DepCSOFiona Deputy Chief Scientific Officer for England englandamrdiagnosticsnhsnet Maximising the use of diagnostic technology to tackle the challenge of antimicrobial resistance November 2018 ID: 739341
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Fiona Carragher FRCPath @DepCSOFionaDeputy Chief Scientific Officer for Englandengland.amrdiagnostics@nhs.net
Maximising the use of diagnostic technology to tackle the challenge of antimicrobial resistance
November 2018Slide2
The rising tide of Antimicrobial resistanceInfections are increasingly developing that we cannot treat with a rapid spread of multi-drug
resistant (MDR) bacteriaWe may not be able to treat or prevent everyday infections or disease
Existing antimicrobials are becoming
less effective
Bacteria, fungi, viruses are adapting naturally and becoming increasingly resistantInappropriate use of these medicinesAll-time low in new antibiotics being developedRecognising this is a ‘one health’ agenda
WHO priority list of 12 resistant bacteria that pose the greatest threat to human health
www.who.int Slide3
The future if we do not act now
By 2050: more deaths from resistant infections than cancer Slide4
The UK AMR Strategy: a tripartite approachSlide5
The role of diagnostics in AMR
Independent review of Antimicrobial Resistance - Jim O’NeillDiagnostics are critical to the appropriate use of antimicrobialsStep change in the way technology is incorporated into the decision making processCurrently many decisions are based on an empirical diagnosis
Rapid point of care diagnostics enabling a precise, timely diagnosis
Decision support approach to drive change in prescribing
“I call on Governments to ensure that, by 2020, all antibiotic prescriptions will need to be informed by …. a rapid diagnostic test wherever one exists”
Jim O’Neill
“Having rapid, low-cost, and readily available diagnostics is an essential part of the solution to this urgent problem.”
Dr Margaret Chan, DG, World Health OrganisationSlide6
Which diagnostics
could be used in AMR?
Bacterial or viral
Bacterial type
Resistance (which antibiotics must I not use?)Susceptibility (which antibiotics can I
use?)Recognising there is also a role for host response biomarkers
From O’Neill
http://amr-review.org/
Slide7
Diagnostics – the signalling system for the NHS
Direct patients and patient flowsso that the right people get tothe right place at the
right time
Ensure treatment and
management is efficient, effective and coordinatedHave a critical role in prioritising activity so that services are resilient and sustainable Fundamentally shape the health economics of particular patient pathwaysSlide8
UK AMR Diagnostics - Vision
Maximising the use of high quality value driven diagnostic technology to tackle the challenge of antimicrobial resistance
The UK AMR diagnostic collaborative through system leadership, system and strategic alignment, local connectivity and UK oversight will ensure:
A rapid and flexible diagnostic offer tailored to the setting
Development of national standards of quality and safety for point of care diagnosticsPursuing innovation by leveraging system partnerships and health innovation funding bodiesSlide9
UK AMR Diagnostics – Strategy
Ensuring that the
right test
is available at the
right place at the right time.Slide10
Diagnostics – the current view of the system
Complexity
of system
Levers & Incentives
External
Assurance
Adoption
Routes
to use
Standards
Inappropriate
use
(diagnostics)
Models of provision
Service
quality
Data
Infrastrucure
Commissioning arrangementsSlide11
UK AMRDC- Providing a single point of focus for the system
System Leadership
Strategic Direction
UK Oversight
Local connectivity & good practice
System
Alignment
Nat’l Policy, Levers, Incentives,
UKAMRDCSlide12
UK AMR Diagnostic Collaborative Programme
System partners
Public Health England
Health Education England
DEFRA
Key areas of focus
Devolved AdministrationsSlide13
Diagnostic stewardship- definition
Coordinated professional guidance and interventions
to improve patient understanding, care and management through the appropriate use of clinical assessment and clinical scoring algorithms, biomarker tests and/or microbiological diagnostics to guide therapeutic decisions or screening strategies.
It should promote
appropriate, timely diagnostic testing, including specimen collection, and pathogen identification and accurate, timely and audited reporting of results to guide care. It should discourage unnecessary diagnostic testing and the use of tests that yield misleading results. Diagnostic Stewardship should
utilize microbiological data, including accurate and representative AMR surveillance data to inform local treatment guidelines, and AMR control strategies, and should be an integral component of measures to improve antimicrobial stewardship and infection prevention and control
WHO 2016:
Diagnostic stewardship
A guide to implementation in antimicrobial resistance surveillance sitesSlide14
Laboratory as part of the multi-professional approach
Patient presents
Condition postulated
Test ordered
Sample Collection
Sample processed
Reporting
Intervention
selected
PRE-ANALYTIC
POST-ANALYTIC
ANALYTIC
DIAGNOSTIC INPUTSlide15
UK AMR DC 18/19 areas of focus-Diagnostic Stewardship
Use of biomarkers eg
CRP/Procalcitonin in acute settings or as POCT in the community
Quality improvement approach to diagnostics within the blood culture pathway enabling timely review of antibiotic therapy
Urinary infections: Tackling inappropriate use of urinary diagnostics and focus on the urine culture pathway UK wide building on good practise, driving quality improvement and addressing variationSlide16
The CRP Landscape
NICE [CG191] Pneumonia in adults: diagnosis and management
For people presenting with symptoms of lower respiratory tract infection in primary care,
consider
CRP POCT if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. Do not routinely offer antibiotic therapy if CRO < 20 mg/LConsider a delayed antibiotic prescription if CRP 20-100 mg/LOffer antibiotic therapy if the CRP >100 mg/L
Variation in adoption across UKNo coherent commissioning approachBarriers to adoption emergingEconomic case for investment being made at local levelTraining and support for cliniciansQuality oversight of testingSlide17
Learning from the CRP pilot studies
Data from 2017- 34 in total
Implementation stage
6 x confirmed implementation programs
18 x pilot study phase
3 x scoping phase pilot/implementationSettings18 x GP (from individual to multiple)2 x elderly care1 x paediatric
3 x emergency settingSlide18
#ToDipOrNotToDip
ToDipOrNotToDip
aims to:
Improve awareness of AMR, AKI & prevention and diagnosis of UTI by care home staff
Stop inappropriate dipstick testing of urine samplesReduce inappropriate / increase appropriate antibiotic prescribing for residentsImprove communication about suspected UTI between GPs and care home staffEnsure appropriate sending of urine samples for culture and sensitivity test
Implementation:
Education sessions and resources for care home staff
Recommend use of clinical assessment not urine dipsticks to diagnose UTI
Primary care clinicians following local guidelines to treat UTI appropriately
Using an assessment and standard communication tool with primary care clinicians
Use of red top bottles which contains boric acid for preserving the urine
Combines clinical evidence with quality improvement science to improve the management of UTI in care home residents and has delivered sustained improvements in safe and effective patient care.
Uniting the science and practice of clinical improvementSlide19
#ToDipOrNotToDip
Improved appropriate management of UTI, and reduced inappropriate use of antibiotics
56% reduction in the number of residents prescribed antibiotics
67% reduction in the number of antibiotic prescriptions
Improved the management of Catheter Associated UTI
Reduction in E.coli blood stream infectionsReduced calls to primary care clinicians for inappropriately diagnosed UTI saves time
Uniting the science and practice of clinical improvementSlide20
The importance of the end to end blood culture pathwaySlide21Slide22Slide23
Blood culture pathway – next stepsNovember: UK wide survey of blood culture against UKSMI guidanceGain a system wide understanding of current laboratory practice in relation to quality and unwarranted variation
Enable the UK ADC with partners to develop mechanisms to improve servicesIn collaboration with NHS Improvement GIRFT (Getting It Right First Time) programmeOpportunity to align with UKAS inspection regimeSlide24
Innovation: challenging ourselves to go further, faster
Handheld
‘lab on a chip’
High throughput genomic technologies
Point of care testing
Evolving technologies
Disruptive approaches – What else can we learn from:
Big data,
analytics & AI
Developing world approaches
Animal
Health
Other scientific specialismsSlide25
Integration and collaboration is everything
Academia
NHS
Patients
Industry
International
Area of
maximum
advanceSlide26
Innovation work stream – next steps5th December
: Welcome Trust Engagement event to gain an understanding from industry and innovators• The current challenges when accelerating usage of solutions developed by industry
• The challenges and potential solutions to feed into national policy
• Highlight opportunities for test bed working
31st January: With all system partners to understand how health regulation, policy innovation, funding, quality, safety and research can support the government’s ambition to embed rapid diagnostics.Slide27
UK AMR agenda- 2019 and beyond
The government will shortly be setting out a refreshed UK strategy for AMR, this is likely to set out a longer term vision accompanied by a shorter term 5 year National Action Plan
The new plan will take a coordinated approach, setting out challenging ambitions for the next five years and commitments across humans, animals, food and the environment.
For human health this will be aligned to the emerging NHS Long Term PlanSlide28
The Health and Social Care Select Committee released the report from their inquiry into AMR 22nd October 2018Within this there are specific recommendations relating to diagnostics
Continued Focus on AMR DiagnosticsSlide29
The system must be responsive
The work of the UK AMR diagnostic collaborative is crucial in ensuring that all the right groups and agencies are working together to address these challenges.Slide30
The UKAMRDC
Working in partnership
UKAMRDC