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Antibiotic Review Kit - Hospital (ARK-hospital)
Mar$nLlewelynBrightonandSussexMedicalSchool
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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
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Bronzwae S et al 2002 Emerg Infect Dis
Antibiotic consumption correlates with antibiotic resistance
DefinedDailyDosesofbeta-lactamanPbioPcs/1000populaPon
Logoddsofpenicillinresistance
inStrep.pneumoniae
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Antibiotics also place individual patients at risk of resistant infection
• ExploredrelaPonshipbetweenprioranPbioPcuseandanPbioPcresistance• Reviewed24studies
– 19ObservaPonal– 5RCTs– >27,000parPcipants
• UrinaryInfecPons• RespiratoryTractinfecPons
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5
Forest plots of included studies
UrinaryInfecPon RespiratoryTractInfecPonImpactonriskofresistantinfecPon
SubstanPal
LasPng
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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).
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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
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For common indications minimum durations of treatment have not been established
ThereisalackofevidencethatrecommendedduraPonsaresuperiortoanPbioPc-sparingapproaches**w/excepPonofoPPsmedia,HobermanAetalNewEngJMed.2016;375:2446-2456
Recommendedcoursedura$onshavefallen
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And yet it appears to be very hard to reduce antibiotic use in hospitals
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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
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Start‘smart’without‘focus’myactuallyincrease
anPbioPcoveruse
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“wewillcutinappropriateprescribingintheUKbyhalfby2020…”
hlps://www.cdc.gov/features/anPbioPcuse/
How much could antibiotic use be cut? “By2020,significantoutcomeswillinclude:ReducPonofinappropriateanPbioPcuse
By50%inoutpaPentserngsBy20%ininpaPentserngs”
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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
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• 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
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What is ARK-hospital?
TheoverarchingaimofARKistoreducetheincidenceofseriousinfecPonscausedbyanPbioPc-resistantbacteriainthefuture,throughsubstanPallyandsafelyreducinganPbioPcuseinhospitalsnow
A5-yearappliedresearchprogrammefundedbyNIHR
Underlyinghypotheses:
• Inhospitals,mostanPbioPcsarestartedappropriately;butthereisreluctancetostopthemoncestarted
• ShortduraPonsofanPbioPctreatmentaresufficienttotreatmostgenuinebacterialinfecPonsinhospitals
• ClinicalreviewwillidenPfythosewhosecondiPonhasnotimprovedwhoneedtoconPnuetakingthem
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What is ARK-hospital?
TheoverarchingaimofARKistoreducetheincidenceofseriousinfecPonscausedbyanPbioPc-resistantbacteriainthefuture,throughsubstanPallyandsafelyreducinganPbioPcuseinhospitalsnow
A5-yearappliedresearchprogrammefundedbyNIHR
Theprogrammeapplies:Complexbehaviourchangeapproachessuccessfulinprimarycare• Grace-INTRO(InternetTrainingforreducingAnPbioPcuse)• STAR(StemmingthePdeofanPbioPcresistance)EducaPonalprogrammeTo‘ReviewandRevise’decisionstakeninsecondarycare:targetbehaviourbeingtodiscon$nuean$bio$cs
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ARK-hospital has six work packages
1-12
13-24
25-60
M
onths
WP2:dataanalysisofmortalityvaria$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$on;
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ARK-hospital provides • Informa$onforprescribersaboutReviewandRevisedecisionmaking
• Whystoppingsoonerthanwedoissafe• Whynotstoppingsoonercanbeharmful
• Adecisionaidwhich1) acknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain
Areyouprescribingforaprobablediagnosisofinfec1onorapossibleriskofinfec1on?
2) Encouragesprescriberstoreviewdailytakinga“stoporjusPfyconPnue”approach3) Leadstoaseniorclinician’sfinalisedan1bio1cprescrip1on
• Informa$onforpa$entswhohavehadtheiranPbioPctreatmentstopped
• Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise
• StructureforTeamMeePngsandMonitoringtosupportReviewandRevise
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ARK-hospital provides • Informa$onforprescribersaboutReviewandRevisedecisionmaking
• AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain
CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise
2) Encouragesreviewersto“stoporjusPfyconPnue”3) Leadstoaseniorclinician’sfinalisedprescrip1on
• Informa$onforpa$entswhohavehadtheiranPbioPctreatmentstopped
• Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise
• StructureforTeamMeePngsandMonitoringtosupportReviewandRevise
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ARK-hospital provides • Informa$onforprescribersaboutReviewandRevisedecisionmaking
• AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain
CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise
• Informa$onforpa$ents
• RisksandbenefitsofanPbioPcs• Thatreviewingoccurs
• Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise
• StructureforTeamMeePngsandMonitoringtosupportReviewandRevise
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ARK-hospital provides • Informa$onforprescribersaboutReviewandRevisedecisionmaking
• AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain
CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise
• Informa$onforpa$ents
• Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise
• StructureforTeamMeePngsandMonitoringtosupportReviewandRevise
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ARK-hospital provides • Informa$onforprescribersaboutReviewandRevisedecisionmaking
• AdecisionaidwhichacknowledgesthatwhenanPbioPcsarestartedthediagnosisusuallyisn’tcertain
CapturesthedegreeofthisuncertaintytoinforminvesPgaPonandlowerthethresholdtostopatReviewandRevise
• Informa$onforpa$ents
• Informa$onfornursesandpharmacistsaboutwaystosupportReviewandRevise
• Toolsandprocessesforauditandfeedback
• StructureforTeamMeePngsandMonitoringtosupportReviewandRevise
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Timelines, feasibility and pilot
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The ARK-Hospital Team
DianeAshiru-Oredope–PublicHealthEnglandKieranHand–UniversityHospitalsSouthampton
FormoreinformaPonvisithlp://modmedmicro.nsms.ox.ac.uk/ark/[email protected]://$nyurl.com/jbcfxca
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Thank you!
Visit:hlp://modmedmicro.nsms.ox.ac.uk/ark/
Email:[email protected]
SignupasanARKchampion:hcps://$nyurl.com/jbcfxca