Kieran Hand.pdf

The rise of the antimicrobial
pharmacist
Dr Kieran Hand
Consultant Pharmacist Anti‐infectives
BSAC Spring Meeting 23 rd March 2011

Destiny?
c 1885

21 st Century Hospital Pharmacy
£100-200k cost
avoidance per week
36% required
intervention
69% clarify or
correct allergy
47% incorrect
30% errors on
reconciliation
994 interventions per week
20 “potentially lethal”

Increasing collaboration with medical
colleagues
• “We propose that every
clinical team, in primary
and secondary care,
should routinely include
a named pharmacist.
”
Royal College of Physicians February
2009

A potted history
• The Worshipful Society of Apothecaries
(founded 1617)
• The Royal Pharmaceutical Society of Great
Britain
• 17 th Century – conflict between physicians i and
apothecaries
• 1704 The Rose test case – apothecaries evolved
into general practitioners of medicine
• 1815 The Apothecaries Act
• 19 th Century – conflict between apothecaries
and chemists and druggists
• 1841 Founding of the Pharmaceutical Society of
Great Britain (1843 Royal Charter of
Incorporation)
• 1852 The Pharmacy At Act – Register of
Pharmaceutical Chemists
• 1924 Bachelor of Pharmacy degree at
University of London
• 1933 The Pharmacy & Poisons Act –
registration compulsory

Full circle: Pharmacist prescribing

Consultant Pharmacists
DH March 2005

Microbiology, Infectious Diseases and Pharmacy
in the UK:
a history of collaboration
• BSAC Working Party Report: Hospital antibiotic control
measures in the UK (JAC 1994: 34; 21‐42)
– “The potential for an expanded clinical role of the pharmacists should,
in our opinion, be examined in this country.
”
• 2006 –Pharmacists in BSAC workshops
• European Surveillance of Antimicrobial Consumption project
• 2006 –Prof Jonathan Cooke is the first pharmacist to be
appointed to BSAC Council
• 2011 –Dr Conor Jamieson appointed BSAC Honorary
Treasurer elect

Horses for courses

CID 1998

Why can’t we all just get along?

• Core members of a multidisciplinary antimicrobial stewardship team include
an infectious diseases physician and a clinical pharmacist with infectious
diseases training (A‐II), with the inclusion of a clinical microbiologist, an
information system specialist, an infection control professional, and hospital
epidemiologist being optimal (A‐III).
CID January 2007

A National Network for Infection Pharmacists –In the
beginning there was Wendy…
Contacted 100 UK
hospitals
85 hospitals had
no ID pharmacist
15 hospitals had
ID +/‐ HIV
pharmacist
5 hospitals had ID
pharmacist (1 at
Hammersmith)
All were interested
in the
establishment of a
national network
Lawson W et al. J Infect 2000;40:A31

Establishment of a National Group: UK
Clinical Pharmacy Association
Local Support at Hammersmith Hospital 1999
Ann Jacklin, Bryony Dean, Alison Holmes
National Support Support 2001
UKCPA General Committee, Alison Ewing, DoH –Keith Ridge Pharmacy & Prescribing branch
and Interdepartmental Steering Group on Antimicrobial Resistance
UKCPA 2002
I wrote Wendy a submission Lawson: to UKCPA general committee which was accepted

UKCPA Electronic Message Boards
Citi Critical lC Care
• 474 members subscribed
Surgery & Theatres
• 454
Infection Management
Cardiology
Emergency Care
Respiratory
• 422*
• 331
• 243
• 235
*Not all antimicrobial pharmacists

Integration into the Federation of
Infection Societies (2009)

The Hospital Pharmacy Initiative
£12M pump-prime funding
Available 2003-06
Non-recurring
125/183 responses
63% employed new staff
23% expanded current roles
106 pharmacy posts created
50 on fixed-term contracts

Training of Specialist Pharmacists
(2003)
Course changing to residential blocks

Legislative mandate
Health Act 2006
• Abx policy in place
approved by D&T
• Audit program to show
policies implemented
• Rx harmonised with BNF
• Procedures in place to
ensure prudent prescribing.

•“An expert antimicrobial group (EAG) should be
established to address effective and safe
antimicrobial use.”
• “The group should consist of specialist pharmacists,
microbiologists, infection‐control nurses and medical
staff as appropriate.”
p

HPA / DH endorsement of pharmacists
December 2008
• Antimicrobial management
team:
–Micro/ID doctor
–Pharmacist
–IT analyst
• Prescribing audits
– Monthly feedback to wards
• Mandatory training

Why appoint an antibiotic pharmacist?
•Share the burden / blame / credit?
•Abx consumption o surveillance
• Guideline implementation
• Audit and research
• Education
• Formulary management
• Liaison with ward clinical pharmacists

Pharmacists as “eyes and ears” on the wards
• Relatively stable staffing cf. junior
doctors
• Checking allergy, dosing,
interactions
• Surveillance and audit of ward
prescribing
• Enforcing formulary restrictions
• Implementing guidelines, policy
and training
• Supporting micro/ID ward rounds
• Monitoring for efficacy and side
effects
• Promoting streamlining and deescalation
• Encouraging IV‐to‐oral switch
• Integrated with specialist teams

Southampton electronic‐referral referral system
Ward pharmacist identifies patient
for microbiology ward round and
generates electronic request
Request received in microbiology
and relevant laboratory results
retrieved
Audit &
metrics
Ward round recommendations
communicated to doctors and
pharmacists through results system
Patient list printed and consultant
medical microbiologist ward round
takes place

The power of audit and feedback

Hospital guideline websites

Broad spectrum IV antibiotic use
• Now reached a plateau, so looking at different strategies e.g. procalcitonin

Pocket Guide…..brought to you by the
Microbiology and Pharmacy Departments….
Trustwide Antimicrobial Use By Risk Classification
(12 Month Rolling Average)
70%
60%
50%
40%
30%
20%
10%
0%
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Antifungal Antiviral i High risk It Intermediate dit risk ik
Low risk Specialist Ultra broad spectrum

70
60
50
40
30
20
10
0
SUHT Clostridium difficile rates
SUHT Number of C.difficile Cases (>2 Years)
Including SHA Trajectory
64 63
61 64 57 56
46
38 37
34
31
29
9
38
27 28
25 25
25 20 23 22 22
19 18
15
13
13 14
11
9 8 8 9 9 10 1114 11
7 8
5 5
5 6 4
No of Cases
Apr-07
May-
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
SUHT SHA Trajectory Linear (SUHT)

14000
Sum of Total DDD
12000
10000
8000
6000
4000
2000
Drug Type
Meropenem
Imipenem and enzyme inhibit
Ertapenem
Carbapenem use
SUHT 2005-20092009
0
1800
2005 2006 2007 2008 2009
Count of PATIENT NAME
1600
1400
1200
1000
Imipenem I/R isolates
800 SUHT 2005-20092009
600
400
200
0
2005 2006 2007 2008 2009

• All‐Wales Wl co‐ordination i of
microbiologists and pharmacists
in secondary care
• Point prevalence survey 2009
• Antibiotic consumption trend
data for 2005‐2010
• Antibiotic resistance trend data
2005‐2009
• Co‐ordinated and analysed by
Maggie Heginbothom and Robin
Howe

Scottish Medicines Consortium
Scot MARAP & SAPG
• Scottish Management of Antimicrobial Resistance
Action Plan issued in March 2008.
• Made recommendations to ensure prudent use of
antimicrobials.
• Scottish Antimicrobial Prescribing Group (SAPG)
formed to lead and coordinate national delivery of
ScotMARAP – hosted by SMC and funded by
Scottish Government.
• SAPG has same collaborative structure as SMC
i.e. representatives from key national and local
stakeholders

Mark Gilchrist leading on UK OPAT registry project

Antibiotic pharmacists in Primary Care

The next steps: embracing technology

The future? Electronic Rx?
Computer says ‘No’

Acknowledgments
•Dr Berge Azadian, Pippa Roberts, Chelsea &
Westminster
• Wendy Lawson, Prof Ann Jacklin, Prof Alison Holmes,
Hammersmith
•Dr Hayley y Wickens, St. Mary’s
•Mark Gilchrist, Charing Cross
• Philip Howard, Leeds
•Paul Wade, Guy’s and St. Thomas’
• Prof Jonathan Cooke, South Manchester
•Dr Conor Jamieson, Birmingham
• BSAC: Prof fPt Peter Davey, Tracey Guise, Prof fRoger
Finch, Prof Richard Wise

synergy ●n. interaction or cooperation
of two or more organisations, substances
or other agents to produce a combined
effect greater than the sum of their
separate effects.