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Antimicrobial Resistance

London: the unexpected hotbed of exotic diseases


Stephen Hughes

Antimicrobial Pharmacist, Chelsea and Westminster Hospital, London

London provides a unique AMS challenge, according to Stephen Hughes, Antimicrobial Pharmacist at the Chelsea and Westminster Hospital in West London. “There’s no such thing as local resistance here. It’s a hotbed of exotic diseases, with people bringing their flora (and thus, local resistance) from all parts of the world,” he said. This, coupled with national changes to antimicrobial resistance through years of heavy antimicrobial usage, makes for an increasing complex infection case load. “Every day provides an opportunity to see something unique and wonderful.”

Trusts are still tasked with reducing broad spectrum antibiotic usage, with financial incentives in place to encourage it. However, infections like sepsis can force a prescriber’s hand and breed risk-averse decision making.

“It’s a vicious cycle. One day, we’re telling our staff to stop prescribing broad spectrum antimicrobials due to the risk of selecting antimicrobial resistance. The next day, we’re out with our sepsis hat on, telling them of the risks of multi-drug resistant organisms and need for broader antimicrobials. For a junior clinician, it is a very confusing time.”

Changing priorities, complex infections combined with limited resources makes AMS an uphill battle in many acute trusts.

Policing access to antibiotics breeds bad relationships

“Empowerment and technology are infinitely more powerful tools than simply policing clinician’s access to antibiotics”, says Hughes.

“Restricting access to last-line antibiotics is a commonly-used technique, especially when you’ve got limited resources.”

“You’re asking clinicians to jump through hoops in order to gain access to life-saving drugs. It breeds a bad working relationship, but it also means there could be vital time wasted in treating a systematic infection like sepsis.”

Data allows more time on the ward

Assessing real-time patient level data on prescribing and microbiology, through clinical surveillance software such as ICNET, allows rapid feedback to ward-based clinicians and supports the antimicrobial team in making more informed clinical decisions on the wards.

Current diagnostic testing (culturing) can take 48 hours to provide key information about an infection, but this is still too slow when optimising management of a septic patient.

Reduced pre-authorisation and desk-based working also frees up antimicrobial pharmacists and microbiologists to work ward-based with the clinical teams to optimise patient care and reduce the impact of antimicrobial resistance.

“The tech allows us to be out on the wards, working alongside the clinical teams. Everyone benefits from that, and I believe it’s the best way to improve practices within a whole trust,” Hughes said.

Mobile data makes care more refined

Every opportunity to get pharmacists and microbiologists at the patient’s bedside and  working with the responsible clinical team is vital to achieving positive results for patients.

Mobile patient data is changing how AMS strategies are informed and shaped, while also helping to make the most of what are often limited resources.

“Data helps us allocate resources where they are needed most. Live feeds of patient clinical information mean we can spot patients who need specialist care, and focus on them,” says Hughes.

He also says it gives his team the chance to nip poor AMS practices in the bud; a major change from past eras.

“The prolonged feedback cycle used to be hopeless. Annual audit work presented to our prescribers, usually on the previous year’s doctor performance, would not accurately reflect the complex behaviours and practices of current prescribers. As such it is less likely to result in changes to practice in any timely fashion,” says Hughes.

“Now, if a patient is prescribed something inappropriate, we get alerts that allow us to go and see that patient within 10 minutes. Patient outcomes are improved, doctors receive timely feedback and real improvement in prescribing behaviours is evident.”

Achieving better patient outcomes, and measuring success

Many AMS teams are assessed based on what Hughes calls ‘crude measurements of antimicrobial prescribing or usage,’ such as overall antibiotic usage or whether prescriptions are neatly written and accurate. He believes the focus should be on robust patient outcomes.

“The data we have access to enables us to measure our service outcomes based on patient’s length of stay, readmissions within 30 days or mortality rates. The breadth of data available enables us to look more intricately at whether we’re actually improving our patient outcomes,” he said.

“There’s no one answer as to how to improve. But, being able to quickly identify complex patients and improving our communication and working relationship with clinicians on the wards, we can now vastly improve our antimicrobial team’s efficiency while also improving patient care.”

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