1. An Audit to Determine if Prescribers are Reviewing Antimicrobial Prescriptions 48- 72 Hours After Initiation. Natalie Holman, Emma Cramp, Joy Baruah Hinchingbrooke Health Care NHS Trust, 59 antimicrobials were prescribed for the IV route. References 1.Antimicrobial stewardship: Start Smart - Then Focus; Guidance for antimicrobial stewardship in hospitals (England). Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (2011) 2.Public Health England: English surveillance programme antimicrobial utilisation and resistance (ESPAUR) report. 3.UK Five Year Antimicrobial Resistance Strategy 2013-2018 4.Department of Health Chief Medical Officer 2011 Volume two. Infections and the rise of antimicrobial resistance. (London: Department of Health) 5.The Health and Social Care Act (2008). Code of practice for the NHS on the prevention and control of health care associated infections and related guidance. Dept. of Health 2010. 6.Antimicrobial Prescribing Policy. Hinchingbrooke HCT 2014 7.Empirical Adult Antimicrobial Prescribing Guidelines, Hinchingbrooke HCT 2013 8.Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use NICE guidelines 2015 9.World Health Organisation Antimicrobial resistance Fact sheet N°194 Updated April 2015 http://www.who.int/mediacentre/factsheets/fs194/en/ Aim To ensure that Hinchingbrooke Health Care Trust is complying with both national and local policies and guidelines for antimicrobial stewardship, and that best practice is being provided with respect to the timely reviewing of antimicrobials prescriptions. Objectives To assess whether prescribers are reviewing all antimicrobial prescriptions at 48-72hours and are switching intravenous (IV) antimicrobials to the oral route at an appropriate time. To evaluate whether the pharmacists are advocating antimicrobial stewardship by using stickers to prompt the prescribers to record an indication and review/stop dates on all antimicrobial prescriptions, and to switch IV antimicrobials to the oral route if appropriate. Conclusions These results demonstrate that participation in antimicrobial stewardship within Hinchingbrooke Health Care NHS Trust is poor and that further work is needed to ensure prescribers are reviewing 100% of antimicrobial prescriptions within 48-72 hours of initiation, and to promote early IV to oral switching where appropriate. These findings also highlight the need for pharmacists to also improve their practice on the wards with respect to reviewing antimicrobial prescriptions and their engagement in using the yellow stickers to help advocate antimicrobial stewardship. It is paramount these standards are met to prevent antimicrobials being continued unnecessarily in order to help avert the emergence and spread of antimicrobial resistance and avoid the risks associated with prolonged IV therapy. Actions The main actions to facilitate change in practice are: A hospital wide campaign to raise awareness about antibiotic stewardship; displaying posters, distributing leaflets, providing news bulletins, manning a pop up awareness stall and holding face to face discussions with health professionals during European Antibiotic Awareness Week For the medical director to re-enforce the review messages by feeding back the results to consultants within the trust Improved training for doctors and pharmacists within the trust on antimicrobial prescribing and the importance of antimicrobial stewardship To present audit results at pharmacy clinical governance meeting Pharmacists to draw clear stop lines on prescriptions after the duration of an antimicrobial Re-audit to ensure that changes made have helped to meet standards, 59 antimicrobials were prescribed for the IV route. Background Current evidence demonstrates that the inappropriate and prolonged use of antimicrobials favours the emergence and spread of antimicrobial resistance, which is an increasingly serious threat to global public health. (2,3,4,9) Antimicrobials are generally started before a patient’s full clinical picture is known. (1) By 48-72 hours, when additional information is available, including microbiology, radiographic and clinical information, it is important for clinicians to re-evaluate why the therapy was initiated in the first place. This is to gather evidence on whether the current treatment is appropriate and to determine if changes are to be made to therapy, thus taking ownership of antimicrobial stewardship and helping to prevent antimicrobial resistance. (1, 6, 8) Pharmacists also play an important role in the management of the safe, effective and appropriate use of antimicrobials. It is therefore essential that they too are reviewing antimicrobial prescriptions and encouraging the prudent use of antimicrobials to avert antimicrobial resistance. (6, 8) Method The audit took place on the 9 th July 2015 where nine wards were visited by a pharmacist with the aim of reviewing every patient’s drug chart on the ward. Inclusion criteria: Patients prescribed antimicrobials at the time of the audit. Exclusion criteria: Patients prescribed topical or long term prophylactic antimicrobials and patients on paediatric and obstetric wards. A data collection form was completed for each patient meeting the inclusion criteria, this involved reviewing the antimicrobial prescriptions, patient’s notes, and where necessary bloods and microbiology results. Results Standard 1Standard 2Standard 3Standard 4 Percentage of antimicrobial prescriptions with a review at 48-72 hours with clear plans documented. Number of IV antimicrobial prescriptions that were eligible for an IV to oral switch. Percentage of stickers being used by the ward pharmacists to prompt the prescribers to record a review/stop date and indication when required. Percentage of stickers being used by the ward pharmacists to prompt the prescribers to review antimicrobials prescriptions and switch from the IV to oral route when required. 29%1416%14% Standard 1 Prescribers are reviewing 100% of antimicrobial prescriptions at 48-72 hours after initiation, along with a clear documented plan of action. i.e. any of the following are documented in the patient notes: Stop antibiotics Switch from IV to PO Change antibiotics Continue AND document next review/stop date OPAT (1,6) Standard 2 When IV antimicrobials have been prescribed, prescribers are switching all IV antimicrobials to the oral route at an appropriate time. i.e. when the following criteria are met: Oral fluid tolerated No known GI malabsorption Temperature is 36°C for 24hours Patient is clinically improving (1,6) Standard 3 Pharmacists are using yellow antimicrobial review stickers to prompt prescribers to record an indication and a stop/review date according to the Hinchingbrooke Trust policy if not already documented. This is to ensure that 100% of antimicrobial prescriptions have an indication and review/stop date documented. (1,6) Standard 4 Pharmacists are using yellow antimicrobial review stickers to prompt prescribers to clinically review 100% of antimicrobial treatment at 48-72hours and switch from IV to the oral route if clinically appropriate. (1,6) Where no indication or stop date/review date has been stated for an antimicrobial prescription, and/or the criteria for IV to oral switch has been met, a yellow Review Sticker is to be placed in the patients notes. Figure 1. Review Stickers Results Figure 2. 198 patients were audited 74 patients were on antimicrobials 59 antimicrobials were prescribed for the IV route. 99 antimicrobials were prescribed in total