Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND

Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance.

AIM

To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection.

METHODS

A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS.

FINDINGS

The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey.

CONCLUSION

HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

Reduction in post-operative acute kidney injury following a change in antibiotic prophylaxis policy for orthopaedic surgery: an observational study

OBJECTIVES

Evidence has shown that a prophylactic antibiotic regimen of flucloxacillin and gentamicin for orthopaedic surgery was associated with increased rates of post-operative acute kidney injury (AKI). This resulted in changes in the national antibiotic policy recommendation for orthopaedic surgical prophylaxis. This study aimed to assess whether this change from flucloxacillin and gentamicin to co-amoxiclav was associated with changes in the rates of AKI and Clostridium difficile infection (CDI).

METHODS

An observational study and interrupted time series analyses were used to assess rates of post-operative AKI separately in patients undergoing neck of femur (NOF) repair and other orthopaedic operations that required antibiotic prophylaxis. Incidence rate ratios were used to evaluate changes in CDI rates.

RESULTS

Following the change in policy, from flucloxacillin and gentamicin to co-amoxiclav, there was a relative change in rates of post-operative AKI of -63% (95% CI -77% to -49%) at 18 months in the other orthopaedic operations group. In the NOF repair group, there was no change in the rate of post-operative AKI [-10% (95% CI -35%-15%)] at 18 months. The incident rate ratio for CDI in the other orthopaedic operations group was 0.29 (95% CI 0.09-0.96) and in the NOF repair group was 0.76 (95% CI 0.28-2.08).

CONCLUSIONS

The use of co-amoxiclav for antibiotic prophylaxis in orthopaedic surgery was associated with a decreased rate of post-operative AKI compared with flucloxacillin and gentamicin and was not associated with increased rates of CDI.

Antimicrobial Stewardship from Policy to Practice: Experiences from UK Antimicrobial Pharmacists

Antimicrobial stewardship in the UK has evolved dramatically in the last 15 years. Factors driving this include initial central funding for specialist pharmacists and mandatory reductions in healthcare-associated infections (particularly Clostridium difficile infection). More recently, the introduction of national stewardship guidelines, and an increased focus on stewardship as part of the UK five-year antimicrobial resistance strategy, have accelerated and embedded developments. Antimicrobial pharmacists have been instrumental in effecting changes at an organizational and national level. This article describes the evolution of the antimicrobial pharmacist role, its impact, the progress toward the actions listed in the five-year resistance strategy, and novel emerging areas in stewardship in the UK.

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

BACKGROUND

The 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.

FINDINGS

The 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.

CONCLUSIONS

The 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.

Assessing knowledge of antimicrobial stewardship

The Scottish Antimicrobial Prescribing Group (SAPG) is a national clinical multidisciplinary forum that coordinates and delivers antimicrobial stewardship (AS). This work includes ensuring health professionals have the necessary knowledge to contribute to improving the use of antimicrobials and to develop and implement education resources if required. The SAPG undertook a survey to scope the current understanding and learning needs among nurses and midwives in a range of care settings across Scotland. This article reports on the results, which have been used to help develop a dedicated AS education programme for this group of health professionals.

Risk of AKI with gentamicin as surgical prophylaxis

In 2009, the Scottish government issued a target to reduce Clostridium difficile infection by 30% in 2 years. Consequently, Scottish hospitals changed from cephalosporins to gentamicin for surgical antibiotic prophylaxis. This study examined rates of postoperative AKI before and after this policy change. The study population comprised 12,482 adults undergoing surgery (orthopedic, urology, vascular, gastrointestinal, and gynecology) with antibiotic prophylaxis between October 1, 2006, and September 30, 2010 in the Tayside region of Scotland. Postoperative AKI was defined by the Kidney Disease Improving Global Outcomes criteria. The study design was an interrupted time series with segmented regression analysis. In orthopedic patients, change in policy from cefuroxime to flucloxacillin (two doses of 1 g) and single-dose gentamicin (4 mg/kg) was associated with a 94% increase in AKI (P=0.04; 95% confidence interval, 93.8% to 94.3%). Most patients who developed AKI after prophylactic gentamicin had stage 1 AKI, but some patients developed persistent stage 2 or stage 3 AKI. The antibiotic policy change was not associated with a significant increase in AKI in the other groups. Regardless of antibiotic regimen, however, rates of AKI were high (24%) after vascular surgery, and increased steadily after gastrointestinal surgery. Rates could only be ascertained in 52% of urology patients and 47% of gynecology patients because of a lack of creatinine testing. These results suggest that gentamicin should be avoided in orthopedic patients in the perioperative period. Our findings also raise concerns about the increasing prevalence of postoperative AKI and failures to consistently measure postoperative renal function.

Overview of strategies for overcoming the challenge of antimicrobial resistance

The discovery of penicillin undoubtedly transformed the management of life-threatening bacterial infections. However, a less comfortable aspect of the antibiotic revolution was that within 10 years, over 80% of patients with acute bronchitis were receiving antibiotics without any evidence of clinical benefit. Antibiotic use inevitably causes collateral damage to the normal human flora and increases the risk of infection with antibiotic-resistant bacteria and Clostridium difficile. The twin aims of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second to provide convincing evidence and information to educate and support professionals and patients to reduce unnecessary use and minimize collateral damage. We review evidence of progress with these aims in Europe and nationally in Scotland.

Antimicrobial stewardship in Scotland: impact of a national programme

Backgound

The 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.

Findings

Scottish 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.

Conclusions

The 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.

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.

A Descriptive Study of Urban Rabies during the Civil War in Sierra Leone: 1995–2001

A study was conducted to assess the effects of the breakdown in internal infrastructure on the incidence of canine-transmitted human rabies in urban areas of Sierra Leone during the course of the civil war between 1995 and 2001. Data from provincial hospitals in the Western Area and Southern Province indicated that there was a significant increase in the incidence of canine-transmitted urban human rabies chi2 = 39.63, p < 0.0001, particularly among children chi2 = 23.73, p < 0.0001, over the course of the war. In the Western Area in 2001, towards the end of the war, there was a significant increase in adult cases, which was reflected in the observed versus the expected chi2 ratio (70 versus 53). Interview-based questionnaire surveys in Freetown administered between 2001 and 2002 indicated that dogs were commonly kept for security reasons, and were largely unrestrained and unlicensed, regardless of the socioeconomic status of the owner. Virtually all dogs were unvaccinated and were mainly living in close proximity with humans. This study indicated that there is an urgent requirement for appropriate mass rabies vaccination campaigns for pet dogs and for campaigns to manipulate the urban habitat to control free-roaming and wandering but owned dog populations in Freetown and other urban areas in the provinces of Sierra Leone. Interview-based questionnaires administered in three districts of Freetown indicated a relatively high degree of uniformity in dog husbandry and veterinary care habits across a wide range of socioeconomic status categories in dog owners.

Manganese species migration in soil at the Sabine National Wildlife Refuge, Louisiana

A modified sequential extraction procedure was employed to speciate the chemical forms of Mn in sediment using flame atomic absorption spectrophotometry. Concentrations were determined in five different fractions for each sample (Mn in the exchangeable form, bound to carbonates, bound to Mn/Fe oxides, bound to organic matter and in the residual form). The determinations were made for sediments obtained from the Sabine National Wildlife Refuge while a marshland reclamation project was being conducted. Sediment samples were taken from Ship Channel dredge spoils (thought to be contaminated), an old reclamation site, a new reclamation site and a reference site. The results indicated that the Ship Channel sediments were not contaminated, but revealed an Mn "pumping" model, which proposes that additional Mn added to a similar site is concentrated near the surface soil layers by environmental conditions, which may be a cause of the observed slow recovery of vegetation at one of the more recently developed sites.