1. Discussion and Action Plan
Collation of antimicrobial guidelines across Yorkshire and the Humber: opportunities for practice improvement
Avril J. Lynch1, Kevin Frost2, Jade Lee-Milner3, Kathryn M. Ashton3, and Stuart E. Bond3
1. Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield.
2. Airedale NHS Foundation Trust, Keighley
3. Mid Yorkshire Hospitals NHS Trust, Wakefield; for the Yorkshire and Humber Antimicrobial Pharmacy (YAHAP) Group.
This study did not require ethics approval.
Introduction
Results
The Yorkshire and Humber antimicrobial pharmacy (YAHAP) group consists of antimicrobial pharmacists and technicians from 13 acute trusts within the region. The group works together to help improve antimicrobial stewardship (AMS) and infection management through networking, sharing best practice, peer-support, education and joint initiatives. YAHAP group is accountable to the regional Chief pharmacists group.
The British Society of Antimicrobial Chemotherapy (BSAC) recommendations for AMS involve a three pillar approach to overcoming antimicrobial resistance (AMR), the first being optimising the use of existing antimicrobial agents1. Production of antimicrobial guidelines can help to optimise use of antimicrobial agents. NICE2 and BSAC1 state that empirical antimicrobial guidelines should be based on relevant national recommendations but also local microbiology, epidemiology and antimicrobial susceptibility.
Another driver of changes to antimicrobial use is the NHS England AMR CQUIN3. Due to the similar geographical locations of the YAHAP trusts, AMR trends for common infections are comparable and hence antimicrobial guidelines can be compared.
The YAHAP group decided to collate their local antimicrobial guidelines for commons infections regularly prescribed for within secondary care setting, to review for trends and variations between the trusts.
Antibiotic agents, routes and durations varied between the YAHAP group guidelines for CAP, HAP and urinary tract infections (UTIs). The graphs below show the variation in first line antibiotic agents used for HAP and UTIs within the YAHAP group.
The recommendations for broad spectrum intravenous antibiotics such as piperacillin/tazobactam for HAP differed between the trusts, with some more actively moving away from these agents, a drive influenced by good antimicrobial stewardship practice, the AMR CQUIN and supply issues. Nitrofurantoin was favoured as the first line choice for UTIs due to increasing resistance reported to trimethoprim, however 30% of the trusts still had this as their first line option. Variation in de-escalation guidelines and intravenous to oral switches were also apparent between guidelines.
Discussion and Action Plan
Collation of antimicrobial guidelines in Yorkshire and the Humber has allowed individuals in our region to benchmark their trusts against others and highlight potential antimicrobial guidance for review. It has facilitated a critique of national and local guidelines considering local resistance patterns. This allows production of exemplar antimicrobial guidelines for review among AMS teams, to facilitate optimum patient care in our region.
Standardisation between our trusts, to form a single antimicrobial guideline throughout the region, could aid junior doctor’s adherence to these guidelines, as they often move between the trusts and get confused between the differing recommendations. Challenges may arise in engaging local microbiologists and specialty teams to adopt a regional guideline and antimicrobial stock issues could be exacerbated if all the trusts adopted a single treatment pathway for these infections.
Methods
Over a 6 month period, representatives from all the regions trust submitted their current local antibiotic guidelines to a nominated member of the group to collate the antimicrobial guidelines for common infections, regularly prescribed for patients within secondary care trusts.
The guidelines collated within the YAHAP group included: community acquired pneumonia (CAP,) hospital acquired pneumonia (HAP) and urinary infections.
During YAHAP group meetings we evaluated the collated antibiotic guidelines. As expert pharmacists within this field, we began to analyse for trends and variations between the regional and national guidelines e.g. NICE and the British Thoracic Society (BTS) for CAP treatment.
References
British Society of Antimicrobial Chemotherapy. BSAC: Practical Guide to antimicrobial stewardship in hospitals. Hospitals.pdf (accessed 9th August 2018).
National Institute for Health and Care Excellence. NICE: Antimicrobial stewardship: Prescribing antibiotics. KTT9. (accessed 9th August 2018).
NHS England Antimicrobial Resistance 2017/19 CQUIN. (accessed 10th August 2018).