1. Bacteraemia in Buckinghamshire Healthcare NHS Trust
An Audit on the Appropriateness of Antibiotic Prescribing in Patients with Escherichia coli
Bacteraemia in Buckinghamshire Healthcare NHS Trust
Paige Johnson – Pre-registration Pharmacist Supervisor: Claire Brandish (Antimicrobial Pharmacist)
Introduction
The misuse of antibiotics can lead to resistance. Currently in the UK, the greatest and increasing threat from drug resistant organisms is from Gram-negative bacteria1. According to the ESPAUR report, the commonest cause of bacteraemia was E.coli in 2016; of these, 41% were resistant to co-amoxiclav and almost one in five were also resistant to at least one other key antibiotic2. Since April 2017, there has been an NHS ambition3 to halve the number of healthcare associated Gram-negative bacteraemias by
Objectives
The objectives of this audit were to investigate the appropriateness of antibiotic prescribing for the treatment and 6 month period prior to development of E.coli bacteraemia. The antimicrobial sensitivities of the causative E.coli were also investigated. To provide data which will enable us to benchmark with other Trusts within the region.
Standards
The standards for this audit were separated into two parts:
Part 1: 100% of patients with E.coli bacteraemia in hospital were:
Treated with appropriate empiric antibiotics in accordance with Trust guidelines4-7
Prescribed antibiotics later shown to be effective against the isolate (within 72 hours)
Treated for the appropriate length of time in accordance with Trust guidelines4-7
Part 2: 100% of patients were:
Treated with appropriate antibiotics in the 6 months prior to the E.coli bacteraemia in accordance with Trust and community guidelines8 as well as known resistance data, if applicable
Method
This retrospective audit did not require ethics approval. Trust approval was granted. Patients with a positive E.coli bacteraemia were identified for a two month period (August-September 2017) using the National Enhanced Mandatory Surveillance.
Patient notes, drug charts and e-documents were used to ascertain antibiotic prescriptions for the E.coli bacteraemia (part 1) and for the preceding 6 month period (part 2). Patients were consented for Summary Care Record (SCR) access and GP surgeries contacted for complete antibiotic histories.
Each prescription was assessed for “appropriateness” according to empirical treatment guidelines (1a, part 2) and known sensitivities (1b, part 2). Antibiotics were assessed for an appropriate treatment duration (1c, part 2)
Results
Discussion
None of the standards of this audit were met
One fifth of patients did not receive appropriate antibiotics initially. It is important to ensure patients receive antibiotics according to Trust guidelines as these are based on local sensitivity results. The “correct” antibiotic choice will ensure patients with sepsis are treated more effectively – reduced mortality risk
A 72 hour review was undertaken in 96% of patients with an E.coli bacteraemia indicating good adherence with focused efforts to improve antibiotic prescribing principles (AMR CQUIN introduced in 2016/17)
Poor adherence to community guidelines was observed. It may be that inappropriate choice and/or duration of therapy contributed to the E.coli bacteraemia thus creating some selection bias
Of the 35 antibiotic courses included in part 2; 24 were for the treatment of UTIs – however only 6 of these were prescribed appropriately (both antibiotic choice and course length)
Limitations
A number of patients (17) were excluded due to time constraints (deceased patients) and insufficient notes on EVOLVE
In order to assess the appropriateness of antibiotic treatment, indication must be known – it was not always possible to obtain this information if antibiotics had been prescribed in other hospitals (0 antibiotic courses initiated in hospital were assessed in the 6 month period prior to the bacteraemia)
Audit bias as only E.coli bacteraemia patients were considered for appropriate antibiotic use in the community – mainly UTIs being treated so is not truly representative of adherence to community guidelines
Recommendations
Discuss the audit findings with A&E consultants – timing of doses is critical and treatment for sepsis is usually initiated within this department
Pool and share results with other Trusts within the region (South Central Antimicrobial Network) and benchmark against results obtained at Southampton
Share the findings of this audit with the CCG – is there a wider issue of lack of adherence to community guidelines, potential for another audit looking solely at community prescribing for UTIs within Buckinghamshire with a focus on treatment length
Re-audit in a year to see if improvements can made in terms of duration of antibiotic treatment – consider signing up to the Antibiotic Review Kit (ARK) Study which is aimed at the 72
hour review and treatment duration
Antibiotic Choice Appropriate?
No: 10 (29%)
Number of Patients Identified using National Enhanced Mandatory Surveillance of Gram-negative Bacteraemia Form (Aug – Sept 2017): 52
6 Excluded
Part 1 – Treatment of Bacteraemia
Part 2 – Preceding 6 Month Period
46 Included
11 Excluded
41 Included
6 Insufficient Notes
10 Deceased
1 No Consent
35 Antibiotic Courses
Prescribed Antibiotics?
Yes: 18
No: 23
Yes: 24
No: 11
Yes: 14 (40%)
No: 8 (23%)
Standard 1a
Initially Appropriate?
Yes: 37 (80%)
No: 9
72 Hour Review Appropriate?
Standard 1b
Yes: 44 (96%)
No: 2
Standard 1c
Course Length Appropriate?
Yes: 38 (83%)
No: 8
Figure 1: A Flow Diagram Showing the Results Obtained for Both the Treatment of the Bacteraemia (Part 1) and the Preceding 6 Month Period (Part 2)
Yes: 3 (9%)
Graph 1: Appropriateness of Antibiotic Prescribing for 6 Month Period Prior to Bacteraemia (Part 2)
67%
33%
49%
51%
40%
60%
Antibiotic Choice
Course Length
Antibiotic Choice AND Course Length
n = 35
References
Buckinghamshire Healthcare NHS Trust. Care of Adult Patients with Suspected Neutropenic Sepsis.
Public Health England. Guidance - Health Matters: Preventing Infections and Reducing Antimicrobial Resistance.
Buckinghamshire Healthcare NHS Trust. Management and Antibiotic Therapy for Respiratory Tract Conditions in Adults.
Public Health England. English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017.
Buckinghamshire Healthcare NHS Trust. Assessment and Management of Urinary Tract Infections in Adult Patients.
Public Health England. Preventing Healthcare Associated Gram-negative Bloodstream Infections: an Improvement Resource.
Medicines Management, Aylesbury Vale and Chiltern Clinical Commissioning Group. Management of Infection Guidance for Primary Care.
Buckinghamshire Healthcare NHS Trust. Immediate, First Dose of Antibiotic for the Management of Adult Septic Patients.
Buckinghamshire Healthcare NHS Trust. Management of Abdominal Infection.
Acknowledgements
Alexa Conrad, Rachel Tannian, Lisa Pazik, Tshuma Siphathisiwe,
Duncan Cooke, Natasha Hamilton, Rachel Cox, Richard Musk