Confirmed Minutes of the Scottish Antimicrobial Prescribing Group Meeting Held on Monday 19th th December 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 Mr William Malcolm, Pharmaceutical Advisor, Health Protection Scotland Ms Julie Wilson, AMR Manager, Health Protection Scotland Dr Charis Marwick, Clinical Senior Lecturer, University of Dundee Professor Ian Gould, Consultant Microbiologist, NHS Grampian and Scottish Microbiology and Virology Network Dr Gail Haddock, General Practitioner, NHS Highland. Videoconference 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 Dr Linsey Batchelor, Consultant Microbiologist, NHS Dumfries and Galloway Mrs Suzanne Clark, Public Partner Mrs Alison Cockburn, Antimicrobial Pharmacist, NHS Lothian Ms Anne Thomson, Lead Clinical Pharmacist Prescribing, NHS Greater Glasgow and Clyde Dr Robbie Weir, Consultant Microbiologist, NHS Forth Valley Dr Ursula Altmeyer, Consultant Microbiologist, NHS Ayrshire and Arran Dr Simon Hurding, Medicines Management Adviser, NHS Lothian Dr Conor Doherty, Consultant in Paediatric Infectious Diseases, NHS Greater Glasgow and Clyde Dr David Griffith, Consultant Microbiologist, NHS Fife Mrs Jo McEwen, Antimicrobial Nurse, NHS Tayside Mr Howard McNulty, Public Partner Mrs Fiona McMillan, NES Pharmacy Dr David Wilks, Consultant Physician, NHS Lothian Dr Adam Brown, Consultant Microbiologist and Infection Control Doctor, NHS Highland, Videoconference Dr Busi Mooka, Infection Diseases Consultant, NHS Tayside Mrs Jo McEwen, Antimicrobial Nurse, NHS Tayside Mr Howard McNulty, Public Partner Mrs Suzanne Clark, Public Partner In attendance: Dr Jacqueline Sneddon, Project Lead Scottish Antimicrobial Prescribing Group Dr Sian Robson, Information Analyst, Scottish Antimicrobial Prescribing Group Ms Andrea Patton, Information Analyst, Scottish Antimicrobial Prescribing Group Ms Susan Paton, Project Officer, Scottish Antimicrobial Prescribing Group 1
Guests Mrs Gillian Orange, Chair of the Scottish Microbiology and Virology Network. Ms Nykoma Hamilton Infection Control Nurse, NHS Fife Mr Eddie McArdle, AMR Data Manager Mrs Hazel Smith, Horizon Scanning Administrator, Scottish Medicines Consortium Dr Nicholas Reid, Association of Scottish Antimicrobial Pharmacists from Ayrshire and Arran Mr Abdul Mohana, PhD pharmacist, University of Strathclyde (Carbapenems study) Apologies: Professor Alistair Leanord, Senior Medical Adviser HAI, Scottish Government Mrs Abigail Mullings, HAI Professional Adviser, Scottish Government Dr Gill Walker, Programme Director for HAI, NHS Education for Scotland Ms Rachael Dunk, Team Leader, Safe Team, Chief Nursing Officer Directorate Dr Michael Lockhart, Medical Microbiologist, Health Protection Ms Ysobel Gourlay, Lead Antimicrobial Pharmacist, NHS Greater Glasgow and Clyde Ms Rita Nogueira, Senior Information analyst, Information Services Division Professor Andrew Smith, Professor and Consultant Microbiologist, NHS Greater Glasgow and Clyde and University of Glasgow Professor Alexander Crighton, University of Glasgow Dental School Mrs Lesley Shepherd, Nurse Consultant, Infection Control, Health Protection Scotland/Healthcare Improvement Scotland Mrs Jill Nowell, Lead Prescribing Adviser, NHS Tayside Dr Martin Connor, Consultant Microbiologist, NHS Dumfries and Galloway and Infection Control Doctors group Dr Alexander Mackenzie, Consultant in Infectious Diseases, NHS Grampian Mr Samuel Whiting, Infection Control Manager, NHS Borders Item 1. Welcome and Apologies The Chair welcomed all present and advised of apologies and guests as noted above. 2. Declaration of interests The Chair requested that any member declarations of interest should be highlighted in advance of relevant items. 3. Membership changes and announcements The Chair advised there have been no membership changes since the last meeting. Dr Nicholas Reid, Past Chair of Association of Scottish Antimicrobial Pharmacists is leaving NHS Ayrshire and Arran to take up a new post as All Wales Consultant Antimicrobial Pharmacist. The Chair thanked Nik for his contribution to SAPG over the past 8 years. Following a successful interview Dr Andrew Seaton has been appointed as the new Chair of SAPG and will take up this position on 1 st April 2017. 4. Minutes of the previous meeting held on 17 th October 2016. The minutes of the meeting held on 17 th October 2016 were agreed. Action 5. Matters Arising Guidance on Gentamicin dosage in Endocarditis and Amikacin dosage 2
JS confirmed that these documents developed by NHS Greater Glasgow and Clyde and approved by SAPG for use in other boards is now available on the secure area of the SAPG website. Antimicrobial Management Team (AMT) leads and antimicrobial pharmacists have received log in details to access them. Anyone else who requires access should contact SP to set this up. Use of oral fosfomycin JS advised that a communication has now been sent to AMT Leads about the recently launched fosfomycin product and also shared with colleagues from the medicines team in Healthcare Improvement Scotland for communication via their Area Drug and Therapeutics Committee Collaborative newsletter. SBAR on Piperacillin- tazobactam use. JS confirmed the SBAR has now been sent to AMTs. Update on new Healthcare Environment Inspectorate measures. JMac advised that the proposal to inspect hospitals against the recommendations of the Vale of Leven Enquiry Report will not be progressed. A revised broader inspection programme is under development, this will include antimicrobial measures, and JMac will update SAPG once plans have progressed further. Action: Update on new Healthcare Environment measures at future meeting of SAPG. Website JS updated that discussions have taken place on improvements to the SAPG website with recommendation being that SAPG should have its own website separate to the SMC one. JS confirmed that a further update be available in early 2017. Data Visualisation WM advised that he understood that SARHAI have considered and approved a proposal to use Discovery and NHS Inform to host an Infection portal to make all information on HAI and AMR available to NHS boards and the public respectively. Preparatory work is expected to begin in 2017-18. JMac Items for Discussion/agreement 6. SAPG guidance Initial management of neutropenic sepsis (Paper 1) JS advised this guidance has been discussed already at SAPG and comments have now been received from Haematology colleagues. The main change to the guidance is using a NEWS cut-off score of 6 to differentiate standard risk from high risk. Other changes include a maximum gentamicin duration of 3 days without review, reminders about always taking blood cultures, and not using ciprofloxacin for treatment if used for prophylaxis as there may be a risk of resistance. JS advised that as no further comments from SAPG members this version will be uploaded onto the SAPG website. 3
Good Practice recommendations for hospital antimicrobial stewardship in NHS Scotland. (Paper 2) AS advised that there are no major changes and asked members for any comments. JS advised one comment received that doripenem is no longer available and should be removed. HM queried whether parallel guidance would be produced for general practice. JS advised that primary care guidance follows the Public Health England template for management of infections therefore SAPG have not produced this. Action: Minor amendment and proceed with uploading to SAPG website. JS/SP Staph. aureus bacteraemia (SAB) algorithm and SAB Quality Indicators (Papers 3 and 4) The Chair asked for comments from SAPG members. CM queried treatment duration of 10-14 days in paper 4. AS advised that when the quality indicators were developed consensus was not reached on a specific duration therefore it has been left to local decision. SAPG members agreed that duration of IV therapy should be 14 days. Utilisation of the quality indicators was discussed and members confirmed that although these measures are relevant and important they were not widely used due to issues with data collection. JS advised that she has discussed SAB enhanced surveillance with Laurie Imrie, Nurse Consultant Infection Control, Health Protection Scotland and confirmed that two of the quality indicators (source and vascular device) are now part of the national mandatory surveillance programme. Data is collected on all patients with a SAB using an electronic form and HPS collates the data. It may be possible to add details of antibiotic treatment to this form. There are plans to make the SAB data available via the Discovery platform and also for data linkage work to evaluate recurrence rates and other clinical outcomes. Following broad discussion on systems for collection of enhanced surveillance data in boards it was agreed that different models are in place and it would be useful to explore how the additional information about antibiotic treatment and infection specialist review could be captured via the existing process. Infection Control colleagues agreed to discuss within their groups and report back. Action: Consult with infection control community on SAB data collection DH/GO The item on SAB audit by YG will feature at the next SAPG meeting. 7. NHS Highland Lyme Disease Guidance. (Paper 5) AB presented guidance produced by NHS Highland, which provides practical advice and builds on the 2011 position statement by the British Infection Association. DW commented on the lack of evidence for treatment duration. The Chair suggested that SAPG had not previously developed guidance on a particular infection therefore queried whether this was a SAPG role. It was also noted that PHE produced Lyme disease guidance including a referral pathway in 2014. It was agreed that the NHS Highland guidance was a useful document for other boards and that it could be improved with the addition of stewardship principles. The most appropriate use for the 4
guidance would be as a reference document hosted on the SAPG secure site but would not be badged as SAPG guidance. Action: Revise as discussed and re-visit at next SAPG meeting for sign off AB Items for Update 8. UK AMR Strategy AL apologies update at next meeting 9. Controlling Antimicrobial Resistance in Scotland (CARS) update. AL apologies update at next meeting 10. Proposal for new antimicrobial prescribing quality indicators progress within Scottish Government. JS updated that the SAPG proposal was accepted by SARHAI and will now be considered by a Performance Standards short life working group chaired by Sir Harry Burns. AL will be meeting with HB on the 19 th January 2017 to discuss and will advise SAPG after this meeting. SH advised that national therapeutic indicators are agreed and the primary care quality indicator will continue with a revised baseline period of Jan-March 2015. Action: Agenda item for February meeting of SAPG SP 11. Antimicrobial app. further development JS advised that the qualitative measures supporting the proposed new quality indicator for hospital prescribing are already collected and the additional outcome of review measure will be incorporated into the app audit tool. The Chair queried when the additional measure would be available and JS confirmed it will be ready early in 2017 for testing and implementation in 2017-18. 12. National Point Prevalence Survey WM advised that Shona Cairns has reported that data collection is complete in all hospitals, the first local board reports are completed and the process of distribution has commenced. Reports are going out in the order the data came in and will be complete middle to end of January. A meeting will be taking place tomorrow with HPS to discuss the national PPS report on antimicrobial prescribing. 13. Carbapenems Study interviews with clinicians. (Paper 6) AC presented the key messages from interviews with clinicians carried out by Abdul Mohana in 4 board areas. Meropenem started by specialists but often no specialist follow up after initiation and attending teams lack confidence to de-escalate treatment. Education of clinicians on reasons for protecting carbapenems and use of alternative agents highlighted as a learning need. review. Following broad discussion it was agreed that identifying patients who have been prescribed meropenem is problematic in some boards and there was agreement that mandating review of meropenem prescriptions 5
by 72 hours would be beneficial. The practicalities of making this mandatory were discussed and the potential to use the app to collect data to support this. The Chair suggested that AMTs should consider how mandatory meropenem review could be implemented locally and bring back for further discussion at the February SAPG meeting. Action: Discussion of meropenem review at February SAPG All 14. Evaluation of education workbook for nurses and midwives. JS advised that an external evaluation is taking place of workbook uptake and completion. Initial results suggest better uptake in boards who received support for implementation but numbers completing the resource are still low. The main barrier highlighted has been lack of time and comments also highlighted that the workbook is hospital focused. A funding bid has been submitted to add a community section and JMcE advised she would be working with care homes over the next 6 months to inform this. The final report will be shared with SAPG at the next meeting. 15. Urinary tract infection - Revision of Scottish Reduction of Antimicrobial Prescribing (ScRAP) resource (Paper 7) AT advised that the paper details the revised resource, which comprises 6 learning sessions of 30-60 minutes. The three new sessions on UTI were piloted in 3 boards and feedback was good. Currently graphic design is underway and plan is that the resource will be finalised by end of January 2017. The launch ideas have been a Webex with stakeholder groups and a brief discussion has taken place with SH to feature in the national GP cluster quality leads event in February 2017. CD highlighted that paediatric UTI does not feature and advised there are increasing problems with resistance. AT advised much of information is applicable to all patient groups and signposting to resources for specific populations such as paediatrics is included. - PHE & RCGP Urinary Tract Infection leaflet SAPG endorsement (Paper 8) JS advised that the document produced by Public Health England and the Royal College of GPs is based on the format of the respiratory tract infection self-care guide for patients. JS advised that many comments have already been submitted via the Scottish UTI Network and this final version is now on the website. SAPG members highlighted several areas for improvement and clarity of language. JS advised that any further comments should be sent to her for collation and submission to PHE to inform the next review of content. PHE have asked via Cliodna McNulty if SAPG would endorse the leaflet. SAPG members agreed to endorse it subject to comments being addressed. Action: Send comments on leaflet to JS All 6
Action: Collate comments and send to PHE - Choice of antibiotic and course length for urinary tract infection. WM advised duration of UTI treatment with nitrofurantoin has been discussed with PHE colleagues as they are keen to review any surveillance data from Scotland along with the meta analysis suggesting longer course lengths are more effective. Data from Glasgow presented at the Federation of Infection Societies does not support a longer course length and WM advised that analysis of national data is planned in 2017-18. PHE has decided to leave their recommendation as 3 days for now pending further data. First line antibiotics for UTI were also discussed as in England nitrofurantoin rather than trimethoprim is recommended due to concerns about resistance. However, published data from Wales and a study in press from England and several European countries suggest that trimethoprim resistance is primarily an issue in elderly females. SAPG members agreed that trimethoprim would remain a first line antibiotic for UTI in Scotland until evidence of resistance and its impact on outcomes of empirical therapy has been fully evaluated. JS 16. National Prescribing Safety Assessment. JS advised that she and AM have been commissioned to write 10 questions each. Several volunteers have offered to help and a conference call took place to discuss topics. The submission deadline has been extended until the end of January. The Chair advised that good quality questions could result in a sub section in the exam but if we do not show enthusiasm we may lose this. CD offered to provide some Paediatrics questions. JS advised if anyone else wishes to contribute, they should contact her to receive a copy of the question manual and instructions on question format required. 17. Antimicrobial stewardship competency framework for medical undergraduate JS advised that a response has been received from Professor Rona Patey. She has advised that the Undergraduate Deans are supportive of the framework, have no suggestions to modify it and have now passed to curriculum Leads to implement. The Chair advised pharmacy schools have embraced stewardship and the Deans of Nursing have also been approached to offer help with stewardship content. JMcEw advised NMC have recently highlighted priority areas and stewardship is one of them. 18. Update from the Federation of Infection Societies (FIS) Conference. JS advised the conference was useful and the next FIS conference will take place in Birmingham at the beginning of December next year and stewardship will feature heavily. Advised now for SAPG members to think about for planning for next year. 19. European Antibiotic Awareness Day 2016 - Plans for evaluation JS updated that evaluation surveys have been developed for the Community Pharmacy Public health campaign leading up to EAAD, Public Partners involved in board activities 7
and AMTs. This will allow us to capture details of activities, provide ideas for EAAD 2017 and gauge the level of engagement of patients and public. - Public Partner involvement SC advised she attended the new children s hospital to help with EAAD and it was a fun day with colouring sheets and crayons and information for parents. Most staff accepted quizzes and information and many tried the hand cleanliness machine. A snot machine which showed children how far their snot goes when sneezing was popular. HM attended the Golden Jubilee and new children s hospital and experienced two different days. HM advised he has some suggestions which he has forwarded to SP. AS noted that EAAD has grown significantly on social media and world antibiotic week has also increased interest. The Chair congratulated all involved. 20. Antimicrobial Management Team national network events Evaluation of primary care event 1st November 2016 JS advised the November event focused on primary care. About 20 GPs attended and feedback was good, particularly about CD s talk on paediatrics. A few negative comments were received about the catering 14 th March 2017 AMT event programme. Proposed topics for March event include sharing informatics outputs and sharing AMT quality improvement work. The date clashes with the BSAC Spring meeting in London but agreed that it will go ahead as only a few members attending BSAC meeting. 21. 22. Items for information NICE Guidance on common infections https://www.nice.org.uk/guidance/indevelopment/gid-ng10050/consultation/htmlcontent JS advised this is being included for information to highlight the guideline being developed which is going to cover both hospital and primary care. Recent SMC advice Dalbavancin has been accepted for restricted use - NHS boards have received this information in confidence and the advice will be published on the SMC website in January 2017. 23. AOCB Access to antibiotics Online access to antibiotic supply WM advised that he has received several queries about on-line supply of antibiotics and enquired whether SAPG could do anything to raise concerns about this. Following broad discussion of the issues with various virtual routes to antibiotic supply it was agreed that SAPG should explore whether the General Pharmaceutical Council could provide advice. Action: Contact GPhC to communicate concerns WM/JS Sore throat test and treat pilot. 8
JS advised that details of an innovation fund study which was carried out in Boots Yorkshire area community pharmacies using Strep A swab test to triage patients presenting with a sore throat. Media advised the test and treat model was going to be spread throughout England which incorrect and this resulted in several queries in Scotland. Advice on the position in England has been shared with pharmacy colleagues. Patient Group Directions for UTI and other conditions Following the development of a framework for antibiotic supply by community pharmacists via PGD which was considered within the Out-of-hours Review a funding bid has now been submitted by the Directors of Pharmacy to Scottish Government to support national implementation. This will initially cover supply of antibiotics for UTI and impetigo. BNF Dosage information JS advised that following many years of debate the BNF has now revised the recommended dosage of metronidazole for dental infections to 400mg tid (previously was 200mg tid). Rarely used medicines list JS asked for SAPG members advice on the addition of flucytosine to the Rarely Used Urgent Medicines List. This follows a request from National Procurement. Medicines on this list are defined as being required within a 4 hour time period and national stock is procured and stored in location(s) to support this. It was agreed that flucytosine was required for cryptococcal meningitis and that treatment should commence the same day diagnosis is made, Glasgow and Edinburgh were the suggested storage sites. JS confirmed that Pharmacy systems are in place to locate medicines on the list and there is a procedure for transporting supplies. SAPG Vice Chair JS advised that as AS is taking over as Chair on 1 st April 2017 this leaves the medical Vice Chair position vacant. The Vice Chair appointment process has changed since the Chair is now appointed through advert and formal interview. There is now no assumption the Vice Chair will become Chair, rather the role will be supporting the Chair. The new process is the same as that used by SIGN process and group members can nominate themselves. If there is more than one nomination then SAPG members will vote on the preferred candidate. SP will send out the nomination form to SAPG members via email. 24. Date of next meeting Date of next meeting is Friday 17 th February 2017 at 12:30 in Delta House, Glasgow. 9
The following meeting will take place on Friday Tuesday 18 th April 2017 in Delta House, Glasgow. 10