Dilip Nathwani Ninewells Hospital & Medical School Dundee, Scotland DD1 9SY,SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG) 2008,Where are we now and why?,Antimicrobial Prescribing Facts, 1/3 of all hospitalised inpatients at any given time receive antibiotics up to 1/3 to are inappropriate up to 30% of all surgical prophylaxis in inappropriate Antimicrobials account for upwards of 30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets. Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life,“The desire to ingest medicines is one of the principal features which distinguish man from the animals”Osler W.Aecquanimitas,1920,OVERUSE,Why So Many Mistakes,High number and complexity of drugs High number and complexity of syndromes and pathogens Poor training in antibiotic use Variability over time and place in - pathogen prevalence - antibiotic susceptibilities - antibiotic formularies,Interventions to improve antibiotic prescribing practices for hospital inpatients Cochrane Systematic Review,i.gould courtesy,Antibiotic use and resistance in the hospital,MRSA: temporal series (Aberdeen, 1996-2000),Monnet et al. Emerg Infect Dis 2004; 10:1432-41,What is Antimicrobial Stewardship?,A marriage of infection control and antimicrobial management Mandatory infection control compliance Selection of antimicrobials from each class of drugs that does the least collateral damage Collateral damage issues include - MRSA - ESBLs - C.difficile - stable derepression - MBLs and other carbapenemases - VRE Appropriate de-escalation when culture results are available,Dellit TH et al Clin Infect Dis 2007; 44: 159-177,How can we reduce consumption, improve quality of prescribing and reduce resistant transmission?,Antibiotic Use,By Patient-staff-patient Patient-patient ?Patient-environment / equipment patient,The Vicious Spiral,Must get right at all cost Inadequate rapid test Lack of faith in tests Defensive medicine Patient expectations Poly-pharmacy Increased prescribing & empiric Rx, cost Resistance C.difficle use of new drugs Use of broad spectrum drugs,Managing risk of empiric therapy,“Many clinicians regard the right to prescribe antibiotics freely (unrestricted) as a basic human right” However“The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk to the patient, ecology and other patients of broad spectrum antibiotic use, particularly C.difficle in the most vulnerable group “The organisation needs to risk manage this conflict and help with solutions “,APP&P KEY DOMAINS FOR RECOMMENDATIONS 2006,SMC SLWG Document communicated by CMO to all NHS Boards 2006,Medical Director,Chief Executive,Infection Control Manager,Drugs & Therapeutics Committee,Antimicrobial Management Team (AMT),Speciality-based Pharmacy leads for APP&P with responsibility for antimicrobial prescribing,Ward Based Clinical Pharmacists,Risk Management Committee,Clinical Governance Committee,Infection Control Committee,Microbiologist / Infectious Diseases Physician,PRESCRIBER,Prescribing support / feedback,Dissemination & feedback,http:/www.scotland.gov.uk,KEY ROLE OF AMT,Antimicrobial management team,Multi-disciplinary team Resourced Supported Multi-faceted interventions (consistently more effective then single interventions) Active team at the coalface,Core Interventions Formulary + restrictions (expert approval) Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences,THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL RESISTANCE ACTION PLAN,ScotMARAP 2007,ScotMARAP Output,3 year programme of work launched on the 17th of March 2008 Total funding of 1.2 million and allocation split between key stakeholders SMC asked to convene, host and service national clinical forum SAPG,SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG),The primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum” as expressed in the APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).,Scottish Medicines Consortium,Scottish Antimicrobial,rescribing,Group,Health Protection,Scotland,NHS Education for,Scotland,NHS Boards Area Drug and,Therapeutics Committees,NHS Quality,Improvement Scotland,NHS Boards Antimicrobial,Management Teams,Clinical Governance,Risk Management,Infection Control Team /,Manager,Prescribers,Reference,Diagnostic,Services,NHS Boards Antimicrobial Management,Team Sub,-,Group of Scottish,Antimicrobial Prescribing Group,Scottish Patient,Safety Alliance,Information Services,Division,Local,Diagnostic,