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Efforts to tackle the rising tide of infections in acute trusts are
beginning to have an impact. Meticillin-resistant Staphyloccocus
aureus infections
have fallen for three quarters in succession and levels of Clostridium
difficile infections, while still rising, are broadly in line with those
seen over the same periods last year.
Rising tide
In response to concerns about failures to tackle health care-associated
infections, Sir Liam Donaldson, the chief medical officer for England,
asked the Healthcare Commission to look into how infection control
practice could be improved. In the resulting report, published at the
end of last month, the commission concluded that the NHS still has
a long way to go.
“While trusts have made some progress, there is still much to be done
if the target of a national 50 per cent reduction in infections of MRSA
in the bloodstream by 2008 is to be achieved,” it says.
Changes in the way health services are delivered have meant that hospitals
are increasingly treating more acutely ill patients, Kieran Hand, consultant
pharmacist in anti-infectives at Southampton University Hospitals NHS
Trust, believes.
“Infection as a presenting diagnosis is increasing
year-on-year,” he says. “So preventing antibiotic expenditure
from rising is progressively more challenging.”
The upward trend in prevalence of infections caused by antibiotic-resistant
organisms, such as MRSA, may be partly explained by increased awareness
and surveillance, Dr Hand says. “However, the current MRSA problem
has been compounded by the widespread use of antibiotics, such as penicillins,
that are not effective against this organism, therefore driving the selection
of resistant strains.”
Modern health care is becoming ever more successful at prolonging life
in vulnerable patients, often with the help of immunosuppressant drugs,
he adds. “These patients are more susceptible to infection and
are often exposed to multiple courses of broad-spectrum antibiotics.
As a result, they may act as reservoirs for multi-resistant organisms,
posing considerable challenges for infection control in our hospitals.”
He adds: “If hospitals had spare bed capacity and generous staffing
levels, control of infection might not pose such a problem, but the constant
pressure on bed occupancy and staffing is a fact of life in today’s
NHS.”
Nonetheless, the importance of effective infection control is increasingly
being recognised, Conor Jamieson, principal pharmacist for anti-infectives
at Heart of England NHS Foundation Trust, Birmingham, says. “Doctors
and chief executives have become much more receptive to feedback on prescribing
as
health care-associated infections have moved higher up the political
agenda.”
When Dr Jamieson started as an antibiotic pharmacist almost five years
ago, infection control was on the agenda, but it was not seen as a key
priority, he says. “Now it is right at the top of the agenda. Here
at Heartlands the chief executive is chairman of the infection control
executive committee, which shows how seriously it is taken.”
Dr Jamieson believes that the perceived importance of infection control
reached a breaking point when the chief executive at Stoke Mandeville
resigned over the levels of health care-associated infections there. “That
certainly made chief executives at other trusts sit up,” he says. Benefits brought
The Healthcare
Commission’s report describes examples of good practice
observed in trusts. And, as part of this, it highlights clinical pharmacists’ involvement
on ward rounds, including reviewing the use of restricted antimicrobials
and liaising with consultant microbiologists.
“A number of trusts
mentioned the importance of regular ward rounds, which included reviewing
individual prescriptions and involved consultant microbiologists and
pharmacists,” the report says. “When such ward rounds are
carried out with other members of the clinical team, there is an opportunity
for experienced staff to reinforce formal education, in this case in
the use of antimicrobials, by discussion of real-life cases, especially
where those present had been involved in the prescribing process.”
Martin Shepherd, head of medicines management at Chesterfield Royal Hospital
NHS Foundation Trust, believes that the establishment of infection control
expertise within the clinical pharmacy service at his trust has delivered
benefits on a number of levels.
It has enabled close links to be established between the pharmacy team
and microbiologists and specialist infection control nurses. This has,
he says, proved invaluable in achieving consistency in strategies to
address infections acquired in hospital. It has also provided the capacity
to allow anti-microbials formulary controls to be introduced and prescribing
policy and antibiotic consumption to be monitored, as well as promoting
the need for intensive monitoring of antibiotic prescribing and driving
up standards of practice undertaken by individual pharmacists, he says. Appropriateness of treatments
A key way in which pharmacists can improve infection control is by
ensuring treatments are appropriate and in accordance with local guidelines,
Dr Jamieson says. This can be achieved by monitoring treatments used,
such as the course length, undertaking therapeutic drug monitoring,
and ensuring decontamination therapy for MRSA is correctly prescribed
and administered.
“There is a large volume of antibiotic prescribing which falls below the
radar of microbiologists or infection control, and pharmacists have an
important role to ensure that this prescribing is appropriate and consistent
with local policy,” he says. Audit of antibiotic consumption data
is a traditional role for pharmacy departments, and feedback of these
data to clinicians is vital for improving practice, he adds.
“Clinical
pharmacists can also play a vital role in educating medical and nursing
staff, whether on ward rounds or dedicated training sessions,” he
says. Often clinical pharmacists are a first port of call for junior
medical staff for prescribing advice in relation to antimicrobials as
well as other medication. This provides an opportunity to reinforce local
guidelines.”
However, the Healthcare Commission found that adequate microbial education
has yet to be a introduced by most trusts. The commission found that
only 8 per cent of the 155 NHS trusts surveyed provided training on prescribing
antimicrobials to all appropriate staff. Over a third of trusts (39 per
cent) said that no reports were provided to clinicians on their prescribing
data and a quarter said they received only one or two reports each year.
Although the benefits to patients of input from infection control pharmacists
appear obvious, finding concrete evidence from large scale trials to
demonstrate the positive impact of interventions is more problematic.
One area in which a direct patient benefit has been shown, however, is
in providing feedback on prescribing habits. Sheldon Stone and his colleagues
at the Royal
Free Hospital in London were able to show that pharmacists’ feedback
to doctors about their prescribing habits can help reduce cases of C difficile and
increase prescribing of narrow-spectrum, rather than broad-spectrum, antibiotics.
Dr
Stone and his colleagues examined the effectiveness of implementing a “narrow-spectrum
antibiotic policy” supported by a pharmacist-led programme of audit and
feedback of antibiotic use and C difficile infection rates. They
were able to demonstrate that changes in use of narrow- and broad-spectrum
antibiotics
were accompanied by a 65 per cent fall in infection rates.
Dr Jamieson says that developing systems to facilitate the feedback process
should help increase the volume of data on antibiotic prescribing provided
by pharmacists to doctors. “Feedback is certainly something that should
happen and, at Heartlands at least, we probably need to try to do more; pharmacists
tend to be good at producing quantitative data, but sometimes lack a means
to feed this back to prescribers.” However, he adds: “Many trusts
now have antibiotic stewardship committees and this provides a useful forum
to achieve this.” Other evidence
Other examples of evidence supporting the effectiveness of infection
control interventions are generally thin on the ground, however. A
2003 systematic review of evaluations of interventions to improve hospital
antibiotic prescribing found that the majority of interventions used
flawed methodology and that there was therefore little evidence for
improvements resulting from the interventions.
A 2007 Cochrane review examined the effectiveness of interventions
to improve prescribing practices for hospital inpatients. The analysis
included
66 studies, in a third of which the intervention was delivered by pharmacists.
Sixty of the studies aimed to reduce unnecessary antibiotic use and overall
the interventions involved in these studies improved prescribing, reduced
infection, reduced mortality, morbidity and length of hospital stay.
However, the researchers found little evidence that these results could
be generalised more widely (only five of the 66 studies were conducted
across 10 or more hospitals) and the possibility of wider analysis was
severely limited by the small number of studies whose results could be
compared. The authors were able to show that a variety of interventions
can improve hospital antibiotic prescribing, but they found no direct
comparisons of the efficacies of different interventions.
One of the reasons for the lack of evidence for which interventions are
most effective is, Dr Jamieson believes, the number of variables involved. “Infection
control is multifactorial,” he stresses. “It is difficult
to quantify the impact that anti-infective pharmacists have on infection
rates in the real world, although it is likely that they do have an impact.
There are a number of confounding variables. An academic might want to
set up two wards and carry out a controlled study changing one variable
at a time, but that is difficult to do in practice.”
In addition, Dr Jamieson observes, even reductions in infections observed
after a change in practice may not be easily attributable to the particular
change made. “When I worked at City Hospital we introduced a restricted
prescribing policy for cefuroxime and we saw a fall in C difficile infections,” he
says. “But we had decided to introduce the policy because of a
rise in infections, so the fall may resulted from other changes made
as a result of the increased awareness of the issue.”
A failure to gather appropriate evidence may, however, be a more general
problem, Dr Hand believes. “I think as pharmacists we generally
invest most of our time doing and less time measuring the impact of what
we are doing,” he says.
Solid outcome data are needed to demonstrate the benefits of interventions
to improve antibiotic prescribing and reassure those who hold the purse
strings of the cost-effectiveness of our activities, he adds. “There
are some promising results from a limited number of studies in this area,
so the precedent has been set, but there is definitely a gap in the literature
in terms of looking at what works and what works best,” Dr Hand
says. “Studies have so far been able to show that interventions
have been effective, but not what type of intervention delivers the best
value in a resource-poor environment." Electronic prescribing
Implementation of electronic prescribing will, Dr Hand believes, go
some way towards solving the current problems, since it will help determine
the extent to which prescribing is compliant with guidelines, providing
information on diagnosis is also captured.
The LDS Hospital in Salt Lake City, Utah, has implemented a computerised
drug ordering system, which integrates prescribing information and
patient administration
information with microbiology results, such as blood culture pathogen identification
and antibiotic sensitivities, and clinicians are alerted if a patient is not
on the appropriate antibiotics, Dr Hand says.
“The system can also be
used to evaluate patterns in prescribing and antibiotic resistance,” he
adds. “A number of UK hospitals are making rapid progress with electronic
prescribing, including the Chelsea and Westminster NHS Foundation Trust in
London, which is evaluating the impact of prescribing systems on antibiotic
use, with input from a specialist anti-infective pharmacist.”
In addition, the next generation of electronic prescribing will incorporate
clinical decision support, Dr Hand believes. “Prescribers will be required
to record a diagnosis, such as respiratory tract infection or urinary tract
infection, when selecting antibiotics. The system can then confirm whether
the chosen agent is an appropriate first-line treatment for that infection
and, if it not, invite the doctor to confirm that the prescription is correct.”
The introduction of decision support systems has been shown to influence
prescribing behaviour. However, Dr Hand adds: “Whether such systems can ever objectively
measure the quality of antibiotic prescribing is unlikely, due to the complexity
of decision-making in this unique area of therapeutics.”
Whatever the impact of such systems, the need for the services of infection
control pharmacists is also unlikely to evaporate any time soon, Dr Jamieson
argues. “There will certainly always be a need for anti-infective pharmacists,” he
says. “C difficile infection is likely to remain a problem
for the foreseeable future and if we manage to resolve that, by then there
will be something else
to deal with.”
Funding
Many infection control services have experienced
difficulties obtaining adequate funding. For instance, 36 per
cent of trusts
told the
Healthcare Commission’s researchers that they had experienced
difficulties reconciling the management of health care-associated
infection and cleanliness with the fulfilment of financial targets.
Pharmacists
also have to compete with other professional groups for funding,
Dr Jamieson stresses. “In terms funding for anti-infective
positions, pharmacists are sometimes competing with the infection
control service, although we have recently made a business case
for a full-time infection control data analyst and that is another
area of potential competition for funds,” he says.
“Some
trusts have had to go down the route of merging anti-infective
pharmacist positions with other responsibilities, in some cases
with managing a directorate, in order to secure funding for anti-infective
pharmacist posts.”
The introduction of £12m of funding for 2003–06 was
designed to facilitate the development of clinical pharmacy services
and provide
a focus on antimicrobial management. Dr Hand says: “It was
hoped that after this initial phase, if services had demonstrated
their value, trusts would continue to fund them.”
However,
in many trusts, demonstrating value was interpreted as saving money
on antibiotic expenditure, he says. “My personal view is
that these services should be viewed primarily as quality improvement
and patient safety initiatives and therefore worthy of funding
irrespective
of drug expenditure outcomes”.
When the Department of Health funding ran out in March 2006, many
posts were disestablished, Dr Jamieson says. “Anyone looking
into a career as an anti-infective pharmacist at that point might
have been nervous about their prospects and wondered whether positions
would be available in future or whether those that had appeared were
just a short-term appointment,” he says.
“But now trusts
have realised the benefits, as well as costs, of anti-infective
pharmacists, some of the volatility in recruitment has settled
down and trusts
are beginning to fund posts reasonably seriously. Most are graded
at around Band 8a and so that is a reasonable incentive for anyone
coming from Band 6 or 7.”
Even for those already at Band 8,
opportunities for further career progression in anti-infective
pharmacy are appearing, such as Dr Hand’s consultant pharmacist
post at Southampton, he adds. |
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The
Pharmaceutical Journal