antibiotic review kit - hospital (ark-hospital)

Antibiotic Review Kit - Hospital (ARK-hospital)

Mar$nLlewelynBrightonandSussexMedicalSchool

The challenge of antibiotic resistant GNRs in the UK Ratesofresistancetokeyagents…

GentamicinCiprofloxacinCo-amoxiclavPiperacillin–tazobactam

….nowcompromisereliabilityasempirictreatmentchoices46%ofE.colibacteraemiaisolatesnowreportedasco-amoxiclavresistant

0

5

10

15

20

25

30

35

40

45

E.coli-Co-amox K.pneumoniae-Pip-tazo%Isolatesre

sistan

t

2010

2011

2012

2013

2014

EnglishsurveillanceprogrammeforanPmicrobialuPlisaPonandresistance(ESPAUR)report2015

Bronzwae S et al 2002 Emerg Infect Dis

Antibiotic consumption correlates with antibiotic resistance

DefinedDailyDosesofbeta-lactamanPbioPcs/1000populaPon

Logoddsofpenicillinresistance

inStrep.pneumoniae

Antibiotics also place individual patients at risk of resistant infection

•  ExploredrelaPonshipbetweenprioranPbioPcuseandanPbioPcresistance•  Reviewed24studies

–  19ObservaPonal–  5RCTs–  >27,000parPcipants

•  UrinaryInfecPons•  RespiratoryTractinfecPons

5

Forest plots of included studies

UrinaryInfecPon RespiratoryTractInfecPonImpactonriskofresistantinfecPon

SubstanPal

LasPng

Giving less antibiotics reduces this risk

1. ChastreJetalJAMA2003•  401paPentswithVAPon51FrenchICUs•  Randomizedto8vs15daysanPbioPctreatment•  ShortcoursepaPentshad

•  equivalentoutcomesoneverysafetymeasure•  halfasmuchanPbioPcexposure•  Lowerriskofresistantre-infecPon

2. SinghNetalAmJRespirCritCareMed20001. 81paPentstreatedforsuspectedVAPrandomisedtoreviewandreviseat3daysorstandardcourse

2. Lowerriskofresistance/super-infecPoninthereviewandrevisegroup(15vs35%p=0.017).

Overall56%(95%CI34-70%)REDUCEDriskofmortalitywithAnPbioPcde-escalaPonstrategies

EffectonmortalityofanPbioPcde-escalaPon

Concluded:

Lower use of antibiotics probably does not increase mortality and likely reduces length of stay.

Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques.

Giving less antibiotic probably improves clinical outcome

For common indications minimum durations of treatment have not been established

ThereisalackofevidencethatrecommendedduraPonsaresuperiortoanPbioPc-sparingapproaches**w/excepPonofoPPsmedia,HobermanAetalNewEngJMed.2016;375:2446-2456

Recommendedcoursedura$onshavefallen

And yet it appears to be very hard to reduce antibiotic use in hospitals

Hospital antibiotic use in England

2010 2011 2012 2013 2014Piperacillin-tazobactam 100.0% 112.8% 130.4% 145.9% 161.7%Carbapenem(inpatients) 100.0% 113.6% 120.4% 130.6% 141.3%Totalantibiotics(inpatients) 100.0% 103.2% 107.8% 111.9% 115.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

160.0%

180.0%

%CHANGEINDDDSPER1000INHABITANTS

PERDAYRELATIVETOYEAR2010

hlp://ecdc.europa.eu/en/healthtopics/anPmicrobial_resistance/esac-net-database/Pages/AnPmicrobial-consumpPon-rates-by-country.aspx(accessedAugust2016)

Consump$onofsystemican$bacterialsinthehospitalsectorinEurope2014

hlps://www.gov.uk/government/uploads/system/uploads/alachment_data/file/477962/ESPAUR_Report_2015.pdf(accessedAugust2016)

Totalandbroad-spectruman$bio$cprescribingNHSEngland2010-2014

UK

CourtesyofDrKieranHand

Start‘smart’without‘focus’myactuallyincrease

anPbioPcoveruse

“wewillcutinappropriateprescribingintheUKbyhalfby2020…”

hlps://www.cdc.gov/features/anPbioPcuse/

How much could antibiotic use be cut? “By2020,significantoutcomeswillinclude:ReducPonofinappropriateanPbioPcuse

By50%inoutpaPentserngsBy20%ininpaPentserngs”

Acutemedicalpa$entsunderaninfec$onphysicianreceivelessan$bio$ctreatment173vs282DOT/100admissions

AllowingforcasemixIDmanagedpaPentswere•  LesslikelytoreceiveananPbioPc(OR=0.25(95%CI0.07to0.84),p=0.03)•  Morelikelytoreceiveashortercourse(RR=0.71(95%CI0.54to0.93),p=0.01)

WithnodifferencesintreatmentfailureormortalityButlongerhospitalstay2(2-6)vs4(3-6)days

•  Documentedday3review•  Q1target25%:median81.6%•  Q2target50%:median88%(38%-100%).(1trust<50%;125submiled)•  Q3target75%:median90.0%(50%-99%).(3trusts<75%;125submiled)

•  Outcomesdataofday3review(Q1);111trustsenteredvoluntarydata•  Stop10%•  ConPnue63%•  IVOS16%•  switchAB12%•  OPAT0.5%

CourtesyofDrDianeAshiru-Oredope

What is ARK-hospital?

TheoverarchingaimofARKistoreducetheincidenceofseriousinfecPonscausedbyanPbioPc-resistantbacteriainthefuture,throughsubstanPallyandsafelyreducinganPbioPcuseinhospitalsnow

A5-yearappliedresearchprogrammefundedbyNIHR

Underlyinghypotheses:

•  Inhospitals,mostanPbioPcsarestartedappropriately;butthereisreluctancetostopthemoncestarted

•  ShortduraPonsofanPbioPctreatmentaresufficienttotreatmostgenuinebacterialinfecPonsinhospitals

•  ClinicalreviewwillidenPfythosewhosecondiPonhasnotimprovedwhoneedtoconPnuetakingthem

What is ARK-hospital?

TheoverarchingaimofARKistoreducetheincidenceofseriousinfecPonscausedbyanPbioPc-resistantbacteriainthefuture,throughsubstanPallyandsafelyreducinganPbioPcuseinhospitalsnow

A5-yearappliedresearchprogrammefundedbyNIHR

Theprogrammeapplies:Complexbehaviourchangeapproachessuccessfulinprimarycare•  Grace-INTRO(InternetTrainingforreducingAnPbioPcuse)•  STAR(StemmingthePdeofanPbioPcresistance)EducaPonalprogrammeTo‘ReviewandRevise’decisionstakeninsecondarycare:targetbehaviourbeingtodiscon$nuean$bio$cs

ARK-hospital has six work packages

1-12

13-24

25-60

M

onths

WP2:dataanalysisofmortalityvaria$on1)withinBirmingham

hospitalsand2)acrossNHSTrustswithdifferentanPbioPcduraPon

policies

WP3:qualita$vestudiesinserviceusersandhealthcareprofessionalsviz.anPbioPcreview/duraPoninhospitals

WP1:overviewofsystema$creviewsofshort-vslong-course

anPbioPcsinhospitalisedpaPents

+ +

EVIDEN

CE/BAR

RIER

S

WP4:Co-designofinterven$onforhealthcareprofessionalsandinpaPents/carerstoopPmise"review&revise"inhospitals

DESIGN

WP6:Withintrialcost-effecPvenessanalysisandhealth

economicsimulaPons

INTERV

ENE

WP5:Mul$-hospitalstudyofan$bio$c

"review&revise“interven$on;

ARK-hospital provides •  Informa$onforprescribersaboutReviewandRevisedecisionmaking

•  Whystoppingsoonerthanwedoissafe•  Whynotstoppingsoonercanbeharmful

•  Adecisionaidwhich1)  acknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain

Areyouprescribingforaprobablediagnosisofinfec1onorapossibleriskofinfec1on?

2)  Encouragesprescriberstoreviewdailytakinga“stoporjusPfyconPnue”approach3)  Leadstoaseniorclinician’sfinalisedan1bio1cprescrip1on

•  Informa$onforpa$entswhohavehadtheiranPbioPctreatmentstopped

•  Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise

•  StructureforTeamMeePngsandMonitoringtosupportReviewandRevise

ARK-hospital provides •  Informa$onforprescribersaboutReviewandRevisedecisionmaking

•  AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain

CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise

2)  Encouragesreviewersto“stoporjusPfyconPnue”3)  Leadstoaseniorclinician’sfinalisedprescrip1on

•  Informa$onforpa$entswhohavehadtheiranPbioPctreatmentstopped

•  Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise

•  StructureforTeamMeePngsandMonitoringtosupportReviewandRevise

ARK-hospital provides •  Informa$onforprescribersaboutReviewandRevisedecisionmaking

•  AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain

CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise

•  Informa$onforpa$ents

•  RisksandbenefitsofanPbioPcs•  Thatreviewingoccurs

•  Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise

•  StructureforTeamMeePngsandMonitoringtosupportReviewandRevise

ARK-hospital provides •  Informa$onforprescribersaboutReviewandRevisedecisionmaking

•  AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain

CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise

•  Informa$onforpa$ents

•  Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise

•  StructureforTeamMeePngsandMonitoringtosupportReviewandRevise

ARK-hospital provides •  Informa$onforprescribersaboutReviewandRevisedecisionmaking

•  AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain

CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise

•  Informa$onforpa$ents

•  Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise

•  Toolsandprocessesforauditandfeedback

•  StructureforTeamMeePngsandMonitoringtosupportReviewandRevise

Timelines, feasibility and pilot

The ARK-Hospital Team

DianeAshiru-Oredope–PublicHealthEnglandKieranHand–UniversityHospitalsSouthampton

FormoreinformaPonvisithlp://modmedmicro.nsms.ox.ac.uk/ark/Oremailm.j.llewelyn@bsms.ac.ukTosignupasanARKchampionvisithcps://$nyurl.com/jbcfxca

Thank you!

Visit:hlp://modmedmicro.nsms.ox.ac.uk/ark/

Email:m.j.llewelyn@bsms.ac.uk

SignupasanARKchampion:hcps://$nyurl.com/jbcfxca