The Strategy for the Control of Antimicrobial Resistance in Ireland

The problem of antimicrobial resistance in Ireland was highlighted by the results of a 1999 study of the epidemiology of MRSA


Executive Summary
The Strategy for the control of Antimicrobial Resistance in Ireland (SARI) was launched by the Minister for Health and Children in April 2001, in response to the findings of the 1999 North-South survey on meticillinresistant Staphylococcus aureus (MRSA) and the European Antimicrobial Resistance Surveillance System (EARSS). The SARI report includes, recommendations on the need for developments in surveillance, improvements in antibiotic stewardship, education and research, and enhanced infection control practice such as hand hygiene.
At national level, there has been some progress during 2005 such as the launch of national recommendations on hand hygiene and the control of MRSA, and the development of guidelines on antibiotic stewardship for hospitals. There has also been significant activity in many regions and at local/hospital level such as general practitioner education on antibiotic prescribing, expanding the role of hospital pharmacists to improve and reduce the use of unnecessary antibiotics, the introduction of new laboratory methods and technologies for antimicrobial susceptibility testing, and the production of educational leaflets for patients and members of the public.
The full implementation of SARI is some way off. This is due to inadequate resources, including a lack of ring-fenced funding for SARI initiatives and delays in the approval of whole-time equivalent staff. This was well highlighted in a gap analysis undertaken in the middle of 2005 and during the joint SARI/Antimicrobial Resistance Action Plan (AMRAP, the equivalent strategy for Northern Ireland) meeting in November 2005, which highlighted significant developments in Northern Ireland, England and Belgium in reducing antimicrobial resistance.
In Ireland, there are inadequate numbers of consultant microbiologists, infection control nurses, antibiotic pharmacists, surveillance scientists and other staff, despite some appointments in recent years. Furthermore, high bed occupancy rates and insufficient numbers of isolation rooms impede the implementation of national guidelines such as in the control of MRSA in hospitals.
The failure to include ring-fenced funding in the estimates of the Department of Health and Children as part of the budget in December 2005 for SARI implementation in 2006 was a great disappointment to those involved nationally in providing leadership in this area, as well as the relevant individuals and groups on the ground, who have worked hard and enthusiastically to implement SARI in the face of inadequate resources.
Given the concern amongst members of the public and patients about antibiotic resistance, including MRSA, and despite re-assurances from the Department of Health and Children, the Tánaiste, and the Health Services Executive, progress is too slow. Five years after the launch of SARI national levels of antimicrobial resistance remain unacceptably high, and in the case of some pathogens have even increased. Levels of antimicrobial consumption in hospitals and the community also remain high. Ireland is one of the few countries in Europe without a national system for surveillance of healthcare-associated infections. There is an urgent need to allocate sufficient ring-fenced resources at national and local level both in the short-terms and for the next five to ten years, and to fast-track key appointments to correct the deficit in terms of personnel.
As healthcare professionals, we strive to provide a high quality service in a safe environment to our patients. There is considerable frustration, and even cynicism, amongst the various committee members, and the relevant healthcare workers on the ground about the priority given to the full implementation of the 2001 SARI recommendations. There are increasing demands for better data, (e.g. MRSA rates) and for improvements in the delivery of healthcare by way of reduced or even contained rates of hospital-acquired infection. However, these demands are not matched by the priority given to this area at national level through central funding and subsequent regional or local funding allocation. The resources allocated to date have provided a basic infrastructure but are insufficient to fully implement SARI. It is essential that in 2006 rapid progress in the implementation of the 2001 recommendations be made. If not, confidence in this strategy will evaporate and the perception of patients of our health system will be damaged.

National Committee
The National Committee has 32 members and has wide representation from the Regions and the various relevant professional groups. Following the re-organisation of the Health Services in 2004, the National Committee reports to the Health Services Executive (HSE) since 2005 but has retained representation from the Department of Health and Children (DOH&C). During 2005, the National Committee met on five occasions.
The Committee reviewed the SARI structures and reporting relationships in the light of the recent changes in the Health Service. The National Committee will continue to provide expert advice to the HSE and the DOH&C on the implementation of SARI and will liaise closely with the HSE/SARI Implementation Group and the DOH&C/HSE/SARI Liaison Committee. It was also agreed that the minutes of the National Committee would be distributed to the members of the HSE/SARI Implementation Group and the DOH&C/HSE/SARI Liaison Committee and that the minutes of these two groups would in turn be circulated to the National Committee. However, there remains considerable confusion and frustration amongst members of the Regional Sub-Committees regarding their reporting relationships, as local structures are still being finalised.
During 2005, a gap analysis (see Appendix II) was carried out to outline of progress in the implementation of SARI and where there remains considerable work to be done. This has identified significant deficiencies, primarily due to inadequate ring-fenced funding and the cap on public sector recruitment. Whilst a national framework has been established, there have been difficulties about ensuring that money allocated for the implementation of SARI has been used for that purpose in some of the old health boards. While 20 surveillance scientists have been appointed since 2001 but there are inadequate numbers of laboratory scientists, consultant microbiologists (12 additional microbiologists have been appointed but there is a requirement for at least an additional 20) and infection control nurses (35 appointed, an additional 30 required). Pharmacists with responsibilities for antimicrobial prescribing are absent in most Irish hospitals.
A pilot project, which was funded by the National SARI Committee in 2004, demonstrated the costeffectiveness of the employment of an antibiotic pharmacist in the HSE Midland Area (see Appendix III). However, this development has not been continued due to a shortage of funding. A general practitioner educational initiative (See Report from Community Antibiotic Stewardship Sub-Committee) was also funded as a pilot project in 2004 by the National Committee, but it has not been possible to extend this nationally due to a lack of funding.
An area that also requires urgent attention is the provision of a national framework for the surveillance of nosocomial or healthcare-associated infections in Ireland. Ireland remains without a national system for surveillance of healthcare-associated infections, despite this being a requirement under European Commission directive 2119/98/EC.
Following discussion at the National Committee, a submission to significantly fund SARI implementation was forwarded to the DOH&C by the HSE in advance of the budgeting estimates. However, there was much disappointment and frustration amongst members of the National Committee, and other Committees when the Departmental estimates did not include any specific allocation for the implementation of SARI during 2006.
The second SARI/Antimicrobial Resistance Action Plan or AMRAP (a similar strategy document to SARI for implementation in Northern Ireland) joint meeting was held in Armagh in November 2005 (See full report in Appendix IV). The theme of the meeting was antibiotic stewardship, and in particular, implementing strategies. There were presentations from Ireland, Northern Ireland, England and Belgium. It was clear that considerable progress has been made in the UK, (e.g. in Northern Ireland the overall consumption of antimicrobial agents has fallen in recent years), and in Belgium where a mass campaign has resulted in significant improvements in antimicrobial prescribing practice. In Northern Ireland the Department of Health, Social Services and Public Safety has launched a five-year implementation plan to reduce healthcare-associated infection, which includes clear implementation targets and commitments to provision of additional infection control resources. The contrast between the progress that is being made in Northern Ireland and in many European countries, with the slow rate of progress in Ireland, is striking. This meeting was attended by over 100 delegates and there were poster presentations on a variety of issues relating to antimicrobial resistance and the control of healthcare-associated infection.
The National Committee is also concerned at the grading of infection control nurses and the failure to recruit suitable individuals in senior positions because of the unattractiveness of the pay scale and the relatively poor grading. Negotiations are ongoing between the relevant parties to try to address this. Finally, the HSE has established a group to review the need for, and the nature of, reference laboratories in Ireland. This will have implications for the surveillance of antimicrobial resistance in Ireland.

Infection Control
The Sub-Committee met on five occasions and amongst its activities were the launch of the guidelines on the control and prevention of MRSA and hand hygiene, by the Tánaiste and the Minister for Health and Children, Ms. Mary Harney in September 2005. There was a general welcome for the national hygiene audit and the results that were disseminated in October 2005. However, whilst hygiene is an important component of infection control and prevention, it is just one facet of a multi-disciplinary approach required to improve the situation in Ireland. In particular, this needs to be addressed with the allocation of appropriate resources if the implementation of national standards for both hygiene and infection control is to be achieved. However it is important that these two linked issues are not regarded as synonymous.
The Sub-Committee discussed in some detail the development of a national programme of surveillance for MRSA in the light of a demand from the public and patients for accurate and meaningful data. Current information is not standardised or audited and therefore comparisons are not valid. Amongst the four options considered were: • improving the data collected as part of EARSS bloodstream infection data collection through linking this with Hospital In-Patient Enquiry (HIPE) data, • accessing and collecting clinical details and risk factors when Computerised Infectious Disease Reporting (CIDR) is fully in place, • initiating a limited form of surveillance in key clinical areas such as the intensive care and orthopaedic wards, • MRSA surveillance as a component of the Hospital Infection Society (HIS) Prevalence Survey of healthcare-associated infection. This survey is being conducted between February and May 2006 in England, Wales, Northern Ireland and Scotland and is an excellent opportunity to benchmark the prevalence of HCAI in Ireland. In addition and this survey will also collect, standardised comparable data on infections caused by MRSA.
A specific on-going national programme of surveillance of MRSA in intensive care units will be reconsidered after the HIS survey has been completed and analysed later in the year, but further national surveillance activity will require investment in personnel and infrastructure at both local hospital and national levels.
The Sub-Committee is conscious of the need to provide more information and education to the public and healthcare staff about healthcare-associated infection and antibiotic resistance. To this end, it has prepared patient information leaflets on general aspects of healthcare-associated infection, and MRSA. The Sub-Committee also heard a presentation from a company that is involved in the delivery of education and materials to healthcare staff in the National Health Service (NHS) in England. The Sub-Committee has recommended to the HSE that it consider such an initiative to update and educate all healthcare staff working in the Irish health service, similar to what is occurring in the UK NHS.
Further tasks for the Sub-Committee include the development of a template for a national infection control manual. Developments on this have already taken place in the Southern and Eastern Areas and the Sub-Committee is conscious of the need not to duplicate efforts. During the year, representation on the Infection Control Sub-Committee was expanded to include Public Health Nursing units.
Finally, it is not clear whether the Sub-Committee should take on board a broader remit of infection control in healthcare facilities generally (e.g. reviewing the facilities, space, ventilation required for various categories of patient areas) and not just that confined to the control of antimicrobial resistance. There is a lack of clarity on the role of this SARI Sub-Committee vis a vis the role and activities of various groups and agencies within the HSE, e.g. the development of infection control standards. This needs to be explored to ensure optimisation of effort and unnecessary duplication.

Hospital Antibiotic Stewardship
The Sub-Committee developed recommendations on the implementation of hospital antibiotic stewardship in Irish hospitals, including: • Structures and staffing for antibiotic stewardship The Sub-Committee also addressed issues of prescriber education, and developed a draft pocket guide to the prevention of antimicrobial resistance in hospitals. The Sub-Committee also examined options for postgraduate training for clinical pharmacists in antibiotic liaison, including involvement of one or more Irish schools of pharmacy in such training.
The Sub-Committee has identified the following key priorities for 2006: • Implementation of the recommendations on hospital antibiotic stewardship, as included in the SARI MRSA guidelines • Appointment of antibiotic liaison/infectious disease pharmacists, in line with recommendations from the Irish Hospital Pharmacists Association.
• Development and delivery of an education programme for hospital clinicians on prudent antibiotic prescribing.

Community Antimicrobial Stewardship
The Sub-Committee is currently involved in the following activities: • General Practitioner (GP) Educational Initiative • GP Sentinel Study

GP Educational Initiative
In 2003, 112 GPs participated in an educational exercise on antibiotic prescribing in their small group Continuing Medical Education (CME) sessions. This educational exercise was designed to highlight whether or not prescribing was in line with internationally available guidelines, with regard to choice of antibiotics, dosages and durations to use etc. Base line data revealed that only 57% of prescribing was deemed to be compliant with international guidelines used, although most deviations were minor. Discussion of inappropriate prescribing mostly focused on the fact that patients often express a wish to be receive an antibiotic and would be displeased if they didn't get one. Following GP education, there has been a significant increase in the proportion of antibiotic prescriptions in line with guidelines. However, there has been no change in the proportion of patients receiving a prescription for an antibiotic.

GP Sentinel Study
Much of the antimicrobial resistance data that originates from hospital laboratories is skewed towards hospitalised patients and there is less reliable data available on patients being treated by GPs. This study investigated the costs and feasibility of establishing a GP sentinel network to collect data on resistance patterns and antibiotic consumption. Seven group practices, four urban and three rural, fully participated in the data collection. The Microbiology Department of Cork University Hospital processed the microbiological specimens and provided culture and antibiotic susceptibility results. Each GP was asked to send specimens and record data on antibiotic usage patterns and associated diagnoses for four weeks. Nasal swabs were sent on all patients with respiratory symptoms and urine specimens were sent on all patients presenting with urinary symptoms.
An average of two minutes 30 seconds were added to consultation time where urine specimens were collected, with a further one to five minutes of administrative time. The time added collecting nasal swabs was an average of four minutes 30 seconds, with two to seven minutes of additional administrative time.
The estimated costs per specimen for transport was E6.20. When asked what they thought a reasonable remuneration fee would be the GP responses varied between E25-35 per specimen. The increased laboratory time involved in this study was substantial and the laboratory did struggle at times to keep up with the flow of specimens for the study.
Eight positive MSUs of 123 specimens submitted were positive for bacteria; all isolates were sensitive to co-amoxyclav and cephradine. Nasal swabs were taken from 362 patients and there were 70 significant isolates. Antibiotics were prescribed in 240 cases, 216 for immediate use and 36 for deferred use. Antibiotic resistance amongst the organisms isolated, to commonly used antibiotics, was low.

Development of GP prescribing guidelines
There are no Irish GP antimicrobial prescribing guidelines, and therefore guidelines on respiratory tract infections, urinary tract infections and skin infections were developed. These also include a chapter on avoiding unnecessary prescriptions for antibiotics. There is a need for GPs and indeed all doctors to take more ownership of the problem of antimicrobial resistance. Doctors, including GPs, may be more persuaded with evidence of drug safety (or lack of risk) of non-prescribing. The guidelines have been rewritten in the light of this qualitative research.

Development of patient educational materials
Work has just begun on patient educational materials. An MSc student has been recruited to evaluate early drafts and to develop them further.

Surveillance of Antimicrobial Resistance
The Antimicrobial Resistance Surveillance Subcommittee completed its remit and developed a series of recommendations on national surveillance in 2003. The key requirements for further development of antimicrobial resistance surveillance are: • Introduction of standardised susceptibility testing in all diagnostic laboratories (i.e. CLSI methodology) • Introduction of a standardised data collection system in all diagnostic laboratories (i.e. CIDR) • Provision of laboratory scientists with a dedicated surveillance role in all diagnostic laboratories These increases in resistance to individual antibiotic classes has been accompanied by increased reporting of both E. coli and E. faecium strains that are resistant to multiple classes of antibiotics.
A voluntary system for enhanced surveillance of bloodstream infections, based on EARSS data, was introduced in 2004. Because of the additional workload involved in providing additional demographic and clinical data, only a subset of laboratories have the personnel resources to be able to participate in this enhanced surveillance system. Nevertheless, the data has been shown to be representative of the overall EARSS data set. Results from this enhanced system have shown that central venous catheters are the most frequently identified source for S. aureus bloodstream infection, including MRSA bloodstream infection, and that this should therefore be a focus for future surveillance and control measures. The enhanced system has also shown that increased patient age, length of hospital stay, and meticillin resistance are independent risk factors for mortality in S. aureus bloodstream infection. After controlling for other risk factors, the 14-day mortality for MRSA bloodstream infection is approximately twice that of meticillin sensitive S. aureus (MSSA) bloodstream infection.
Detailed results of EARSS and the enhanced bloodstream infection surveillance system are available from www.hpsc.ie.

Surveillance of antimicrobial consumption
The Subcommittee did not meet in 2005, due to staff shortages at Health Protection Surveillance Centre (HPSC). However, a number of antimicrobial consumption surveillance activities continued in 2005. Irish participation in the European Antimicrobial Consumption Surveillance (ESAC) network continues, with data on community antimicrobial consumption calculated from wholesale pharmacy sales data purchased from IMS Health. This data has shown a steady increase in the level of antimicrobial use in the community, coupled with increasing use of "broad spectrum" antibiotics in place of "narrow spectrum" agents. In 2005 the National Centre for Pharmacoeconomics (NCPE) also continued to provide detailed data on community antimicrobial use among patients covered by the General Medical Services (GMS) scheme. This data confirmed the high level of antimicrobial use in the community in Ireland, compared to other European countries.
In 2005 HPSC collaborated with the Hospital Pharmacists Association of Ireland (HPAI) in the collection of national data on hospital antimicrobial consumption. Data on antimicrobial consumption in 2004 was received from 15 hospitals. This showed that the level of antimicrobial consumption in Irish hospitals was considerably higher than the European average. Preliminary data for hospital antimicrobial consumption in 2005 has shown a slight increase compared to 2004 data.
Future priorities for surveillance of antimicrobial consumption are: • Continued funding of surveillance activities at NCPE, to allow local data feedback to support GP antibiotic stewardship projects • Increased participation in hospital antimicrobial consumption surveillance • Establishment of community sentinel pharmacy surveillance, to obtain data on non-GMS antimicrobial consumption Detailed results of antimicrobial consumption surveillance activities are available at www.hpsc.ie and at www.ncpe.ie.

Regional Committees
There are eight multidisciplinary SARI regional committees that meet regularly and, before the setting up of HSE, reported to the Chief Executive of the relevant Health Board/Authority. These committees advise on the implementation of SARI in their region or area, and devise the annual priorities for the SARI strategy in keeping with those defined at a national level. They also advise on the associated resources required to implement the strategy regionally.

Eastern Area
The SARI advisory remit is discharged by the ERHA Infection Control Advisory Committee (ICAC). Each meeting addresses: • Updates from the national SARI committee with regional implications.
• Monitors progress on the agreed regional annual SARI priorities.
• Reviews and distributes the regional EARSS surveillance data.
• Reviews regional funding allocation and distribution.
• Audits SARI funded personnel posts.
• Develops/updates and distributes guidance documents relevant to the strategy.
• Co-ordinates applications for SARI funding.

Achievements
The committee met on four occasions and the priorities agreed and progressed were: • To confirm the requirement of infection control standards as an essential quality component of health care delivery to management of such facilities. This was conveyed in regular communication with regional service planners and commissioners, who in turn communicated with the individual hospital managers.
• To advise on the requirement for adequate hand hygiene facilities and isolation rooms in health care facilities in the region. Any deficit was to be highlighted to management by their relevant professionals and resources sought to remedy the situation.
• The Committee endorsed the National SARI Hand Hygiene and MRSA Guidelines and requested a national one-week hand hygiene implementation initiative. This occurred successfully in October 2005.
• An anonymous pilot regional audit of environmental cleaning in some ERHA health care facilities was presented in May 2005. This confirmed deficits that were later published from the July 2005 national audit.
• An audit of the regional use of SARI training funds proved that this was a well utilised ring fenced resource in all health care facilities and supported the work of the strategy at a local level.
• Continuous audit of SARI funded personnel posts demonstrated a deficit in some appointments, despite SARI funds already allocated to these institutions. Various reasons were given for this: (1) A cap on appointments, this affected 4.5 whole time equivalent (WTE) infection control nurses, a Grade 5 Clerical Officer and one WTE Public Health Specialist for the SARI core group at the ERHA; (2) Difficulty in finding appropriate appointees after advertisement.
• The committee produced a document advising on strategic regional SARI funding priorities to be considered for 2006, this was distributed regionally and to the National Committee. Individual facilities prepared and submitted their detailed SARI funding requests for 2006 to the HSE by July 2005 as requested.

Achievements
The infrastructure that has been funded for SARI implementation includes: • Equipment • Automated zone readers for susceptibility testing have been purchased for three laboratories • Clerical support in one hospital The following SARI related activities took place in 2005: • Regional EARSS data available and a system for distribution agreed • Laboratory antimicrobial resistance surveillance being developed for urinary tract susceptibility data • Introduction of CLSI methodology, for antibiotic susceptibility testing, in three laboratories.
• Hospital-acquired infection (HAI) surveillance project commenced with the appointment of a surveillance assistant. Surveillance data is now being collected in three centres.
• Nationally funded projects interim reports were made available.
• Additional funds made available for expansion of pneumococcal project.

South Eastern Area
Achievements Infection Control • The regional decontamination policy for acute hospitals in the South East was revised and distributed by the Infection Control Nurses (ICNs) in the region and education programmes took place. The policy is being adapted for the long stay hospitals.
• An Infection Control Committee for the district, psychiatric and longstay hospitals in Carlow/Kilkenny was established. These are the only counties in the South East in which there is an ICN appointed (SARI funded) to non acute facilities.
• An infection control link nurse programme commenced in Wexford General Hospital and the setting up of a similar programme in Waterford Regional Hospital is being explored.
• Setting up of multidisciplinary postoperative wound infection surveillance in Wexford General Hospital is being planned. Members of the Northern Ireland Healthcare Associated Infection Surveillance Centre (HISC) attended a meeting in Wexford General Hospital to outline their experience and give advice to the multidisciplinary team.
• The Central Line Infection Control Policy has been revised.
• A Urinary Catheter Care Policy was produced by the ICNs.
• A formal annual infection control service plan was presented to the Infection Control Committee in each acute hospital at the beginning of the year and a progress report was presented at each subsequent Infection Control Committee meeting.
• There was considerable involvement by one of the ICNs and one of the Consultant Microbiologists in the hospital accreditation process in Wexford General and Waterford Regional Hospitals.
• Surveillance of endoscopy rinse water was commenced to comply with current recommendations.
• Bi-monthly infection control newsletters were produced by the ICNs for nurse mangers in Waterford Regional Hospital.
• A report on isolation room deficits was complied by one the ICNs in Waterford Regional Hospital for the hospital manager.
• A meeting was convened in a long stay hospital with a rehabilitation unit by the hospital manger to discuss issues relating to MRSA positive patients in the hospital.

Microbiology Laboratory
• Accreditation was obtained for four sections of the microbiology laboratory.
• The category 3 laboratory was commissioned. It was officially opened by the Minister for Health, Ms. Harney.

Department of Public Health
• An infection control policy for nursing homes was produced.
Antibiotic Usage • One of the consultant microbiologists attended general practitioner CME meetings in Carlow and Kilkenny: Items discussed were appropriate use of the laboratory, MRSA and general practice and appropriate use of antibiotics.
• A number of initiatives have been established in the pharmacy departments in Waterford Regional Hospital and St. Luke's Hospital Kilkenny (e.g. surveillance of antibiotic usage, pharmacist ward visits).

Achievements
The following are the achievements at regional level • An information booklet on MRSA for public and families (patients and visitors) -"Get Well -Stay Well", was produced.
• Audits of hand washing facilities and practice were carried out in five acute hospitals to establish adequacy of hand washing facilities and is being reviewed regarding resource implications.
• Alcohol hand rubs have been introduced in all acute hospitals in the Mid-Western Area.
• In one hospital, 114 staff were trained in standard infection control precautions, 31 infection control and antibiotic policies were revised, and care plans for MRSA and enteric pathogens were developed

Western Area
• A joint Regional Infection Control / SARI Committee was established.
• Each hospital now has an Infection Control Committee.

NorthWestern Area
• A regional infection control committee was established.
• A Surveillance Scientist is now in place in Sligo General Hospital.
• Interviews took place and the post accepted for a permanent Surveillance Scientist in Letterkenny General Hospital. The person currently acting in this capacity has been very active but got a promotional post elsewhere. Therefore this position is now vacant.

North Eastern Area
No report received

Achievements
The main achievement in this region was the work undertaken in relation to antibiotic stewardship in Midland Regional Hospital at Tullamore (MRHT), Co Offaly, which has national implications if implemented elsewhere. An evaluation of the project showed it to be highly effective in reducing inappropriate antibiotic prescribing with a resulting improvement in patient care, reduction in secondary infections and hospital costs. This involved - • Prescribing guidelines to reduce risk in prescribing and administering antibiotics •Reduction in antibiotic expenditure against an increase in overall drug expenditure Full details are to be found in Appendix III.

On-going Challenges and Difficulties in the Full Implementation of SARI
There is considerable frustration, and even cynicism, amongst the various committee members, and the relevant healthcare workers on the ground about the slow pace of the full implementation of the 2001 SARI recommendations. There are increasing demands for better data, (e.g. MRSA rates), and for improvements in the delivery of healthcare by way of reduced or even contained rates of hospital-acquired infection.
However, these are not reflected in the priority given to this area at national level through central funding and subsequent regional or local funding allocation. The resources allocated to date have provided a basic infrastructure but are not sufficient to fully implement SARI. Feedback from the various committees has highlighted consistent and very prevalent themes. These are: The HSE Reform Process • The HSE reform process, commenced in 2005 created uncertainty as to the structures within which the Regional Committees should operate. This relates to confusion about the new administrative areas that do not coincide with the service delivery areas. The number of regional committees required nationally remains undecided. The reporting relationship of the Regional Committees is unclear and the route to seek resources for the strategy regionally requires clarification. One committee decided to suspend all its activities until clarification on the above was available, and an administrator assigned to the committee for SARI implementation resigned in July 05 due to HSE reallocation of duties, with no replacement. It has also been stated that there is a need for clarification of governance and accountability structures between HSE directorates in terms of SARI implementation.

Lack of ring-fenced funding and personnel
• Many SARI-related activities could not take place in 2005 due to lack of adequate resources and ceiling on staff appointments. SARI funds are also sometimes difficult to identify within general health board/HSE regional funding.
• Activities, developments and implementation of SARI strategy in 2006 will also be seriously restricted due to lack of adequate resources.
• A lack of feedback on the requests for 2006 SARI funding before the end of the year has had a negative impact locally and places Regional Committees in a redundant position. The absence of feedback is due to inadequate communication mechanisms between the DOH&C, the HSE and all those involved in SARI.
• The lack of additional resources allocated to the strategy in 2005 impeded further implementation. One committee advised approval of the requests for an additional three WTE Surveillance Scientists but these appointments were not progressed due to lack of funding. However, there is a responsibility on all healthcare professionals to comply with best professional practice in this area but the opportunity to optimise compliance is being lost.
• Deficits in the containment of patients with infections, including those with antibiotic-resistant bacteria, such as inadequate isolation facilities, are a major impediment. High bed occupancy is identified as a major obstacle to flexibility to facilitate isolation and cohorting of patients with transmissible infections.
• The recommended number of Infection Control Nurses for one region is seven but only five are in post.
Two further infection control nurses and a Divisional Nurse Manager in Infection Control are required here also. Only one of the eight ICN posts sought for the district and long stay hospitals in one region has been funded to date; a senior grade ICN is also required. There are also gaps in many regions and hospitals in terms of administrative support, biomedical (laboratory) and surveillance scientists and public health specialists.
• There is insufficient hospital pharmacy staff in most hospitals to provide the required input to monitor and advise on antibiotic usage in conjunction with the clinical microbiology personnel.

I Members of the National Committee, Sub-Specialty Committees and Chairpersons of the Regional Committees Membership of SARI National Committee, including Chairpersons of Regional Committees (2005)
The

Overall Results
• Definite prescribing trend changes with shift in prescribing from broad spectrum to narrow spectrum agents (Table 1) • Reduction in secondary fungal and viral infections, e.g. thrush. This is supported by a decrease of 50% and 18% in the expenditure on antifungals and antivirals respectively.    IV. Report of the 2nd Joint Conference on the Antimicrobial Resistance Action Plan (AMRAP) and the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) -Antibiotic stewardship -Implementing Strategies

Background
The second joint AMRAP/SARI meeting took place on 30th November 2005 in the City Hotel, Armagh. This year it was decided to focus particularly on antibiotic stewardship, as this is a key component of both strategies, North and South. In addition to the formal presentations, there were also 21 posters which covered such areas as the use of antibiotics, in vitro laboratory investigations of antibiotic resistance, epidemiology of antibiotic resistance, and the control and prevention of health-care associated infection. The day was divided into three sessions, the first considered implementing strategies to reduce healthcareassociated infections, the second focussed on European and English perspectives on antibiotic stewardship, and finally issues relating to antibiotic stewardship in the hospital and in the community, in particular, were covered in the last session. The meeting was organised by Mr. Jeff Dudgeon, Department of Health, Social Services and Public Safety (DHSSPS), Belfast and the Organising Group consisted of himself, Dr Hugh Webb, Dr. Tim Wyatt, Professor Hilary Humphreys and Dr. Robert Cunney.

Implementing Strategies
This session, which was chaired by Professor Hilary Humphreys (SARI Chair), looked at the current approaches to controlling healthcare-associated infection (HCAI) in the North and in the South. The first presentation was by Dr. Lorraine Doherty, Consultant Epidemiologist/Senior Medical Officer at DHSSPS in Belfast. She sketched the background to the development of Northern Ireland's five-year strategy to reduce HCAI, including recent issues such as endoscope decontamination, hygiene, MRSA and other matters. It is accepted that this strategy will minimise but cannot eradicate or eliminate all HCAI. Priorities in the strategy include appropriate organisation, enhancing the culture of infection prevention, education, governance, surveillance and a partnership between patients, the public and healthcare professionals. Each hospital trust will be required to produce an annual plan for reducing HCAI and the existing HCAI surveillance infrastructure will be strengthened, with the appointment of a HCAI surveillance coordinator to each trust. The commitment of all stakeholders to the implementation of this strategy and a time frame were especially noteworthy. be subsumed by risk management, for example. There was also some discussion on the role of the media in recent controversies concerning MRSA. Speakers from the floor argued that the health professionals should use the media better and not engage in blaming the media for inappropriate stories.

The European and English Perspective
This session was chaired by Dr. Hugh Webb (AMRAP Chair) and looked at issues concerning the use of antibiotics throughout Europe and interventions to improve antibiotic use in hospitals. The first speaker was Professor Herman Goossens who has a high international profile in the area of antibiotic stewardship. In particular he was organiser of a European conference on antibiotic use in 2001 during the Belgian EU presidency. He traced back developments at EU level to 1998, during the term of the Danish Presidency. A meeting held then recommended that surveillance systems should be put in place and that certain antimicrobial agents be phased out of food production. This was a major decision that appears to have resulted in reduced vancomycin-resistant enterococci (VRE) in Europe. In 2002, the EU looked at whether recommendations had been implemented and in 16 states there were plans in place and in 14, these were in preparation. However, it was recognised that it was difficult to collect data on antibiotic use in hospitals. In Belgium, there has been a public campaign to reduce the pressure on prescribers to use antibiotics to treat respiratory tract infections in the community. This has taken the form of media campaigns and almost E450,000 has been allocated each year to this component of antibiotic stewardship by the Belgian government. This has resulted in reduced overall antibiotic use since 1997 in Belgium, reduced antibiotic costs and these campaigns have been accompanied by a fall in the prevalence of penicillin-resistant pneumococci, a common community pathogen. The direct savings in antibiotic costs alone are almost 10times higher than the annual cost of the programme. Similarly in France, there has been a 16% reduction in antibiotic use since 2001. One of the priorities of the recently established European CDC has been to co-ordinate surveillance activities and the Framework 7 Programme includes antibiotic resistance among its priorities. This presentation clearly illustrated what can be done when there is a national programme that is adequately resourced to reduce the use of unnecessary antibiotics nationally.
The next speaker was Dr. Erwin Brown, who is a Consultant Microbiologist in Bristol and who is a member of the British Society for Antimicrobial Chemotherapy Working Party that has conducted a Cochrane review looking at what interventions result in better antimicrobial use in hospitals. The group conducted a major literature search resulting in 743 articles of which 56 were appropriate for further analysis. It was found that there was no difference between single or multiple interventions or between educational and restrictive antibiotic approaches, however restrictive interventions have a greater immediate effect. The only clear beneficial effect as assessed by microbiological results was a reduction in Clostridium difficile infection in four or five studies that sought to improve antibiotic use. It was not clear from the review whether the costs of the various interventions were less than cost savings due to less antibiotics being used. The group has proposed that interrupted time sequence studies are the best research approach for assessing the impact of interventions and that these should be accompanied by at least three observations before the intervention and twelve afterwards. It is likely that multiple interventions are effective but it is not clear which ones are the most effective. Finally, he advocated the importance of an antibiotic control committee as a sub-group of a drugs and therapeutics committee in every hospital to oversee the appropriate use of antibiotics.
After the two formal presentations, the panel discussion focussed on the design of appropriate trials to look at antibiotic interventions, the role of nurses in helping ensure optimal antibiotic stewardship. For example, there is often significant time savings for nurses if fewer and more focussed studies are used. Finally, it was advocated that antibiotic stewardship programmes should be linked closely with infection control and prevention strategies in the hospital.

Antibiotic stewardship in the hospital and the community
This session looked at recent developments the North and in the South and also reviewed the role of the infectious disease pharmacist in antibiotic stewardship. The session was chaired by Dr. Tim Wyatt, CDSC/Mater Hospital, Belfast. Dr. Robert Cunney, who is a Consultant Microbiologist at The Children's University Hospital, Temple Street, Dublin and the Health Protection Surveillance Centre, Dublin and Honorary Secretary of SARI, reviewed recent antibiotic consumption data in the Republic of Ireland. There has been an increase of 16.3% in antibiotic consumption overall from 1993 to 2004, and compared with other European countries we are in the high to moderate range of antibiotic consumers. This contrasts with the overall reduction in antibiotic use in Northern Ireland over the same time period. Similar to high usage countries, there is considerable seasonal variation in overall antibiotic use in Ireland. The data from 15 hospitals for 2004 were also reviewed. There was much greater variation in antibiotic use in smaller hospitals. Compared with other European countries we are again in the high to moderate usage group. In a household survey in which there was a 27% response rate, 40% of the public had had an antibiotic in the previous 12 months. General Medical Service (GMS) patients were more likely to have had an antibiotic. In another survey of public perceptions, 18% believed that an antibiotic helped them to get better if they had an upper respiratory tract infection and 44% had expected an antibiotic by the time they consulted a doctor with an upper respiratory tract infection. Although some of the data are better than a similar recent survey in the USA, the results were inferior to similar surveys carried out recently in Belgium where there has been considerable investment in public education campaigns.
The next presentation was by Professor Bryony Dean Franklin, Principal Pharmacist at the Hammersmith Hospitals in London. Here there are four hospitals in one Trust and they have a multi-disciplinary team looking at antibiotic stewardship. Barriers to optimal antibiotic stewardship include parallel hierarchies, consultant clinical autonomy and the lack of shared vision. However, since 1995, one infectious disease pharmacist has resulted in savings of £77,000 per year. A recent national UK initiative has increased the proportion of UK hospital trusts with infectious disease pharmacists from 30% in 2000 to 90% in 2005. An antibiotic steering group in the hospital can take initiatives in antibiotic restrictions, encouraging IV to oral switch, conduct antibiotic audits and provide internet and pocket guidelines for optimal antibiotic use. Recent point prevalence surveys have been carried out every six months since 1999 and this data is collected over 1 to 5 days. These have shown that approximately 33% of patients are on antibiotics at any one time, there is no seasonal variation in antibiotic use, and 54% of patients on antibiotics were receiving them intravenously. She argued that antibiotic stewardship needs to be integrated with the infection control and prevention team, such as looking at the prevalence of Clostridium difficile, and this can then be used as a performance management indicator.
Professor Colin Bradley, who is Professor and Head of the Department of General Practice in University College Cork, reviewed recent efforts to develop policies and procedures in General Practice. A review of the reasons for prescribing antibiotics included the clinical need, patient expectations, the use of a therapeutic trial to make a diagnosis etc. Patients may anticipate an antibiotic because that is what they received in a similar situation in the past. Furthermore, the presence of a bacterium does not indicate the need for an antibiotic, as many bacterial respiratory tract infections are self-limiting. Vital signs and a history of smoking and age are important considerations when deciding whether or not to use an antibiotic. Guidelines have been developed by the SARI Community Antibiotic Stewardship Subcommittee, which is chaired by Prof Bradley. These guidelines include the rational for antibiotic use, guidance on the treatment of acute infections and what microbiological tests if indicated, should be done. As part of the evaluation of these guidelines, 112 GPs have been asked to collect data on 100 consultations to assess the level of adherence. To date the data has shown that there is 40% strict adherence. It was agreed that sometimes the guidelines were unclear and GPs were uncomfortable prescribing antibiotics in 5.5% of consultations.
In the panel discussion that followed, and which also included Dr. Brenda Bradley, Senior Prescribing Advisor, Belfast, there were suggestions regarding how these GP guidelines could be extended beyond the local area. It was also argued that individual feedback to GPs and GP practices was more beneficial than formal meetings in driving change. Finally, although there have been some developments, it was agreed that electronic prescribing was not the answer at this stage to better antibiotic use either in hospital or in the community.

Conclusions
This was a very successful and well-organised meeting, which attracted 150 delegates from North and South. A feature of the meeting was also the presentation of posters covering a range of areas related to antibiotic resistance and the prevention of HCAI. It was clear that the issue of antibiotic stewardship in particular struck a chord with many of those present as attempts to reduce antimicrobial resistance must focus on better antibiotic use as a priority. It is also clear that there is a need for annual meetings of this kind but that they should focus on a particular aspect of antibiotic resistance rather than trying to cover too many broad areas of the subject. It is also obvious that national initiatives that are adequately resourced and funded, e.g. the resources put in to reducing antibiotic use in Northern Ireland, Belgium and France, are essential if we are to contain antibiotic resistance. However, central government agencies and others must acknowledge this.
Hilary Humphreys on behalf of the Organising Group February 2006