In Birmingham in February 2020 together with over 500 colleagues from across the “whole health economy” we will review the CQUIN results and look forward to see what progress is required to deliver the “Long Term Plan” targets in Infection Prevention & Control. We will review the new structures and working group initiatives of NHSE and PHE.
In 2016 the former Health Secretary, Jeremy Hunt launched new plans to reduce infections in the NHS. He announced the government’s programme to halve the number of gram-negative bloodstream infections by 2020. The actions included the Serious Infection CQUIN 2017-2019 which was designed to tackle issues such as AMR and deteriorating conditions such as sepsis. As we enter a new decade we will take a fresh look at the challenges that we face today and those we will face in the coming days and years.
The UK Government has long been an advocate of action to address antimicrobial resistance, with a national strategy and action plan in place since 2000.
In 2013, we reinforced our approach with a One-Health perspective and published our first fully integrated five-year strategy and plan for tackling resistance across human and animal health. The 2013–2018 strategy and UK Government ambitions on antimicrobial resistance have helped reduce antibiotic use in both humans and food-producing animals. Other achievements under the strategy include strengthened surveillance data in the UK, investing more in better coordinated research, stimulating global awareness and momentum, and helping to secure global commitments to address resistance, including through the UN General Assembly and UN Environment Programme resolutions, and G7 and G20 declarations. Despite these achievements, drug resistant infections in humans continue to increase in the UK. While the proportion of Escherichia coli (E. coli) blood stream infections that are resistant to one or more drugs remained stable between 2013 and 2017, the overall number of E. coli blood stream infections increased by 23.3% in England, indicative of Contained and controlled: The UK’s 20-year vision on antimicrobial resistance 6 increases across the UK. This increase in absolute numbers creates greater potential for resistance to emerge.
Worryingly, we have seen an increase in Carbapenemase producing Gram-negative organisms, such as E. coli, resistant to key antibiotics due to importations from abroad, local spread and poor prescribing practices. It is critical that we avoid the spread of these organisms in the UK as, once the key antibiotics used to treat them stop working, there are few remaining alternatives. At the same time, we continue to be high users of antibiotics compared to some other European countries, using twice as many as the lowest user in Europe, demonstrating that we have some way to go. Figure 3: Antibiotic use in the UK. The drivers, spread and impact of resistance in the environment and food chain remains poorly understood and needs more study. More research is also needed to understand which interventions work best to limit the development and spread of resistance in different contexts, at home and abroad.
In 2019 NHS Improvement announced two new antimicrobial resistance schemes to support NHS acute providers implement the five-year UK Antimicrobial Resistance (AMR) national action plan in 2019/20. This plan, published by the Department of Health and Social Care on 24 January 2019, includes new targets to tackle antimicrobial resistance:
halve healthcare-associated Gram-negative bloodstream infections
reduce the number of specific drug-resistant infections by 10% by 2025
reduce antimicrobial use in people by 15% by 2024; including a 25% fall in overall use in the community from the 2013 baseline and a 10% fall in the use of ‘reserve’ and ‘watch’ antibiotics in hospitals from the 2017 baseline.
The two NHS Improvement schemes supporting delivery of the national plan by acute providers are:
NHS Standard Contract for acute providers: this now includes the target for 2019/20 of reducing total antibiotic consumption by 1% from the 2018 baseline by the end of Q4 2019/20
Commissioning for Quality and Innovation (CQUIN) indicators:
– improving the management of lower urinary tract infections in older people
– improving appropriate use of antibiotic surgical prophylaxis in elective colorectal surgery
During the 2017-19 “Reducing the impact of serious infections” CQUIN scheme, acute providers have succeeded in improving 72-hour review of antibiotic prescriptions for sepsis, by aligning their local antimicrobial stewardship guidance with that of “Start Smart Then Focus”. Their performance is reported on the PHE AMR Fingertips Portal.
“While we can count many successes from our 2013-18 Antimicrobial Resistance (AMR) Strategy, resistance has continued to increase. In the United Kingdom we have seen a 35% increase in resistant blood stream infections in humans from 2013-17.
The number of bloodstream infections (BSIs) is increasing each year. Although the proportion of antibiotic resistant BSIs remain stable year to year, the burden on resistance increases. This is mostly due to increasing prevalence of E.coli bloodstream infections.
Estimates of the multi-resistant cases can be made, however not all the bacteria are tested against the same antibiotics, so a definitive number of cases cannot be given. The Public Health England Fingertips tool also has an indicator showing the rolling quarterly average proportion of E. coli blood specimens non-susceptible to at least three of the key antimicrobials (gentamicin, ciprofloxacin, piperacillin/tazobactam, 3rd-generation cephalosporins or carbapenems). For England this is 5.5% with little fluctuation over time.
This is exactly why the UK’s five-year national action plan for AMR, published alongside the UK 20-year vision for AMR on 24 January 2019, includes a strengthened focus on infection prevention and control, renewing our commitment to halve levels of healthcare associated Gram-negative blood stream infections (mostly E.coli) by 2023-24. The plan also sets a world-first target to reduce the actual numbers of resistant infections, with the aim to reduce them by 10% by 2025.
We are working with the devolved health administrations to develop consistent methodologies for reporting the incidence and mortality of key antibiotic resistant infections and antimicrobial use to allow us to report progress on the ambitions of the AMR national action plan.
As reductions in inappropriate prescribing also reduces the risk of promoting the growth of antibiotic-resistant bacteria, interventions to reduce antibiotic prescribing or transmission of the bacteria are complementary.”
Baroness Blackwood of North Oxford–Parliamentary Under-Secretary (Department of Health and Social Care 2019) Replying to a written question in the House of Lords.
Topics to be explored on the day will include antimicrobial resistance strategies, e coli and GNBSI progress (which will include UTIs and CAUTIs/CLABSIs), SSIs and sepsis (managing deteriorating conditions). Other areas will be AMR prescribing, increasing the use and scope of diagnostics, and ensuring the accuracy and understanding of data. There will be a both a national view together with local best practice case studies. The day will also showcase the latest innovation and technology with an opportunity to interact with healthcare professionals from around the world.
