Introduction to the Infection Intelligence Platform (IIP) Professor Marion Bennie National Services Scotland University of Strathclyde

National reduction in “4C” antibacterials in primary care Data from Scottish Antimicrobial Prescribing Group Primary Care Prescribing Indicators reports, 2010 and Target antibacterials: 1.Cephalosporins 2.Ciprofloxacin 3.Clindamycin 4.Co-amoxiclav

From Strategy To Bedside Care

Better Access To And Use Of Surveillance

IIP - Vision Improving patient outcomes and reducing harm from infection through an innovative, integrated database, to support clinicians within the NHS in Scotland

PATIENT (Community and Healthcare acquired Infection) Intrinsic (patient) Age/gender Colonised Morbidity Drug history Vaccine history Extrinsic (environment) - Medicines (prior use) - Lines/Catheters - Hand Hygiene - Surgery - Length of stay Prevention Intervention SIPS - Standard infection control precautions Antimicrobial stewardship Patient outcome Infection Management Antibiotic policy Infection control (TBP - Transmission based precautions) Monitoring/Surveillance Intended consequences Unintended consequences IIP - Vision

ECOSS (resistance) PIS (prescribing) HMUD (prescribing) ACaDMe (acute cancer, deaths and mental health) AMIDS PCs (users in NHS) Combined Data: Use & AMR Use & CDI Standard reports Snapshot all NHS boards Trend board vs Scotland Step 1 - AMIDS (Antimicrobial Integrated Database Scotland)

Fluoroquinolone use and resistance (Ecoli bacteraemia) NHS Board and Scotland

SCI STORE Local Hospital Medicines Database Orthopaedic Surgery Serum Creatinine Local Prescribing Post-operative Acute Kidney Injury, all patients, unadjusted analysis – pre vs. last post-operative creatinine measurement (NHS Tayside, Peter Davey) Antibiotic Policy Change New Antibiotic Policy fully implemented SMR01 Step 2 - Unintended Consequences

Step 3 – Policy Support Strategic Case –NHS Scotland eHealth Strategy Board in March 2013 (agreed) Business Case –Clinical engagement (review group) – SGHCD HAI National Advisory Group in July 2013 (approved)

Setup Capability building Full Capability Future Position Enhanced connectivity and linkage of existing national and local information to improve prevention and management of infection, reduce harm and minimise waste Current Position No strategic approach: Uncoordinated integration of databases through small pockets of resources from national and local programmes on an hoc basis Infrastructure to routinely connect current relevant national databases with infection information. Generic capability to support patient care, enable measurement of intended and unintended consequences of interventions. Incremental planned studies focussing on key infection related clinical goals. Further enhancement of connectivity to include current and future local databases. IIP - Road Map

IIP - Benefits (improve care - reduce harm - reduce variation) Patients –Support individual prevention/treatment plans NHS Boards –Drive quality improvement in local service delivery model (intended/unintended consequences) National Surveillance –Identify emergence of antimicrobial resistance Research –Support evidence based clinical practice

Case Vignette - Patient with catheter urinary tract infection (UTI) A 75 year old man in a residential home with long term catheter multiple co-morbidities (diabetes mellitus and congestive heart failure) Discharged from hospital 6 weeks ago following a catheter related UTI. Since return home he has had a non-severe episode of C.difficile (CDI) diarrhoea which resolved with treatment. Seen by the out of hours service with a probable recurrence of a catheter related UTI and prescribed trimethorpim. 24 hours later he has become more unwell with sepsis and is admitted to hospital and treated with empiric amoxil and gentamicin. Risk factors Is this patient at increased risk of CDI in both settings? Is the patient at increased risk of CDI recurrence within 3 months of the original episode? Treatment What is the likely local and national antibiotic sensitivity and clinical effectiveness of different antibiotics in both clinical settings? Outcomes Is current treatment of UTI in the community associated with increased hospital admissions with sepsis? What is the 30-day mortality of patients admitted with sepsis? Is the use of gentamicin in the acute empiric setting associated with increased acute kidney injury (AKI)?

Deliverables ( ) To gain the necessary information governance approvals To build the required IM&T Infrastructure to support the IIP by technically linking six sources initially To complete a series of exemplar clinical studies to test the IIP capability and effectiveness

IIP - Project Governance

Key Datasets ECOSS Electronic Communication of Surveillance in Scotland (antimicrobial resistance data) HMUD Hospital Medicines Utilisation Database PIS Prescribing Information System (primary care prescribing) SCI Store Clinical Information (e.g. Lab results, Radiology reports) Repository SMR Scottish Morbidity Record (SMR) –SMR01 – Inpatients, Day Cases, Discharge & Diagnosis –SMR02 – Maternity Inpatients, Day Cases, Discharge & Diagnosis –SMR99 – Mortality SSIRS Surgical Site Infection Reporting System

Clinical StudyWork Stream Risk factors SAB & E Coli bacteraemiaRisk Factors Routine analysis risk factors for common bacteraemiaRisk Factors Primary Care prescribing and HAI CDIInterventions Primary Care prescribing and other HAIInterventions UTI Primary Care prescribing and AMRInterventions Other Primary Care prescribing and AMRInterventions High risk antibiotic prescribing and outcomes from emerging resistant pathogensInterventions Validation of IIP for SSI surveillanceOutcomes Mortality associated with SSI, SAB, CDI, HAIOutcomes MRSA and CDI deaths routine reportingOutcomes 30 day mortality after blood culture – SAPG restrictive policy evaluation Outcomes Standardised 30 day blood culture mortality – SPSP sepsis collaborative evaluation Outcomes Consequences of secondary care antibiotic policy changes – AMR and clinical outcome Outcomes Surgical prophylaxis changes – AKI in NHS Lanarkshire and across Scotland (n=2) Outcomes Addition of local datasets (e.g. ICNet, HEPMA, HMUD) to IIPTechnical IIP – Clinical studies

Acknowledgements IIP Core Project Team IIP User Group IIP Joint Project Board