and 2017. We estimated a further projected increase of 12.5% between 2018 and 2021. To measure the impact of our QI initiative SAPG agreed to employ a national indicator with a target that ‘use of IV antibiotics in hospitals will be no higher in 2021 than it was in 2018’. Conclusion This national indicator will evaluate progress with achieving reliable and timely review of IV antibiotic therapy to reduce hospital antibiotic use and contribute to reduction in total antibiotic use in humans which is a key ambition of the UK AMR National Action Plan.

Optimizing carbapenem use through a national quality improvement programme.

Concern about increasing carbapenem and piperacillin/tazobactam use led the Scottish Antimicrobial Prescribing Group (SAPG) to develop national guidance on optimal use of these agents, and to implement a quality improvement programme to assess the impact of guidance on practice. To evaluate how SAPG guidance had been implemented by health boards, assess how this translated into clinical practice, and investigate clinicians' views and behaviours about prescribing carbapenems and alternative agents. Local implementation of SAPG guidance was assessed using an online survey. A bespoke point prevalence survey was used to evaluate prescribing. Clinicians' experience of using carbapenems and alternatives was examined through semi-structured interviews. National prescribing data were analysed to assess the impact of the programme. There were greater local restrictions for carbapenems than for piperacillin/tazobactam. Laboratory result suppression was inconsistent between boards and carbapenem-sparing antibiotics were not widely available. Compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antibiotics. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antibiotics decreased during the course of the programme. A multifaceted quality improvement programme was used to gather intelligence, promote behaviour change, and focus interventions on the use of carbapenems and piperacillin/tazobactam. Use of these antimicrobials decreased during the programme-a trend not seen elsewhere in Europe. The programme could be generalized to other antimicrobials.

Building a national Infection Intelligence Platform to improve antimicrobial stewardship and drive better patient outcomes: the Scottish experience.

The better use of new and emerging data streams to understand the epidemiology of infectious disease and to inform and evaluate antimicrobial stewardship improvement programmes is paramount in the global fight against antimicrobial resistance. To create a national informatics platform that synergizes the wealth of disjointed, infection-related health data, building an intelligence capability that allows rapid enquiry, generation of new knowledge and feedback to clinicians and policy makers. A multi-stakeholder community, led by the Scottish Antimicrobial Prescribing Group, secured government funding to deliver a national programme of work centred on three key aspects: (i) technical platform development with record linkage capability across multiple datasets; (ii) a proportionate governance approach to enhance responsiveness; and (iii) generation of new evidence to guide clinical practice. The National Health Service Scotland Infection Intelligence Platform (IIP) is now hosted within the national health data repository to assure resilience and sustainability. New technical solutions include simplified 'data views' of complex, linked datasets and embedded statistical programs to enhance capability. These developments have enabled responsiveness, flexibility and robustness in conducting population-based studies including a focus on intended and unintended effects of antimicrobial stewardship interventions and quantification of infection risk factors and clinical outcomes. We have completed the build and test phase of IIP, overcoming the technical and governance challenges, and produced new capability in infection informatics, generating new evidence for improved clinical practice. This provides a foundation for expansion and opportunity for global collaborations.

Investigating Orthopaedic Surgical Prophylaxis Changes and Post-operative Acute Kidney Injury (AKI) in NHS Grampian – a Test Case for NHS Scotland

ABSTRACT
 ObjectivesTo support reduction of Clostridium difficile infection (CDI), in 2008 the Scottish Antimicrobial Prescribing Group recommended that all NHS boards in Scotland restrict the use of antibiotics associated with a high risk of CDI. In NHS Grampian the policy for antibiotic prophylaxis in orthopaedic surgery was changed in June 2010. Trauma patients undergoing internal fixation or arthroplasty received flucloxacillin or co-amoxiclav before the policy change and flucloxacillin and gentamicin after the policy change. Previous studies have found similar policy changes resulted in an increase in post-operative acute kidney injury (AKI) and this study examined rates of post-operative AKI before and after this policy change in the NHS Grampian region of Scotland. Patients undergoing elective arthroplasty received either flucloxacillin or co-amoxiclav or cefuroxime before the policy change and cefuroxime afterwards.
 ApproachAll NHS Grampian patients who underwent an orthopaedic surgical procedure with prophylaxis during the period 01 June 2008 to 31 May 2012 were selected. Cases were linked to local creatinine data to detect post-operative AKI. Cases were further linked to national coverage data: (i) hospital discharge data to create the Charlson score for comorbidity, (ii) patient-level community prescribing data to identify previous exposure to any medicines which predispose to renal impairment, (iii) patient-level infection data to identify any post-operative CDI and (iv) Scottish Renal Registry data for case exclusion purposes. Segmented regression analyses of interrupted time series were used to evaluate changes in level and trend associated with the intervention and estimate effect sizes.
 Results3,870 trauma cases and 5,475 elective cases were examined. There was a significant increase in AKI rate following the policy change (β=0.28; 95%CI, 0.03 to 0.53; p=0.028) in trauma patients, equating to an increase of 0.28 cases of AKI per 100 procedures per month and a relative intervention effect at 24 months of 150% (95% CI 25% to 250%) There was no significant change in AKI rate among elective patients.
 ConclusionWe found that a change in orthopaedic antibiotic prophylaxis policy in NHS Grampian to flucloxacillin plus gentamcin was associated with an increase in post-operative AKI. This is consistent with observations in other boards and supports the new recommendation away from this policy made by SAPG in 2012. In cohort of trauma patients we found the change in policy was associated with an increase in post-operative AKI rate.

Six years of a national antimicrobial stewardship programme in Scotland: where are we now?

BackgroundThe Scottish Antimicrobial Prescribing Group (SAPG) was established in 2008 to lead delivery of the national antimicrobial stewardship programme. We performed a national self-reported survey in 2014 to evaluate stewardship activities delivered by regional Antimicrobial Management Teams (AMTs). An on-line survey was developed utilising validated indicators from a published European study along with questions specific to the Scottish context. Descriptive statistics were used to evaluate the responses received.FindingsThe survey was completed by 14 of the 15 AMTs (response rate 93 %). Results demonstrated good compliance with 9 of the 10 key European indicators included in the survey; 7 (50 %) of AMTs achieved all 9 indicators and 14 (100 %) of AMTs achieved at least 6 out of 9 indicators (67 %). Progress was also demonstrated across a range of stewardship activities and areas for further work were identified.ConclusionsThe survey results suggest the national stewardship programme in Scotland has reached maturity but consolidation and ongoing development are required. Collaborative working between SAPG and AMTs together with central funding has been key to achieving this level of success.

Development of an expert professional curriculum for antimicrobial pharmacists in the UK.

The role of antimicrobial pharmacists has changed considerably over the past 15 years. We describe here the development and ratification of a new expert professional curriculum to guide the training and development of antimicrobial specialist pharmacists. The curriculum has been developed by the UK Clinical Pharmacy Association Pharmacy Infection Network and endorsed by the Royal Pharmaceutical Society as a tool to support pharmacists in meeting the requirements for joining the Royal Pharmaceutical Society Faculty. This new resource has also been endorsed by PHE, the Scottish Antimicrobial Prescribing Group and the BSAC, and will support antimicrobial pharmacists in delivery of antimicrobial stewardship, which will in turn help the fight against antimicrobial resistance.

A RETROSPECTIVE REVIEW OF ANTIMICROBIAL PRESCRIBING AND INFECTION PREVALENCE IN A PALLIATIVE CARE UNIT

IntroductionHospice patients are highly susceptible to infections of the urinary and respiratory tract.1 2 3 4 The use of antimicrobials for symptom control should be considered against the burden of...

How pharmacists in Scotland can help combat antimicrobial resistance

Jacqueline Sneddon, project lead for the Scottish Antimicrobial Prescribing Group, and Annamarie McGregor, professional support pharmacist at the Royal Pharmaceutical Society, explain how pharmacists in Scotland can improve antimicrobial stewardship.

From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals.

BackgroundIn 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing.MethodsIn 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols.ResultsIn the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS.ConclusionsThe baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.

Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement

Following advice from the Scottish Antimicrobial Prescribing Group, we switched our antibiotic prophylaxis for elective hip and knee replacement surgery from cefuroxime to flucloxacillin with single-dose gentamicin in order to reduce the incidence of Clostridium difficile associated diarrhoea (CDAD). A clinical impression that more patients subsequently developed acute kidney injury (AKI) led us to examine this possibility in more detail. We examined the incidence of AKI in 198 consecutive patients undergoing elective hip or knee surgery. These patients were given the following prophylactic antibiotics: cefuroxime (n = 48); then high-dose (HD) flucloxacillin (5-8 g) with single-dose gentamicin (n = 52); then low-dose (LD) flucloxacillin (3-4 g) with single-dose gentamicin (n = 46) and finally cefuroxime again (n = 52). Patients receiving HD flucloxacillin required more vasopressors during surgery (P = 0.02); otherwise, there were no statistically significant differences in pre- and peri-operative characteristics between the four groups. The proportion of patients with any form of AKI by RIFLE criteria was first cefuroxime (8%), HD flucloxacillin with gentamicin (52%), LD flucloxacillin with gentamicin (22%) and second cefuroxime (14%; P < 0.0001). Odds ratios for AKI derived from a multivariate logistic regression model, adjusted also for sex and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, with the first cefuroxime group as a reference category were: HD flucloxacillin with gentamicin 14.53 (4.25-49.71); LD flucloxacillin with gentamicin 2.96 (0.81-10.81) and second cefuroxime 2.01 (0.52-7.73). Three patients required temporary haemodialysis. Biopsies in two of these showed acute tubulo-interstitial nephritis. All three patients belonged to the HD flucloxacillin with gentamicin group. None of the patients developed CDAD. We have shown an association between the prophylactic antibiotic regimen and subsequent development of AKI following primary hip and knee arthroplasty that appeared to be due to the use of HD flucloxacillin with single-dose gentamicin. We found no evidence to suggest that this association was confounded by any of the co-variates we measured.

Antimicrobial stewardship in Scotland: impact of a national programme

BackgoundThe Scottish Antimicrobial Prescribing Group (SAPG) was established by the Scottish Government in 2008 to lead the first national initiative to actively address antimicrobial stewardship. Healthcare associated infection (HAI) is a priority in Scotland and the work of SAPG contributes to the national HAI Delivery Plan. SAPG's early work has focused on restricting the use of antibiotics associated with a high risk of Clostridium difficile infection (CDI) and development of national prescribing indicators to support reduction of CDI.FindingsScottish Antimicrobial Prescribing Group has developed prescribing indicators for hospital and primary care, which are measured and reported in all 14 NHS board areas. Improvement in compliance with the indicators has been demonstrated with resultant reductions in CDI rates and no adverse effect on mortality or antimicrobial resistance patterns.ConclusionsThe establishment of a Scottish national antimicrobial stewardship programme has made a significant contribution to the HAI agenda, particularly in relation to CDI. The programme is supported by local antimicrobial teams, a national framework for education, surveillance of antimicrobial use and resistance and sharing of data for improvement. Antimicrobial stewardship has been integrated with other national programmes on patient safety and quality improvement.

Development of national prescribing indicators for antimicrobials to support reduction in Clostridium difficile infection: Category: Scientific free paper

The Scottish Antimicrobial Prescribing Group (SAPG) is a national multi-disciplinary clinical forum formed by the Scottish Government and hosted by the Scottish Medicines Consortium to implement the recommendations of Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP). SAPG directs national improvement initiatives via a network of NHS Board Antimicrobial Management Teams (AMTs).

Scottish Antimicrobial Prescribing Group (SAPG): development and impact of the Scottish National Antimicrobial Stewardship Programme

In 2008, the Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) was published by the Scottish Government. One of the key actions was initiation of the Scottish Antimicrobial Prescribing Group (SAPG), hosted within the Scottish Medicines Consortium, to take forward national implementation of the key recommendations of this action plan. The primary objective of SAPG is to co-ordinate and deliver a national framework or programme of work for antimicrobial stewardship. This programme, led by SAPG, is delivered by NHS National Services Scotland (Health Protection Scotland and Information Services Division), NHS Quality Improvement Scotland, and NHS National Education Scotland as well as NHS board Antimicrobial Management Teams. Between 2008 and 2010, SAPG has achieved a number of early successes, which are the subject of this review: (i) through measures to optimise prescribing in hospital and primary care, combined with infection prevention measures, SAPG has contributed significantly to reducing Clostridium difficile infection rates in Scotland; (ii) there has been engagement of all key stakeholders at local and national levels to ensure an integrated approach to antimicrobial stewardship within the wider healthcare-associated infection agenda; (iii) development and implementation of data management systems to support quality improvement; (iv) development of training materials on antimicrobial stewardship for healthcare professionals; and (v) improving clinical management of infections (e.g. community-acquired pneumonia) through quality improvement methodology. The early successes achieved by SAPG demonstrate that this delivery model is effective and provides the leadership and focus required to implement antimicrobial stewardship to improve antimicrobial prescribing and infection management across NHS Scotland.