Apologies: Item Action Welcome and Apologies Membership changes Minutes of the previous meeting held on 20th June 2016.

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1 Confirmed Minutes of the Scottish Antimicrobial Prescribing Group Meeting Held on Monday 22 nd August 2016 Healthcare Improvement Scotland, Delta House, Glasgow Present: Professor Dilip Nathwani (Chair), Consultant Physician, NHS Tayside Dr Andrew Seaton, Consultant Physician, NHS Greater Glasgow and Clyde Dr Brian Cook, Medical Director, Acute Services, Royal Infirmary of Edinburgh Mrs Christine Gilmour, Chief Pharmacist, NHS Lanarkshire Mrs Alison Wilson, Director of Pharmacy, NHS Borders Professor Marion Bennie, Chief Pharmaceutical Advisor, National Medicines Utilisation Unit, Information Services Division Dr Gill Walker, Programme Director for HAI, NHS Education for Scotland Mr William Malcolm, Pharmaceutical Advisor, Health Protection Scotland Ms Julie Wilson, AMR Manager, Health Protection Scotland Dr Michael Lockhart, Medical Microbiologist, Health Protection (teleconference) Dr David Griffith, Consultant Microbiologist, NHS Fife Dr David Wilks, Consultant Physician, NHS Lothian Mr Samuel Whiting, Infection Control Manager, NHS Borders Mrs Jacqueline MacRae, Head of Quality of Care, Healthcare Improvement Scotland (HIS) Dr Stephanie Dundas, Consultant in Infectious Diseases, NHS Lanarkshire Ms Deirdre Harris, Nurse Consultant Infection Control, NHS Fife and Infection Prevention Society Ms Ysobel Gourlay, Lead Antimicrobial Pharmacist, NHS Greater Glasgow and Clyde Dr Linsey Batchelor, Consultant Microbiologist, NHS Dumfries and Galloway Dr Simon Hurding, Medicines Management Adviser, NHS Lothian Dr Conor Doherty, Consultant in Paediatric Infectious Diseases, NHS Greater Glasgow and Clyde Dr Busi Mooka, Infection Diseases Consultant, NHS Tayside Mrs Suzanne Clark, Public Partner Mrs Alison Cockburn, Antimicrobial Pharmacist, NHS Lothian Professor Andrew Smith, Professor and Consultant Microbiologist, NHS Greater Glasgow and Clyde and University of Glasgow Ms Anne Thomson, Lead Clinical Pharmacist Prescribing, NHS Greater Glasgow and Clyde Mrs Jo McEwen, Antimicrobial Nurse, NHS Tayside Mrs Alison Macdonald, Lead Antimicrobial Pharmacist, NHS Highland (Videoconference) In attendance: Dr Jacqueline Sneddon, Project Lead Scottish Antimicrobial Prescribing Group Professor Alistair Leanord, Senior Medical Adviser HAI, Scottish Government Mrs Abigail Mullings, HAI Professional Adviser, Scottish Government Dr Sian Robson, Information Analyst, Scottish Antimicrobial Prescribing Group Ms Susan Paton, Project Officer, Scottish Antimicrobial Prescribing Group Guests Ms Kim Kavanagh and Dr Jiafeng Pan from University of Strathclyde Dr Pauline Dunlop, Veterinary Advisor for CARS Dr Nicholas Reid, Principal Pharmacist, Antimicrobial Pharmacotherapy, NHS Ayrshire and Arran Dr Ursula Altmey, Consultant Microbiologist, NHS Ayrshire and Arran 1

2 Apologies: Ms Rachael Dunk, Team Leader, Safe Team, Chief Nursing Officer Directorate Dr Charis Marwick, Clinical Senior Lecturer, University of Dundee Mr Guy McGivern, Principal Information Analyst, Information Services Division Ms Clare Colligan, Antimicrobial Pharmacist, NHS Forth Valley Ms Andrea Patton, Information Analyst, Scottish Antimicrobial Prescribing Group Mr Howard McNulty, Public Partner Mrs Fiona McMillan, NES Pharmacy Mrs Lesley Shepherd, Nurse Consultant, Infection Control, Health Protection Scotland/Healthcare Improvement Scotland Dr Chloe Keane, Consultant Microbiologist, NHS Ayrshire and Arran Dr Gail Haddock, General Practitioner, NHS Highland Mrs Jill Nowell, Lead Prescribing Adviser, NHS Tayside Professor Ian Gould, Consultant Microbiologist, NHS Grampian and Scottish Microbiology and Virology Network Professor Alexander Crighton, University of Glasgow Dental School Dr Martin Connor, Consultant Microbiologist, NHS Dumfries and Galloway Dr Alexander Mackenzie, Consultant in Infectious Diseases, NHS Grampian Dr Adam Brown, Consultant Microbiologist and Infection Control Doctor, NHS Highland Item 1. Welcome and Apologies The Chair welcomed all present and advised of apologies and guests as noted above. The Chair requested that any member declarations of interest should be highlighted in advance of relevant items. 2. Membership changes The Chair advised of membership changes as follows: Susan Seigal, Public Partner, has stood down. Suzanne Clark, new public partner. Guy McGivern, Information Analyst ISD, as moving to new post based in Scottish Government. 3. Minutes of the previous meeting held on 20 th June The minutes of the meeting held on 20 th June 2016 were agreed subject to one minor amendment. 4. Matters Arising Nitrofurantoin course length - retrospective data. AS advised preliminary results from research project are showing no increase in repeat prescriptions with 3 days of nitrofurantoin compared with 5 or 7 day courses and that current thinking is to continue with three-day duration. A formal report will be shared with SAPG when the study is complete. WM advised that the NSS team could look at scaling up this work to national level using PIS. SAPG members agreed this would be helpful and it was agreed that this should be incorporated into the Infection Intelligence Platform future workplan. Aztreonam supply issues JS advised that following advice from national procurement the manufacturer BMS were contacted and have responded that they have increased their forecast Action 2

3 for usage in NHSScotland for the coming year. The company also advised that they are working to address the global supply problem. SAPG members that this issue will be kept live. Items for Discussion/agreement 5. Presentation Quantitative evaluation of Scottish Reduction of Antimicrobial Prescribing programme - presentation JP presented on the quantitative analysis of the impact of the SCRAP programme which commenced in 2013 and was rolled-out in a phased manner across several boards. The results showed the positive impact of ScRAP on prescribing rates and this was greatest in large practices and those with high prescribing rates. The Chair thanked JP for a conducting a difficult analysis and for an informative presentation. He also noted that the study output would benefit from broader dissemination, perhaps via the AMT event on primary care, and from creating some key learning messages 6. CDI HEAT target prescribing indicator report (Paper 1) The Chair asked members to note results to date and highlight any continuing issues with data collection. The Chair queried the lack of data for NHS Shetland and it was agreed that a supportive letter would be sent to the AMT Lead in Shetland. It was also suggested that making stronger links with Highland and Grampian to support Shetland with data collection could be included in the letter. Action: Letter to NHS Shetland DN/JS 7. Quality Indicators for Antibiotic use The Chair advised that the O'Neill short life working group will be taking place to discuss future targets for HAI and AMR and that two papers have been produced for discussion at SAPG in advance of the working group meeting. Primary care (Paper 2) WM proposed that the current approach of using best in class to reduce unnecessary antibiotic use in primary care would be retained but the baseline would be reset to Jan - March Based on reductions to date it is predicted that this would achieve a similar reduction in unnecessary prescriptions to that proposed in England. It was agreed that this methodological approach was reasonable and would support a high level percentage reduction Hospital Prescribing (Paper 2a) JS advised that this paper on the development of a quality indicator for acute hospital antibiotic use has now been updated to include discussions from the previous meeting of SAPG. It was agreed that the quality indicator will utilise the current CDI HEAT target measures and incorporate a quantitative element similar to that currently being used in England. The proposed baseline year is 2015 as this data is already available. Part A (quantitative element) It was highlighted that although national prescribing is increasing across hospitals Boards with lower rates of antibiotic use may struggle to make the required reductions. AS suggested, that total volume should be reported to put changes in context. SD 3

4 highlighted the risk of unintended consequences e.g. sepsis, and DW suggested that this data is needed to reassure clinicians. MB agreed that the Infection Intelligence Platform could facilitate a matrix of balancing measures but availability of national lab data is required to facilitate this. YG suggested that using admissions as a denominator requires some clarity and WM agreed to look into this further. Parts B & C (qualitative element) JS advised the proposed measures will be very similar to the CQUINS measures in England and will ustilise the current CDI HEAT target measures plus an additional data field on outcome of review.. Review of patients on IV antibiotics within 72 hours will support the quantitative measures by ensuring duration is not excessive. The relative merits of a quality improvement approach and a repeated audit approach were discussed. Members agreed that a quality improvement approach was the preferred option with several months of data collection in a ward until improvement is realised before moving on to another ward. As a long-term objective it is envisaged that clinical teams will engage with and participate in data collection and reporting to make stewardship everyone s business. Capacity for data collection was identified as a concern. The number of wards to include was discussed at length and it was agreed that initially 5% or 3 wards (whichever is greater) in each acute hospital and including one medical and one surgical ward.this process would be subject to review after 6 months. These new measures would replace the current CDI HEAT target measures and data would be collected via the SAPG app. Practicalities of how the data collection would be done would be agreed locally and could be incorporated into antimicrobial ward rounds if this is feasible. CD advised that for Paediatric wards such measures are not suitable as every child gets a daily review but clinicians are keen to be involved to improve practice. The Chair agreed that a flexible and meaningful approach needs to be developed for Paediatrics. CD welcomed this and agreed to discuss possible measures for paediatrics with colleagues and report back to SAPG. The Chair advised that recommendations from discussions would be communicated at the O Neill group meeting on Thursday. 8. Evaluation of the effectiveness of carbapenem and piperacillin-tazobactam (piptazo) prescribing guidelines within NHS Scotland: Quality improvement opportunity - review of alert policies (Paper 3) AC presented this paper detailing suggestions for strengthening alert policies to complement the paper at the last SAPG meeting on appropriate use of piptazo. AC discussed the robust alert policy in HS Fife that has also been adopted by NHS Highland but acknowledged such an approach may be more difficult to implement in larger boards. Following broad discussion it was agreed that while helpful to share the Fife model that alert policies were not the only way to optimise use of restricted antibiotics and that 4

5 the new quality indicators will support boards in controlling use of these agents. Communication to AMTs should provide SAPG advice about not using piptazo as first line treatment except for neutropenic sepsis. Action: Prepare advice for AMTs on piptazo use AC/JS 9. Gentamicin dosage in endocarditis (Paper 4) The Chair advised that the paper had been circulated to SAPG members as this guidance exists in GG&C and antimicrobial pharmacists had suggested it may be helpful to adopt it as national guidance. It was agreed that the guidance was useful particularly for patients with impaired renal function but the supporting evidence base should be included. JS agreed to contact Alison Thomson concerning evidence and add this to the guidance. Action: Contact Alison Thomson regarding evidence Action: Prepare SAPG version of good practice guidance for website JS JS 10. Amikacin dosage (Paper 5) Similar to the gentamicin in endocarditis guidance this guidance from GG & C was suggested as being useful to have as national good practice guidance. SAPG members agreed that this guidance was also helpful as amikacin is rarely used in many boards but this paper also requires the addition of supporting evidence. YG advised that she would send the supporting evidence to JS. Action: Prepare SAPG version of good practice guidance for website JS 11. Informatics Information Data Visualisation (Paper 6) WM advised that at the AMT event in June there had been presentations on NSS data visualisation platforms and discussions on how to utilise them to share the IIP outputs and other SAPG data. This paper presents a brief stock take of where this work is at present and plans for the future. WM advised that data visualisation in the form of infographics has been included in the AMR report on 2015 data. The Chair advised that a Scottish version of the Public Health England Fingertips portal had been discussed and AL advised that SG have commenced a piece of work in this area with HPS and SARHAI endorsement. The work is in early stages and requires discussions with ISD and SG performance colleagues on how to operationalise. The vision is for all HAI data to be accessible on one site and timelines will be shared once known. Action: Update on progress at future meeting AL Items for update 12. Annual report on antimicrobial use and resistance in humans 2015 WM advised that the annual report will be published on the 30th August. The format is very similar to last year's report with a brief narrative paper and detailed appendices. 5

6 WM advised that an early draft had been circulated to the SAPG Project Board members and feedback had informed the final report. Pre-release of the embargoed document will be shared with SAPG members. 13. National Point Prevalence Survey WM advised that he has spoken to the team leading the implementation of the national PPS and training is well underway. The data collection will commence 1st September and will run through September, October and November. 14. Personalised GP Feedback Reports WM advised the system is set up and the first two quarterly reports have been sent to 200 practices. The content of the next two reports are planned and an evaluation of impact will follow in Antmicrobial App JS advised that the antimicrobial app was launched on 1st August. Feedback has highlighted minor issues that have been corrected promptly. Boards will have the facility to customise by adding their own local guidance. Teleconferences will be taking place with the App administration leads in Boards to discuss the audit tool and how this can be further developed. JS asked members that if there are any additional issues to contact the SAPG secretariat. JS advised that later this year an editing and governance meeting will be organised with the administration leads. 16. Evaluation of education workbook for nurses and midwives The Chair noted that the workbook was included in the recent HAI bulletin. GW advised that the evaluation company have started engaging with staff in Boards to ascertain how the workbook has been promoted and used. They will then conduct focus groups and interviews within the four pilot implementation Boards and two other Boards. There has been an issue with the workbook not being on learnpro that has now been resolved. The workbook will continue to be a document for use in the workplace but users can now sign up via learnpro at commencement and sign off when finished allowing boards to have a record. GW is also now engaged with pre reg nursing education providers across Scotland on a formal basis around antimicrobial stewardship and national slides will be provided with voiceover by Jo McEwan. The Chair thanked the nursing in stewardship team for their work. 17. UK AMR Strategy. AL advised that the next meeting will take place in two weeks and there will be an update for the next meeting of SAPG. 18. Controlling Antimicrobial resistance in Scotland (CARs). AL advised that the CARS Group would not be meeting again until the end of September. CARS will have four workstreams and AL advised that work is progressing quickly on the animal health side. The Chair asked for an update on progression of this work when available. MB highlighted that going forward the strategy for human adults, 6

7 children and animal health reporting needs to be discussed. AL advised that he will update on this further at the December meeting of SAPG. 19. European Antibiotic Awareness Day JS advised that planning is progressing and that antimicrobials have a Community Pharmacy Campaign slot running from October until November. A new poster has been designed and the antibiotic guardian leaflet and poster will also still be available. Items for information 20. Standing item antimicrobials submitted to the Scottish Medicines Consortium JS advised that Fosfomycin sachets are now available in the UK and SMC advice (accepted for use) will be in the public domain from September. This advice has already been communicated to NHS Board Area Drug and Therapeutics Committees. 22. AOCB JS advised that a survey on providing advice on antimicrobial treatment has been received from ESCMID requesting responses from infection specialists. JS has shared the survey with SAPG members and AMT Leads for onward local dissemination. 23. Date of next meeting Date of next meeting is Monday 17 th October 2016 at 12:30 in Delta House, Glasgow. The following meeting will take place on Monday 19 th December 2016 in Delta House, Glasgow. 7