Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.

Lead Research Organisation: Imperial College London
Department Name: Dept of Medicine

Abstract

Context of the research:

Antibiotics are important to prevent infections after several types of surgery. The growing number of infections that cannot be treated with antibiotics may mean that many basic types of surgeries cannot continue. Around the world a large amount of all antibiotics are used during the surgical process. Antibiotics in surgery are used to prevent infections from happening after surgery (it is called 'prophylaxis') and for the treatment of infections after surgery. Infection after surgery is a growing concern in many countries. 23 million infections after surgery (or 'surgical site infections', SSIs) lead to 2 million deaths every year. Using antibiotics in the right manner is a sure way of preventing infections after surgery. For example, if the right antibiotics are given at the right time before surgery, then up to seven times less antibiotics are needed after surgery because less people get infections.

Aims and objectives:

The care before, during and after surgery (inside and outside of hospital) must include using the right antibiotics at the right time for the correct amount of time, making sure that there are no missed or late doses. The wellbeing of patients including nutrition and ability to move about can also affect how quickly they recover if they do get an infection. To get this care right at each stage, a lot of coordination and communication is needed between all the different health professionals (nurses, surgeons, anaesthetists, pharmacists), patients and carers involved. Because so many key parties are involved in this process, it is an ideal place to do research to understand ways of thinking about the correct use of antibiotics and behaviours such as hand hygiene which can prevent infections from happening in the first place. This study will use social science research to find out what helps individuals, teams and patients to practice safely and use antibiotics in the right way as described above.

The study will research these issues in England and Scotland as they each have different ways of organising and managing surgery. We will also carry out research in countries where there are less resources but they still manage surgery in the same way (India, South Africa and learning from Rwanda). The studies in countries outside of the UK will also tell us how behaviours can be changed when different health professionals are involved, and when antibiotics are less available within hospitals but also available from other sources.

Methods: The study will last four years and will start with an analysis of all factors within and outside of healthcare organisations which may influence how antibiotics are used. The methods we use at the moment to change behaviours of professionals and patients will be evaluated. New methods will also be designed, developed and also evaluated, and may include using new technologies such as computers or smartphones. We may also change the roles and expectations of different professionals within teams or changing the incentives or penalties associated with proper use of antibiotics. Some of these may involve patients and carers taking a more active role.

Potential applications and benefits:

By understanding the full context where surgery occurs, we will cover aspects of care within and beyond healthcare settings. As we will understand factors such as availability of antibiotics, financial pressures, regulation as well as what patients expect of their healthcare system and professionals, the solutions we will propose will be tailored for each setting. As we will be looking at how professionals, patients and carers behave and use antibiotics, it is likely that the new solutions that we propose would become part of routine practice, helping us to keep antibiotics working for much longer.

Planned Impact

The intended beneficiaries are public/patients/carers, healthcare professionals in primary, community, secondary care and public health, national/international and organisational policy makers, medical, surgical and health professional associations and networks.

The short term benefit to patients will be reduced risks of infection and better recovery after surgery. Patients and carers will be better equipped when preparing for surgery by knowing all the steps that they can take to help prevent infections. These will be about the role of general health and wellbeing as well as specific issues relating to infection control and the role of antibiotics. In the long term, future patients will still have access to surgery (currently threatened by AMR).

In addition, if we are able to streamline the antimicrobial stewardship processes around surgery in all healthcare organisations, then new and advanced forms of surgery can continue to develop. Here, industry and innovators will benefit from this research.

Healthcare professionals will benefit from this enhanced way of working and using efficient behavioural (proven) methods to optimise antibiotic use.

Policy makers will benefit by having access to a user-friendly (transparent) decision tool to look at how previously intangible behavioural effects can be modelled in real settings.

What will be done to ensure that they have the opportunity to benefit from this activity?

Because the research will be conducted in a way that includes co-design with multi-disciplinary professionals, researchers, patients and carers and informed by rich qualitative work, the proposed solutions will be relevant and realistic.

Our detailed plan of pathways to impact (enclosed) shows how this research institute and team and collaborators have a very strong track record in ensuring that research outputs are effectively translated to interventions for practitioners and patients to address antibiotic use. Nationally, the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London (Director: Alison Holmes) is an established collaboration with Public Health England, utilising data and expertise across a range of themes and leveraging wider networks for dissemination. To address the global threat of AMR, in 2015 Imperial established the Antimicrobial Research Collaborative (www.imperial.ac.uk/arc/), led by Prof Alison Holmes. ARC is a truly multidisciplinary, cross-College approach to AMR, addressing the complex interlinking biological and societal drivers of this threat. ARC involves over 100 PIs working across the Imperial College Academic Health Science Centre. Through ARC and infrastructure awards such as the NIHR Diagnostic Evidence Cooperative we also have strong industrial networks.

Publications

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Charani E (2017) Opportunities for system level improvement in antibiotic use across the surgical pathway. in International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases

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Charani E (2019) Antibiotic Stewardship-Twenty Years in the Making. in Antibiotics (Basel, Switzerland)

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Charani E (2018) The Differences in Antibiotic Decision-making Between Acute Surgical and Acute Medical Teams: An Ethnographic Study of Culture and Team Dynamics. in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

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Charani E (2019) Implementation of antibiotic stewardship in different settings - results of an international survey. in Antimicrobial resistance and infection control

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Charani E (2017) Understanding antibiotic decision making in surgery-a qualitative analysis. in Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases

 
Description International Journal of Infectious Diseases paper, Charani et al April 2017
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
URL http://dx.doi.org/10.1016/j.ijid.2017.04.020
 
Description Leadership Team meeting - Med Res Funded National PhD Training Programme in AMR
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
URL http://www.rcuk.ac.uk/documents/amr/avison-the-mrf-national-phd-training-programme-in-amr-pdf/
 
Description Primary Healthcare Reforms Project webinar
Geographic Reach Asia 
Policy Influence Type Influenced training of practitioners or researchers
Impact R Ahmad gave webinar for primary healthcare reforms project on 'Theoretical frameworks for analysis of provider and user behaviour'. 30 minute talk and then discussion.
 
Description WISH Delphi consensus
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact E Charani has collaborated on a WISH funded international Delphi consensus to develop core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus apprpoach.
 
Description ESRC Impact Acceleration Award
Amount £20,000 (GBP)
Organisation Imperial College London 
Sector Academic/University
Country United Kingdom
Start 01/2018 
End 04/2018
 
Description ESRC Theme 4 supplementary award
Amount £82,412 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 04/2018 
End 03/2019
 
Description ESRC additional funding (STEP-UP)
Amount £82,412 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 04/2018 
 
Description Wellcome Trust Institutional Strategic Support Fund Faculty Fellowship
Amount £21,476 (GBP)
Organisation Imperial College London 
Sector Academic/University
Country United Kingdom
Start 10/2017 
End 03/2018
 
Description Amrita 
Organisation Amrita Vishwa Vidyapeetham University
PI Contribution Imperial College London led successful application to ESRC for grant funding Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.
Collaborator Contribution Collaboration with Dr Sanjeev Singh, Medical Superintendent of large hospital in Kerala, India and Mr Puneet Dhar, surgeon, they bring expertise in hospital management, infection prevention and control and surgery to the project.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description Butare University Teaching Hospital 
Organisation University Teaching Hospital of Butare
PI Contribution Imperial College London led successful application to ESRC for grant funding Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.
Collaborator Contribution Collaboration with Dr Jules Ndoli Minega and Mr Christian Ngarambe who bring expertise in anaesthesia, surgery and hospital management to the project.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description India Collaborative on Surgical Prophylaxis 
Organisation University of Antwerp
Country Belgium 
Sector Academic/University 
PI Contribution Dr Sanjeev K Singh involved in India Collaborative on Point Prevalence Survey of Surgical Prophylaxis.
Collaborator Contribution Support and participation in this Indian collaborative for PPS in surgical prophylaxis
Impact None yet
Start Year 2018
 
Description King's College London 
Organisation University of Sao Paulo
Department Institute of Psychiatry
Country Brazil 
Sector Academic/University 
PI Contribution Imperial College London led on the successful application to the ESRC for this grant funding.
Collaborator Contribution Profs N Sevdalis, E Ferlie, Mr A Leather are the collaborators from King's College London on this ESRC grant funding.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description University of Cape Town 
Organisation University of Cape Town
Country South Africa 
Sector Academic/University 
PI Contribution Imperial College London led successful application to ESRC for grant funding Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.
Collaborator Contribution Collaboration with Professor Marc Mendelson and Mr Mark Hampton who bring expertise in healthcare management, infection prevention and control and surgery.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description University of Hertfordshire 
Organisation University of Hertfordshire
Country United Kingdom 
Sector Academic/University 
PI Contribution Imperial College London led successful application to ESRC for grant funding Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.
Collaborator Contribution Collaboration with Dr Reda Lebcir who brings expertise in System Dynamics to the project.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description University of Leicester 
Organisation University of Leicester
Country United Kingdom 
Sector Academic/University 
PI Contribution Imperial College London led successful application to ESRC for grant funding Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes.
Collaborator Contribution Collaboration with Dr Carolyn Tarrant who brings expertise in Health Psychology to the project.
Impact ESRC Grant funding for Optimising antibiotic use along surgical pathways: addressing antimicrobial resistance and improving clinical outcomes. Multi-disciplinary: management science, behavioural research, infection prevention and control, surgery, pharmacy, implementation science, health economics, modelling.
Start Year 2017
 
Description AMR Cross Council Initiative Workshop 2017 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact 2 day Cross-Research Council meeting, specifically on Antimicrobial Resistance (AMR) for award holders, workshop to explore challenges and opportunities. Presented in the 'Research Challenges (UK and global setting) session on 'Clinical, Social, Cultural and Historical Challenges', followed by round table discussion. Day two was an open session. Keynote speaker was Sally Davies, presentations and representation from funders and policy makers.
Year(s) Of Engagement Activity 2017
 
Description Antimicrobial Resistance Students' Conference: Advocating Behavioural Change 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact All day conference held at collaborator's King's College London, event on advocating behavioural change to tackle AMR run by students, for students. Interesting, broad programme which sparked good discussion. Has led to a number of enquiries about internship opportunities and an abstract being submitted to ECCMID 2018. Further impact will be realised. R Ahmad and E Charani gave lecture 'Behaviour change wheel and Antimicrobial Resistance' and ran workshop 'How to Run a Public Health Campaign'.
Year(s) Of Engagement Activity 2017
 
Description Application for surgical prophylaxis in adult CVST 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Dr Sanjeev K Singh presented PDCA- Application for surgical prophylaxis in Adult CVST at Institute of healthcare Improvement,Boston
Year(s) Of Engagement Activity 2017
 
Description BMC Medicine - invited blog - 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Invited blog
Year(s) Of Engagement Activity 2016
URL http://blogs.biomedcentral.com/blog/author/timothymilesrawson/
 
Description ECCMID 2017 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact following posters accepted to ECCMID

Rawson et al. Mapping decision pathways for acute infection management in UK secondary care: a qualitative study

Rawson et al. : Patient-centred interventions to promote citizen engagement with infection-related decision making

Rawson et al. Evaluating behaviour change in antimicrobial stewardship interventions: a review of UK state-of-the-art conferences

Rawson et al. Optimizing intermittent vancomycin therapy using C-reactive protein: investigating the role for AUC:EC50 in secondary care

Rawson et al. Clinical decision support systems for antimicrobial management: a systematic review of interventions in primary and secondary care
Year(s) Of Engagement Activity 2017
 
Description ECCMID 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Conference Posters submitted on the following:(1) Evaluating behaviour change in antimicrobial stewardship interventions: a review of UK state-of-the-art conferences (2) What does a systematic review of clinical decision support systems for antimicrobial management tell us? (3) Demonstrating the effectiveness of sustainable, long-term, bundled interventions to reduce blood culture contamination (4) Mapping decision pathways for acute infection management in UK secondary care: a qualitative study (5) Patient-centred interventions to promote citizen engagement with infection-related decision making (6) Optimizing intermittent vancomycin therapy using C-reactive protein: investigating the role for AUC:EC50 (7) Clinical decision support systems for antimicrobial management: a systematic review of interventions in primary and secondary care (8) Exploring the epidemiology and diversity of fungal isolates in a large tertiary haematology unit in London, UK
secondary care
Year(s) Of Engagement Activity 2017
 
Description ECCMID oral presentation - Gabriel Birgand 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Infection control specialists' perception of antimicrobial resistance in European hospitals: the Percept-R study. G Birgand, N Mutters, E Tacconelli, JC Lucet, A Holmes. Increasing research capacity to tackle AMR internationally and improve the consistency of practices and strategies.
Year(s) Of Engagement Activity 2018
 
Description Esmita ICID (Buenos Aires) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The study on the International implementation of antibiotic stewardship been accepted as a poster at ICID (Buenos Aires) conference.
Year(s) Of Engagement Activity 2018
 
Description Esmita poster ECCMID, Madrid 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The study on the International implementation of antibiotic stewardship has been accepted as a poster at ECCMID (Madrid)
Year(s) Of Engagement Activity 2018
 
Description Online course "Antimicrobial Stewardship: A competency-based approach" 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Online course "Antimicrobial Stewardship: A competency-based approach" launched on OpenWHO. This course provides a framework for approaching each clinical encounter from the perspective of combating antimicrobial resistance. Using case-based examples the course will highlight how antimicrobial stewardship principles can be applied to common clinical scenarios.
Year(s) Of Engagement Activity 2017,2018
URL https://openwho.org/courses/AMR-competency
 
Description Patient feedback for patient enagement module and engagement with patient rep on steering committee 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Patients, carers and/or patient groups
Results and Impact 18 patients were successfully recruited to pilot the PPI/E module. Their feedback was all positive and validated that the tool was appropriate and acceptable to the target audience. 87% of participants reported that they would like to use the module again. The Project's Patient and Public Representative,Fran Husson, the patient representative on our steering group has been involved in the development of a draft manuscript reporting these findings and will be a named author. Fran is also a regular attendee at the research steering Group/Oversight Committees allowing regular updates on the projects progress to be provided. We also updated our wider "potential patient/public panel" writing to them to update them on project progress, and sending electronic copies of two publications which had resulted from the work. Those written to were also offered an incentive to comment further on the patient engagement module, however no further comments were received despite the incentive.
Year(s) Of Engagement Activity 2017
 
Description Reda Lebcir - Herts 6th Dec 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Reda Lebcir presented on the project "Health, systems, and health systems: The public health threat of Antimicrobial resistance". 6th Dec 2017, the University of Hertfordshire
Year(s) Of Engagement Activity 2017
 
Description Royal Institution: Technology vrs Infectious 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Royal Institution: Technology vrs Infectious Diseases summit, took place on 26 September 2017. The summit brought together leaders in academia, industry, NGOs and young entrepreneurs to reveal how the best in UK technology is helping to combat bacterial, viral, parasitic and fungal diseases. Following an afternoon of presentations, the audience enjoyed a showcase of technologies that included EPIC IMPOC (this award) as well as ProMED, an Internet-based reporting system dedicated to rapid global dissemination of information on outbreaks of infectious diseases; POCAST and Target, facilitating navigation, access and use of national antimicrobial guidelines to support clinical prescribing decisions; and Microreact, open data visualisation and sharing for genomic epidemiology. Over 20 people signed up to receive our newsletter/further information about our work. There was also a mention of the event in the Evening Standard newspaper.
Year(s) Of Engagement Activity 2017
 
Description Santosh Rath, peer to peer 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Santosh Rath, surgeon, Imperial College London, presented on barriers to implement evidence into practice in India and issues encountered during AMR work.
Year(s) Of Engagement Activity 2017
 
Description Workshop on how to successfully implement behaviour change interventions in IP and AMS, ICID Buenos Aires 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact E Castro Sanchez and E Charani held a work shop for international attendees at ICID Buenos Aires on how to successfully implement behaviour change interventions in infection prevention and stewardship in hospitals
Year(s) Of Engagement Activity 2018