Confirmed Minutes of the Scottish Antimicrobial Prescribing Group Meeting Held on Monday 17 th October 2016 Healthcare Improvement Scotland, Delta House, Glasgow Present: Professor Dilip Nathwani (Chair), Consultant Physician, NHS Tayside Mr William Malcolm, Pharmaceutical Advisor, Health Protection Scotland Ms Julie Wilson, AMR Manager, Health Protection Scotland Dr Michael Lockhart, Medical Microbiologist, Health Protection Dr Charis Marwick, Clinical Senior Lecturer, University of Dundee Mr Samuel Whiting, Infection Control Manager, NHS Borders Professor Ian Gould, Consultant Microbiologist, NHS Grampian and Scottish Microbiology and Virology Network Dr Gail Haddock, General Practitioner, NHS Highland 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 Alexander Mackenzie, Consultant in Infectious Diseases, NHS Grampian 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 Ms Rita Nogueira, Senior Information analyst, Information Services Division Dr Ursula Altmeyer, Consultant Microbiologist, NHS Ayrshire and Arran Mrs Lesley Shepherd, Nurse Consultant, Infection Control, Health Protection Scotland/Healthcare Improvement Scotland 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 Guests Ms Jo Johnston, Prescribing Support Pharmacist Mrs Gillian Orange, Chair of the Scottish Microbiology and Virology Network. Ms Jean Sneddon, Principal Information Development Manager (IIP Service / Programme Manager) Ms Jenny Armstrong, Information Analyst, Prescribing Team, ISD Mr Craig Collins, Principal Information Analyst, Prescribing, ISD Apologies: 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 1
Professor Marion Bennie, Chief Pharmaceutical Advisor, National Medicines Utilisation Unit, Information Services Division Dr Linsey Batchelor, Consultant Microbiologist, NHS Dumfries and Galloway Professor Alistair Leanord, Senior Medical Adviser HAI, Scottish Government Mrs Abigail Mullings, HAI Professional Adviser, Scottish Government Dr Simon Hurding, Medicines Management Adviser, NHS Lothian Dr Conor Docherty, Consultant in Paediatric Infectious Diseases, NHS Greater Glasgow and Clyde Dr Gill Walker, Programme Director for HAI, NHS Education for Scotland Ms Rachael Dunk, Team Leader, Safe Team, Chief Nursing Officer Directorate Dr David Griffith, Consultant Microbiologist, NHS Fife Dr David Wilks, Consultant Physician, NHS Lothian Mrs Alison Macdonald, Lead Antimicrobial Pharmacist, NHS Highland Mrs Jo McEwen, Antimicrobial Nurse, NHS Tayside Mr Howard McNulty, Public Partner Mrs Fiona McMillan, NES Pharmacy 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 Jill Nowell, Lead Prescribing Adviser, NHS Tayside Dr Martin Connor, Consultant Microbiologist, NHS Dumfries and Galloway Dr Adam Brown, Consultant Microbiologist and Infection Control Doctor, NHS Highland Dr Busi Mooka, Infection Diseases Consultant, NHS Tayside 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: Dr Robbie Weir, Consultant Microbiologist, NHS Forth Valley, new representative for NHS Forth Valley. Clare Colligan has stood down. Ms Rita Nogueira, Senior Information analyst, ISD will now take Guy s McGivern s place at SAPG Dr Ursula Altmeyer, Consultant Microbiologist, will be new member for NHS Ayrshire and Arran replacing Dr Chloe Keane Action 3. Minutes of the previous meeting held on 22 nd August 2016. The minutes of the meeting held on 22 nd August 2016 were agreed. 4. Matters Arising Aztreonam supply issues IG raised concern at continued shortage of Aztreonam. advised that correspondence has been ongoing for some time now to try to resolve and detailed updates have been advised at previous meetings. The Chair advised that has tried to resolve the shortage in different ways and that this item will be kept live. Guidance on gentamicin for endocarditis and amikacin dosage and Guidance 2
on surgical prophylaxis advised that the two guidance papers on gentamicin for endocarditis and amikacin dosage developed by NHS GG&C were discussed at the last meeting of SAPG. SAPG members agreed that although the guidance is very useful the documents required the addition of evidence supporting the suggested dosing advice. advised that details of the evidence has been added but as it is limited, she suggested not suitable to publish on the SAPG website as national guidance. It was agreed the document would be published on a secure page of the SAPG website for SAPG members only. Action: Publish both documents on the secure page of the SAPG website Items for Discussion/agreement 5. Presentation Development of a potential primary care antimicrobial prescribing composite measure Ms Joanna Johnson (Presentation) Ms Joanna Johnson, Prescribing Support Pharmacist, from NHS Greater Glasgow and Clyde presented her Masters project work on the development of a composite measure of antibiotic prescribing quality for primary care. The project used a modified Delphi method to gain consensus of the eight most important prescribing indicators from the current suite of over 50 indicators. JJ invited SAPG members to provide feedback on the results and on taking the work forward into practice to provide a single measure for overall quality of prescribing. Further work is required to model how the eight indicators should be weighted to give this single measure. WM verified that the measure would not replace the national quality indicator for reduction of total use of antibiotics in primary care. It was agreed that an update of progress would be presented to a future meeting of SAPG and further discussion regarding the practical application of the composite measure. The Chair thanked JJ for a very informative presentation. Action: Progress on the development of prescribing composite measure to a future meeting of SAPG. 6. Guidance on management of neutropenic sepsis (Paper 1) advised that agreed amendments have been made following discussions on the paper at the last meeting of SAPG. asked members for views on the two versions using EWS and NEWS scoring. SAPG members agreed to only have a NEWS version as all boards are moving to this. It was also agreed that advice for gentamicin duration should be 3 days. confirmed Haematology/Oncology colleagues had been consulted on scoring and the updated document will be sent to them again before being published on the SAPG website. Action: Consult with Haematology/Oncology colleagues before publishing 7. Guidance on surgical prophylaxis (Paper 2) The Chair sought comments from SAPG members on the updated Guidance on surgical prophylaxis. confirmed with members that body weight based dosing of gentamicin is used in all boards. It was also agreed that a Caution note should be added on using high dose flucloxacillin in orthopaedics. Action: Make final amendments and publish on SAPG website /SP JJ 3
8. Use of oral fosfomycin updated on current issues with use of fosfomycin. SMC had recently accepted Monuril (fosfomycin oral sachets) for use in urinary tract infections in women and this product is significantly less expensive than generic fosfomycin previously available from specials units. However, the product licence for Monuril does not cover use in men therefore if used for this group of patients would constitute off label use. ML has also raised the potential problem of widespread use of fosfomycin now it is more freely available and this poses a risk in terms of increasing resistance. advised that a recent Drug and Therapeutics Bulletin article concluded that fosfomycin should be reserved for resistant infections. SAPG members agreed that these issues should be communicated to boards to ensure a standardised approach to use. Action: Discuss with colleagues within Healthcare Improvement Scotland and issue a communication to boards. 9. Update on UK Antimicrobial Resistance Strategy and Controlling Antimicrobial Resistance in Scotland Deferred to the next meeting. 10. Update on carbapenem and piptazo use to June 2016 (Paper 3) WM presented paper 3 showing a reduction in carbapenems and piperacillintazobactam (piptazo) use from January 2016 to June 2016 following an upward trend for several years. SAPG members agreed this was encouraging and that this information should be communicated to Antimicrobial Management Teams (AMTs) ahead of introduction of the new quality indictor for 2017. It was agreed that presenting the data as a chart of monthly antibiotic use would be helpful to evaluate the trend against national and local interventions. YG noted that the continuing decrease in meropenem and piptazo was resulting in an increased spend on aztreonam. SAPG members agreed that within the communication to AMTs it should be noted that there are increased drug acquisition costs for alternative antibiotics. This item will be discussed again at the February meeting of SAPG once there is clarity about the new quality indicators. The Chair thanked WM and colleagues for sharing this data. Action: Updated paper for February SAPG to agree communication to AMTs. advised that the appendix to the paper presents discussions and agreed recommendations for use of piptazo in an SBAR format. It was agreed that this should be shared with AMT Leads. Action: SBAR to be sent to AMT Leads to support local review of piptazo use WM/RN /SP 11. Proposal for new quality indicator to support reduction of antibiotic us advised that the proposed new quality indicators to support reduction of antibiotic use are now under discussion within Scottish Government along with those for other HAI targets. The Chair advised that information on how the new target will be communicated has not been clarified and that this will be shared with SAPG members and AMT Leads as soon as this information is available. 12. Infection Intelligence Platform progress report (Progress Report Paper) 4
WM advised that the paper for SAPG members summarises the work of IIP Phase 1 and outlines priorities for the future. WM advised that the paper outlines the importance of moving towards using patient centered data to inform decisions. It was agreed that study outputs from IIP and development work on Clinical Decision Support topics should be presented at the March 2017 AMT event. CM advised that the first phase of outputs have included journal articles and presentations at European and UK conferences. CM advised that reports and posters of the studies are all available on the IIP website. ML asked about national laboratory data mapping and WM advised that this has already been scoped and option appraisals are available but no way forward agreed. WM advised that the current funding ends March 2017 and next steps are under discussion with SG colleagues. WM highlighted that the IIP journey is only beginning as there are 3 phases to the programme and colleagues have delivered phase 1. Action: IIP update at March 2017 AMT event. 13. Items for update 14. National Point Prevalence Survey WM advised that a number Boards have now completed the national point prevalence survey. Analysis of the data collected is underway and local reports will follow once quality checking is complete and HPS will liaise with Boards on evaluation. SAPG members agreed the survey is going well and has benefited from resource being provided by Scottish Government. 15. Antimicrobial App. advised that the App has been in place for a few months now and no further issues have been highlighted. Tactuum are now working with Boards to help add local guidance to the App. and a teleconference is being organized with App. Administrators in December to discuss the governance process for local guidance within the App. The next few months will see additional data fields built into the audit tool data to support the new quality indicator. advised that Ann Wales from NES will carry out a formal evaluation of the App. 16. NICE guidance Preventing infective endocarditis - information for the public advised that while NICE guidance does not have any status in Scotland, clinicians in Scotland do consider NICE guidance as good practice. To this end, it has been highlighted that the recent update of NICE guidance on Preventing infective endocarditis - information for the public includes a small change to advice about antibiotic prophylaxis for dental procedures. This has caused some concern amongst colleagues in NHS GGC and advice has been requested from SAPG and the Scottish Microbiology and Virology Network (SMVN). The guidance now states that for dental procedures, antibiotic prophylaxis is not recommended routinely and there is uncertainty of what this means in practice. This was discussed and and the view amongst members was that if the NICE process couldn t give more guidance on the non-routine circumstances when antibiotics would be required then SAPG would not wish to attempt to do this either. The consensus was that decisions on using prophylaxis should be made on an individual WM/ 5
patient basis and generally, infection specialists would endorse prophylaxis when there is clinician anxiety usually previous endocarditis and a prosthetic valve/structural defect/ graft. This will be shared with colleagues from NHSGGC and with AMTs. Action: Share advice on NICE guidance /SP 17. Antimicrobial Pharmacist Specialist Training. (Paper 4) The Chair advised that paper 4 details progress with the Antimicrobial Pharmacist Specialist Training programme and asked SAPG members to forward any questions on the to the authors. AC advised that the next cohort of learners have just started the programme and progress will be updated to SAPG members in due course. 18. Scottish Reduction of Antimicrobial Prescribing (ScRAP) Urinary Tract Infection content AT advised that the new content of ScRAP focusing on UTI is now complete and an update of the existing content of ScRAP is underway. Piloting of the UTI content is taking place across 10 sites in 3 board areas to inform the final version. The format has been agreed as three 30-minute sessions and will be published in January 2017 on the NES website. The Chair encouraged wide dissemination and support for increasing awareness of the resource. AT confirmed that SH and GH will be contacted to support as GP members on SAPG along with John McKay, the GP on the SCRAP steering group. 19. National Prescribing Safety Assessment. advised that she and AM had attended a one-day training session that included critique of sample questions for the national prescribing safety assessment. advised that a teleconference is being organised with volunteer question authors to go through the types of questions required. and AM have been commissioned to provide at least 10 questions each and will take questions from the volunteers and upload into the on-line question bank. Once submitted the questions will be considered by the PSA group at a meeting held in Warwick in May 2017. Those questions selected will go into the tests for the following year for medical students graduating in 2018. If a large number of questions can be created and receive good feedback from student evaluation then there may be an opportunity to create a section within the test on stewardship. asked that if any further SAPG members would like to write questions they should contact her as soon as possible. 20. European Antibiotic Awareness Day 2016 (EAAD) advised that plans are now in place for EAAD and the final resources will be with Boards soon. SAPG have designed a new poster and leaflet this year with help from HIS communications. The poster and leaflets are now displayed in all community pharmacies in Scotland as their Public Health Campaign for October. The Chair advised that a new video about antimicrobial resistance has produced by the British Society for Antimicrobial Chemotherapy (BSAC) and he will seek permission for this to be shared. It was agreed the video would have benefit if shown in GP surgeries and shared via social media. Action: Seek permission to share the BSAC video 6
Items for information 21. Standing item antimicrobials submitted to the Scottish Medicines Consortium Nothing to report 22. Guidelines Publication advised that she has been contacted to ask to share some of the SAPG guidance via the Guidelines website and printed bulletin, which is aimed at primary care prescribers. The SAPG guidance of interest was on antibiotic use in the frail elderly and advice on long-term antibiotics in acne and rosacea. SAPG members agreed to share guidance. GH advised that new Dermatological guidelines from the Royal College of General Practitioners (RCGP) suggested that a 3-momth trial of antibiotics was sufficient in acne and agreed to forward details to. Action: Send Dermatological guidelines to 23. CRP Study GH attended the RCGP conference to present the SAPG CRP study and updated that a similar study in England by nurse practitioners had shown significant reductions in antibiotic prescriptions and in return appointments. GH advised that she will send the paper to for further dissemination. Action: Send English CRP paper to SP DN GH GH/SP The Chair suggested it would be helpful to collate all recent evidence on CRP testing to support utilisation in Scotland. Action: Collate CRP studies presented at conferences and recent publications 24. Federation of Infection Societies (FIS) conference advised that the FIS conference will take place in Edinburgh next month and SAPG have 6 posters. WM will be presenting on prescribing data in Scotland. 25. AOCB CC advised that there are some minor errors in the SAPG AMR report on 2015 data published on 30 th August 2016 and that these are being worked through with colleagues. The revised report will be published on 22 th November 2016. 26. Date of next meeting Date of next meeting is Monday 19 th December 2016 at 12:30 in Delta House, Glasgow. The following meeting will take place on Friday 17 th February 2017 in Delta House, Glasgow. 7