Evaluation of the effectiveness of carbapenem and piperacillin- tazobactam prescribing guidelines within NHS Scotland

Alison Cockburn Abdulrhman Mohana,

SAPG Carbapenems Study Project Manager PhD candidate, Lead Antimicrobial Pharmacist University of Strathclyde NHS Lothian Agenda

. Background

. Survey and NAS-PPS key results

. Clinician interviews – key findings

. Recommendations Quality Improvement Approach

. Survey of implementation of prescribing guidance in boards . Point Prevalence Survey (PPS) of carbapenem and piperacillin-tazobactam use in Scottish acute hospitals . Case studies to investigate best practise in use of these agents Survey Key Results Summary

. Prescribing restrictions – for Meropenem, less for Piptaz

. Authorisation restricted to micro/ID for Meropenem but junior clinicians also authorise Piptaz

. Supplies freely available for Piptaz, not for Meropenem

. Low level of laboratory result suppression

. Small range of Carbapenem-sparing antibiotics available BSAC National Antimicrobial Stewardship Point Prevalence Survey system (NAS-PPS) Compliance With Antibiotic Policy

Compliance high for meropenem, lower for piperacillin-tazobactam Documentation Of Indication

High level of documentation of Indication for meropenem,slightly lower level for piperacillin- tazobactam Documentation Of Review/Stop Date

Review/stop dates poorly documented in most boards for both meropenem and piperacillin-tazobactam Conclusions – Meropenem:

. Meropenem is subject to prescribing restrictions in most boards and compliance with antibiotic policies is high – Alert Antibiotic Policies . Indication for use is well documented but review/stop dates were poorly documented . Access mechanisms are in place in most boards and 60% boards use automatic suppression of lab reporting . Low use of carbapenem sparing agents in boards Conclusions: Piperacillin-tazobactam . Piperacillin-tazobactam is not subject to prescribing restrictions in most boards and compliance with antibiotic policies is much lower (only 4 boards in top quartile) . Indication for use was well documented in most boards but review/stop dates poorly documented in the majority . Freely available for use using a variety of mechanisms, only a minority of boards routinely suppress reporting by the laboratory In-depth case studies to understand levers and barriers for prescribing Meropenem and Carbapenem-sparing agents

Presented by: Abdulrhman Mohana, PhD candidate Supervised by: Professor Alexander Mullen & Professor Marion Bennie Method

Setting: Four health boards were selected; Fife, Forth Valley, Tayside, GGC; based on: • Overall performance in survey and NAS-PPS (part one & two) • Reduction in meropenem or increase in carbapenem-sparing antibiotic consumption between 2008 and 2014

Study participant: • Consultants within the selected health boards and senior/junior doctors were recruited from different specialities. • 28 one-to-one, semi-structured interviews, conducted between June - November 2016 • Interview times between 16 to 30 minutes Major themes

Initiation Continuation Improvements

• Local guidelines • Formal review •Auditing and policies • Documentation • Prescribers • De-escalation •Piptaz use • Patient related • Cultures & factors sensitivity •High risk wards • Carbapenem- sampling & sparing agents reports •Communication prescribing levers •Education needs Initiation

Meropenem and Carbapenem-sparing “Meropenem doesn't have a “Meropenem is place in the guidance except prescribed on for febrile neutropenia”… ID recommendationPatient related System Prescribers Senior registrar base only”… factors Consultant General “Aztreonam is in our Micro Surgery Guidelines empirical prescribing reports guidelines. Temocillin we've “Carbapenem- used as well, again it's in our sparing based on Policies and Advice from prescribing guidelines”… culture and restriction Micro/ID Medicine Senior registrar sensitivity”… Care of elderly consultant Senior Carbapenem-sparing agents

Levers of prescribing Carbapenem-sparing

“There's“… people been don'ta lot moretend to be Local system temocillinaware ofand them aztreonamKnowledge and they are recommended,rarely, if ever, and suggested it's made by the its waymicrobiologist on to the empirical as an alternative when you're phoningDrugs up and System Prescriber guidance, empirical treatment, andasking… from there they're we feltnotprofile moreon their comfortableroutine sensitivity using it”… reports ”… MedicineAcute careSenior consultant registrar Guidelines Education Microbiology reports Logistics “I think“…if havingI'm being them told embedded by Micro/ID advice in themicrobiology empirical guidelines they've got is a bug Leadership and AMT verythat's helpful that”… sensitive ID Experienceconsultant to... then I'll AMT happily go with thatof use”… Communication Haematology Consultant Continuation

Meropenem Follow-up & monitoring “I think it's not very well documented as “Confidence in the use of oral duration of Prescriptionalternatives to Meropenem. Whether treatment” Documentation“We advise the De-escalation pivmecillinamreview is effective …and how … Medicine Senior fosfomycin can be used orally or IV I consultant to registrar think that's difficult”… ID consultant prescribe it. We wouldn't necessarily“We're not as good as see the patient “I think on some occasions it's not Duration putting a durationLack of as Once only quite clear where you go to plan again… If you havewe should confidencebe” deescalate from Meropenem… I think any concerns about… Micro consultant better guidance on ... where to go the patient at that following Meropenem would benefit point, call us back” ...”… FY2 Medicine … Micro consultant Areas for improvement

“…they shouldn't“It would bebe agreat free -tofor have- a all, theyrobust should generic come under way to have “If the clinician doesn't pick up the controlledpost drugs…should prescribing review” be … ID Initiation Improvements phone to speak to the Continuation supervisedconsultant”… Respiratory microbiologist, then the • Local guidelines • Formal review consultant •Auditing microbiologistand policies will not know about• Documentation “…not sending off enough them”… General surgery consultant • Prescribers • De-escalation “…thereclinical should specimensbe• anTazocin advice usebefore • Patient related • Cultures & about forantibiotic how long therapy or when is initiatedthis “I mightfactor be the big Meropenem sensitivity would needincreases to be thereviewed•High likelihood risk wardsso that user…• notCarbapenem my other- colleagues”… IDsampling & that it isyou not will just treat about without starting sparing agents consultant reports an antibioticknowing when what• Communicationyou the choose prescribing it, but also about reviewing it levers infection”…ID consultant “…focusing on the areas where it's right from the beginning•Education”… need used most”… Respiratory consultant Anaesthesia“...I'm consultant not sure meropenem or tazocin are on the IV/oral policy”… FY2 medicine Summary of key issues

• Clinicians rely on infection specialists for advice on initiation and continuation/de-escalation - lack of confidence amongst clinical teams

• Overuse of ultra-broad spectrum agents acknowledged but tools to support review and de- escalation/IVOST required – formal review

• Lack of awareness and confidence amongst clinicians in using carbapenem-sparing agents unless within local guidelines and/or microbiology reports