Jeff Aston

Comparison of antimicrobial prescribing between two specialist paediatric centres in the UK and Latvia

Objective To compare the use of antibiotics among hospitalised children in the UK and Latvia at two specialist paediatric centres. Methods Two point prevalence surveys were undertaken on a single day in May and November 2011. Data collection included demographic details such as gender, age and specialty, prescribed antibiotic(s), indication, dose, frequency, route of administration and day of treatment. The data were analysed using Microsoft Excel and SPSS 20.0. Results The demographic details at the two institutions were similar. A number of differences were noted in antimicrobial prescribing. The most common groups of prescribed antibiotics were penicillin/β-lactam combinations in the UK and third-generation cephalosporins in Latvia. In both centres the most common therapeutic indication for antibiotic therapy was lower respiratory tract infection, which was predominantly treated in the UK with co-amoxiclav and in Latvia with ampicillin/amoxicillin. The intravenous route was most commonly used in both centres, but this was substantially higher in Latvia than in the UK (mean across both surveys 87.4% vs 62.6%). Conclusions A number of differences were observed in antibiotic prescribing between these two paediatric centres. By sharing audit data and antimicrobial stewardship initiatives, further changes in practice may be observed at both institutions.

Children/young people taking long-term medication: a survey of community pharmacists' experiences in England

To determine whether community pharmacists undertake medication reviews with children/their carers and to identify the type of medication‐related experiences presented to them when a child is taking long‐term medication.

MEDICATION REVIEW OF CHILDREN ON LONG TERM MEDICATIONS: A REVIEW OF THE LITERATURE

Introduction Children on long term medication may be under the care of more than one medical team including the patients GP. Children on chronic medication should be supported and their medications reviewed, especially in cases of polypharmacy. Medicines Use Reviews (MURs) were introduced into the pharmacy contract in 2005. The service was designed for community pharmacists to review patients on long term medication. The service specified that MURs were done on patients who can give consent and cannot be conducted with a parent or carer. Hence the service may be inaccessible to paediatric patients. This review aims to find studies that identify medication review services in primary care that cater for children on long term medication. Methods A literature search was conducted on 6th June 2015 using the keywords, (“Medication” or “review” or “Medication Review” or “Medicines use review” or “Medication use review” or “New Medicine Service”) AND (“community pharmacy” OR “community pharmacist” OR “primary care” OR “General practice” OR “GP” OR “community paediatrician” OR “community pediatrician” OR “community nurse”). Bibliographic databases used were AMED, British Nursing Index, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO and Health Business Elite. Inclusion criteria were: paediatric specific medication review in primary care, for example by either a GP, community paediatrician, community nurse or community pharmacist. Exclusion criteria were studies of medication review in adults/unclear patient age and secondary care medication reviews. Results From the 417 articles, 6 relevant articles were found after abstract and full text review. 235 articles were excluded after title and abstract review (11 did not have full text in English); 96 were adult or non-age specified medication review/MUR/New Medicine Service studies; 63 referred to observational, evaluative studies of interventions in adults; 6 were non-paediatric specific systematic reviews and 17 were protocols, commentaries, news, and letters. The 6 relevant articles consisted of 1 literature review (published 2004), 3 research articles and 1 published protocol. The literature review[1] recommended that childrens long term medication should be reviewed. The published protocol stated that the NMS minimum age for inclusion in the trial was for children aged over 13 years of age. The four studies were related to psychiatrists reviewing paediatric mental health patients in the USA, a pharmacist using Drug Related Problem to review patients in GP practices in Australia, a UK study based on an information prescription concept by providing children dispensed medications in community pharmacy with signposting them to health information and one GP practice based study observing pharmaceutical care issues in children and adults. Conclusion The results show that there are currently no known studies on medication use reviews specific to children, whereas in adults, published evaluations are available. The terms of the MUR policy restrict childrens access to the service and so more studies are necessary to determine whether children could benefit from such access.

A comparison of antibiotic use in three specialist paediatric hospitals in France, Latvia and the UK

Objectives This article analyses antimicrobial use in three tertiary-care paediatric hospitals with the aim of improving antimicrobial stewardship in paediatric hospitals. Methods A point prevalence survey (PPS) was undertaken during November 2012 using validated and standardised ARPEC (Antibiotic Resistance and Prescribing in European Children) methodology. The data collected contributed to the ARPEC study. Results Antimicrobials were prescribed to 116 patients (48%) in Birmingham, 114 (38%) in Paris and 128 (37%) in Riga. Respiratory tract infections were the most common indications for antibiotic use in Riga, but in Birmingham and Paris antibiotics were used most for prophylaxis in case of medical problems. The most common age group of patients receiving antimicrobials across all three sites was children aged 1–5 years old: there were 41 (35%) children in this age group in Birmingham, 37 (32%) in Paris and 36 (28%) in Riga. The most common antimicrobial used for the treatment and prophylaxis of paediatric patients was co-trimoxazole in Birmingham and Paris and ceftriaxone in Riga. Antimicrobials were mainly used parenterally: there were 100 (55%) parenteral prescriptions in Birmingham, 122 (50%) in Paris and 111 (75%) in Riga. Conclusions The PPS identified differences in antimicrobial use in the three hospitals and problem areas requiring improvement: high use of third-generation cephalosporins for paediatric patients (especially in Riga) and predominant use of parenteral antibiotics. Further collaboration between pharmacists operating at each site is needed in order to improve antimicrobial stewardship initiatives.

9 Children/young people taking long-term medicines – a survey of the experiences of community pharmacists

Aim To identify the experiences of community pharmacists in caring for children/young people, or their parents/carers, taking long-term medicines. Method A pre-piloted 13 point semi-structured survey, participant information leaflet, consent form and pre-paid return envelope were posted to all 354 community pharmacists who had dispensed a prescription from a single specialist paediatric hospital during November and December 2015. Community pharmacy addresses were obtained from the National Health Service Business Services Authority ePACT system. Telephone follow-up of non-responders and, if necessary, a repeat mailing was made from 3 weeks after the original return by date. Participants were asked about their experiences of undertaking a medication review with either children/young people or their parents/carers, medication-related problems presenting to them, adherence, information needs of patients/carers and what issues were reported to them from this group. The data were analysed using SPSS version 22 and NVivo version 10. Results A response rate of 76/354 (21.5%) was achieved. Eighteen (23.7%) respondents had undertaken a Medicines Use Review (MUR),122 (28.9%) a New Medicines Service (NMS)2 review and 16 (21.1%) had undertaken another type of medication review in a child/young person. Respondents reported that patients or their carers had presented to them with adherence issues including stopping the medicine (24, 31.6%) and changing the dose (28, 36.8%) without informing the prescriber. Patients or their carers had requested information from them about the indication (59, 77.6%), dose regime (63, 82.9%), administration (64, 84.2%) and adverse effects (58, 76.6%). Respondents also reported patients/carers experiencing difficulties obtaining further supplies of a medicine from their community pharmacy (47, 61.8%) and patients’ general practitioners declining to prescribe a medicine recommended by the patient’s hospital-based specialist (27, 35.5%). Conclusion This study has demonstrated that children, and their carers, taking long-term medicines experience a range of issues that they present to community pharmacists. Many of these issues would fall within the purview of currently funded medication review services namely the NMS and MUR.1,2 However, the proportion of pharmacists in this study undertaking formal medication review with children or their parents/carers was low. Further work is required to demonstrate the outcomes that such a review could have in this cohort of patients. References Pharmaceutical Services Negotiating Committee. MURs: The basics. What is the medicines use review and prescription intervention service? [Internet] 2016. Available from: MURs: The basics http://psnc.org.uk/services-commissioning/advanced-services/murs/murs-the-basics/ [Available: 19 May 2016]. Pharmaceutical Services Negotiating Committee. New Medicines Service (NMS ) [Internet] 2016. http://psnc.org.uk/services-commissioning/advanced-services/nms/ [Available: 19 May 2016].

A telephone survey to determine the experiences of children and their parents/carers, following the initiation of a new medicine

Objective To determine what issues are experienced during the first few weeks of therapy by patients, and their parents/carers, when a child/young person has been prescribed a new medicine. Method One hundred patients aged ≤18 years of age prescribed a new medicine for ≥6 weeks were recruited from a single UK National Health Service specialist paediatric hospital outpatient pharmacy. Six weeks after the first dispensing of their new medicine the patient or their parent/carer received telephone follow-up by a researcher and verbally completed a questionnaire containing both open and closed questions. Patient or parent/carer experiences were identified and analysed using thematic analysis and descriptive statistics. Results Eighty-six participants were available for telephone follow-up. Six (7%) had not started their medicine. Paediatric patients and their parents/carers experienced a range of issues during the first few weeks after starting a new medicine. These included additional concerns/questions (24/80, 30%), administration issues (21/80, 26.3%), adverse effects (29/80, 36.3%) and obtaining repeat supplies (12/80, 15%). The Morisky Medication Adherence Scale indicated that 34/78 (43.6%) participants had a high adherence rating, 35/78 (44.9%) medium and 9/78 (11.5%) a low rating. Conclusions Paediatric patients and their parents/carers experience a range of issues during the first few weeks after starting a new medicine. Further research is required to determine the type of interventions that may further support medicines use in this group of patients.

IMPROVING COMMUNICATION ABOUT ANTIBIOTICS—AN EVALUATION OF AN ANTIBIOTIC PRESCRIBING SECTION ON A PAEDIATRIC DRUG CHART

Aim The aim of this study was to evaluate the impact of a new designated section for antibiotic prescribing on a drug chart. Method A before and after study to determine the impact of a redesigned drug chart with a designated antimicrobial prescribing section. Four ward areas (Paediatric Assessment Unit (PAU), Paediatric Intensive Care Unit (PICU), Liver Unit and General Surgery) that contributed to 42.9% of antibiotic prescribing in previous audits were selected for investigation. Data were collected on one day during June and September 2013 (pre-redesigned drug chart) and January 2014 (post new drug chart) and included allergy status, route of administration, documentation of indication and the presence of a stop/review date. The data were reviewed by an antimicrobial pharmacist and data were collated using Microsoft Excel 2007 and analysed using descriptive statistics. Results Seventy-six prescribed antibiotics were audited on one day in Jun 2013 and Sept 2013 and 70 prescribed antibiotics were audited between 26th and 30th Jan 2014. In January, 60 patients were prescribed seventy antibiotics. Twenty six antibiotics were prescribed on Paediatric Admissions Unit (PAU), 32 on Paediatric Intensive Care Unit (PICU), three on Liver Unit and nine on General Surgery. All sixty patients had documentation of allergy status and nature of allergy documented. Overall, 41/70 (58.6%) prescribed antibiotics had a documented stop/ review date, compared with 12/25 (48%) for the Jun 2013 audit and 12/36 (33.3%) for the Sept 2013 audit. Of those prescribed IV antibiotics, 58/59 (98.3%) had a documented stop/review date and 3/11 (27.3%) oral antibiotics had a documented stop/review date. It was found that PAU had a review/stop date for 16/26 (61.5%), PICU 24/32 (75%), Liver Unit 0/3(0%) and General Surgery 2/9 (22.2 %) for the patients on antibiotics. Sixty nine of the seventy prescriptions reviewed (98.6%) had documented indication, compared with 15/25 (60%) for the Jun 2013 audit and 20/36 (55.6%) for the Sept 2013 audit. Conclusion A designated antibiotic section on a drug chart can have a positive impact on antimicrobial prescribing. The documentation of indication has improved and as well as stop/review date, which has led to better communication of prescribers intention. Further work needs to be done to improve prescribing on the surgical and liver wards. This study demonstrated that an improvement in antimicrobial stewardship can be achieved by designing a drug chart that supports good prescribing practice. This supports the national approach to good antibiotic prescribing.1

DI-100 Comparison of antibiotic prescribing for paediatric lower respiratory tract infections in three paediatric hospitals in the UK, France and Latvia

Background The most common indications for antibiotic use in hospitalised children are lower respiratory tract infections (LRTI). The point prevalence survey (PPS) allows targets to be identified for quality improvement. Comparing antibiotic use between different countries may help identify successful initiatives that further rationalise treatment. Purpose To compare antibiotic use for LRTI between three paediatric centres in the UK, France and Latvia to identify strategies to optimise treatment. Materials and methods This PPS was a part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). It was conducted at three tertiary-care children’s hospitals in Birmingham (UK), Paris (France) and Riga (Latvia) using ARPEC methodology during November 2012. Results LRTI accounted for 19/211 (9.0%) of antibiotic prescriptions in Birmingham, 29/245 (11.8%) in Paris and 43/168 (26%) in Riga. The most common age group of patients with LRTI across all three sites was under 5 years making up 14/19 (74%) patients in Birmingham, 14/29 (48%) in Paris and 22/39 (56%) in Riga. 7 different antibiotics were prescribed for LRTI in Birmingham, 14 in Paris and 9 in Riga. The most commonly prescribed antibiotics were co- amoxicillin/clavulanic acid 5 (28% of prescriptions) and piperacillin/tazobactam 5 (28%) in Birmingham, amoxicillin 5 (17%) and amoxicillin/clavulanic acid 6 (21%) in Paris and, amoxicillin 13 (30%) and ceftriaxone 9 (21%) in Riga. In Birmingham 13 (68%) antibiotic prescriptions were for community acquired infections, in Paris 24 (83%) and 42 (98%) in Riga. Antibiotics were predominantly prescribed intravenously: 11 (58%) prescriptions in Birmingham, 16 (55%) in Paris and 36 (84%) in Riga. Conclusions The PPS identified differences in antibiotic use in 3 hospitals and the high use of parenteral antibiotics in all hospitals. Further studies are required to determine the appropriateness of the choice of antibiotics in LRTI, the diversity of agents prescribed and the use of broad-spectrum antibiotic treatment. No conflict of interest.

REPEAT ANTIBIOTIC DOSING IN PROLONGED PAEDIATRIC SURGERY—DO WE? SHOULD WE?

Aim To evaluate the current practice of intra-operative repeat dosing of antibiotics during prolonged paediatric surgery. Method The proportion of procedures that lasted longer than four hours were identified from anaesthetic records over a 12 week period. The medical notes, anaesthetic record and medication charts were retrospectively reviewed for a convenience sample of 50 patients. Data were collected on: speciality, the procedure undertaken, antibiotic(s) prescribed, timing of administration in relation to surgery and the timing of additional doses. The data were recorded using Excel and analysed by descriptive statistics. Results A total of 3202 procedures were undertaken over 12 weeks with 163 (5.1%) lasting longer than 4 hours. The most common specialities were cardiac surgery (71/163, 43.6%), neurosurgery (23/163, 14.1%), hepatic and craniofacial surgery (13/163, 8.0% each). In the detailed analysis of 50 patients, the pre-operative dose was administered within 60 minutes prior to incision in 45/50 (90%) cases. A repeat intra-operative dose was administered in 3 (6%) procedures. These were cardiac, neurosurgical and orthopaedic procedures. All repeat doses were administered approximately 4 hours after the initial pre-operative dose. Conclusion The practice of administering an intra-operative repeat dose of prophylactic antibiotics during prolonged surgery was not established practice. National guidance recommends a repeat intra-operative dose in surgery lasting longer than 4 hours or where the duration of surgery exceeds the half-life of the antibiotic administered.1 2 The evidence base for surgical prophylaxis in paediatric patients is limited, however, a repeat intra-operative dose should be considered in prolonged surgery.3 Current practice in paediatric surgery should be reviewed in order to consider the routine use of intra-operative doses of antibiotic prophylaxis.

Prescribed antimicrobial therapy: what parents/carers are told and what they would like to know

Aims The aims of this study were to: Assess the drug related information provided to parents/carers of children prescribed an antibiotic during their in-patient stay and as part of the discharge process from Birmingham Childrens Hospital. Determine the compliance of a tertiary paediatric centre with the ‘Patients, Carers and the Public’ domain of the Antimicrobial Self Assessment Toolkit (ASAT).1 Methods A qualitative investigation of 30 parents/carers of in-patients was undertaken during January and February 2012. Face-to-face interviews were conducted using a semi-structured questionnaire on the ward with telephone follow-up after discharge. The questions were based upon recommendations of the ASAT. The themes included in the questionnaire were knowledge that an antibiotic had been prescribed, indication for use, duration of therapy, knowledge of adverse effects, where to seek advice and whether any information provided met parent/carer expectations. Participant responses were transcribed verbatim and analysed using content analysis. Results Thirty patients consented for a ward based interview with twenty (66.7%) consenting to telephone follow-up. Twenty-five (83.3%) parents/carers had been advised that their child had been prescribed an antibiotic as an in-patient. Six (24%) of these had been informed about the adverse effects associated with treatment. During the discharge process 19/20 (95%) parents/carers were informed that their child had been prescribed an antibiotic. Five (25%) had been informed about adverse effects. Eighteen parents/carers (90%) were advised of the course length. Eleven (55%) patients were informed where to seek further advice on their antimicrobial therapy. Parents/carers suggested a number of areas where they required further information. These included the rationale for antibiotic therapy (n=1), changes made to therapy during treatment (n=1), the long term safety of therapy (n=1), the risk of tolerance/reduced effectiveness (n=2) and assurances of eradication of infection/risk of recurrence (n=5). One parent suggested that a patient information leaflet be provided whilst an in-patient. Conclusions This study demonstrates that a national antimicrobial stewardship quality indicator may be used to assess the provision of information to parents/carers in the paediatric setting. Further work is needed to improve the provision of information on adverse effects and where advice may be sought should these occur following discharge from hospital. Parents/carers required more information about treatment decisions, expressed concerns about the safety of therapy and required assurances of treatment success. Addressing these concerns would further reinforce the importance of prudent antibiotic use among parents/carers and patients. Patient/carer expectations may differ depending on the reason for admission and social/educational background. These were not formally evaluated in this study. The results of this study will inform the development of interventions to improve information provision both at ward level and discharge. The use of written information to supplement verbal counselling is currently being considered.