Tackling antimicrobial resistance in cancer patients at the Christie NHS Foundation Trust

Antimicrobial resistant (AMR) infections are estimated to cause 700,000 deaths each year globally, and this figure is predicted to rise to 10 million with a cumulative cost of US$100tn by 2050^[1]
. In January 2019, the UK government published a five-year national action plan for tackling AMR as part of the a 20-year vision, which encompasses “optimal use of antimicrobials and good stewardship across all healthcare sectors” as a vital component^[1]
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As part of the antimicrobial stewardship strategy, the Christie NHS Foundation Trust in Manchester initiated a monthly point prevalence audit (PPA) in April 2018. The audit results suggest that since April 2018, the trust has not been consistently meeting:

• The 90% target for the audit standards;
• The percentage of treatment in line with trust guidelines standard (i.e. appropriateness of agent).

As a result, a microbiologist and pharmacist-led antimicrobial ward round was initiated to tackle the objectives highlighted in the UK’s AMR five-year plan, which are:

1. Reducing the need for and unintentional exposure to antimicrobials;
2. Optimising the use of antimicrobials;
3. Reducing antimicrobial use by 15% by 2024^[1]
   .

As a trust, we are also aiming to improve the percentage of compliance to the PPA standards in the trust’s high-risk population of people with cancer.

In January 2019, a ward round framework was developed and validated by the infection prevention and control team (IPCT), which allowed measurement of specific post-ward round outcomes. The IPCT initially decided that the inclusion criteria for the weekly ward round was to be all oncology inpatients taking either meropenem or piperacillin with tazobactam. This was done in order to assess inappropriate use of broad-spectrum antibiotics, as discussed in the AMR five-year plan^[1]
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Between February 2019 and August 2019, all inpatients meeting the inclusion criteria were identified by the pharmacy technicians the day prior to the weekly ward round. The specific patients were then discussed within the ward round multidisciplinary team, which consisted of a microbiologist, pharmacist, ward doctor and ward nurse. Outcomes of the antimicrobial clinical discussion were documented and categorised into four different areas:

• Oral step down;
• Continue current regimen;
• Stop antibiotics;
• Optimise antimicrobial regimen.

During this period, 146 meropenem and piperacillin/tazobactam prescriptions were assessed on the weekly ward round. The results show that 16% of patients (n=24) had their antibiotics stepped down to an appropriate oral agent, 66% of patients (n=96) continued their current antimicrobial regimen, 6% of patients (n=9) had all of their antibiotics stopped and 12% of patients (n=17) had their current antimicrobial regimen optimised.

Overall, inappropriate antimicrobial use, which was classified at the point of intervention, was reduced by 34%. The PPA audit standard percentage of treatment in line with trust guidelines (i.e. appropriateness of agent) increased from 90% in February 2019 to 95% in August 2019.

The outcomes from the ward round were fed back to the whole of the IPCT, which highlighted the benefit of consistent microbiologist and pharmacist input to the management of infections in cancer patients at the trust.

Additional projects are underway, including the use of smartphone apps, to further improve the compliance with the PPA standards and the UK’s AMR five-year plan, but most importantly, to improve patient outcomes.

Joseph Williams, specialist clinical pharmacist, the Christie NHS Foundation Trust;

Alex Peel, consultant microbiologist, the Christie NHS Foundation Trust and Salford Royal NHS Foundation Trust;

Fozia Tariq, consultant microbiologist, the Christie NHS Foundation Trust and Salford Royal NHS Foundation Trust;

Wayne Gilbart, infection control nurse, the Christie NHS Foundation Trust;

Gary Thirkell, infection control nurse, the Christie NHS Foundation Trust;

Joanne Chambers, infection control nurse, the Christie NHS Foundation Trust;

Paul Chadwick, consultant microbiologist, the Christie NHS Foundation Trust and Salford Royal NHS Foundation Trust.