Prioritising antimicrobial stewardship and prescribing

antimicrobial stewardship
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Professor Diane Ashiru-Oredope, Lead Pharmacist for healthcare associated infections and antimicrobial resistance at the UK Health Security Agency, outlines the UK’s progress in mitigating the threat of AMR, and where further improvements are needed.

The UK is often cited as a driving force in mitigating the threat of drug-resistant infections and bolstering efforts in antimicrobial stewardship and optimal prescribing. As well as its commitment to global AMR-based initiatives including the World Health Organization’s Global Action Plan on AMR, the UK is readily addressing AMR at the national level, most notably through its commitments outlined in the five-year plan for AMR (2019-2024) which highlights the importance of working collaboratively, across sectors, to improve diagnostic procedures, prescribing and the availability of supporting data.

To discuss the UK’s efforts in more detail, as well as other strategies that are integral to improving public awareness and antimicrobial stewardship programmes across care settings, Lorna Rothery spoke to Professor Diane Ashiru-Oredope. Professor Ashiru-Oredope is Lead Pharmacist for healthcare associated infections (HCAI) and antimicrobial resistance (AMR) at the UK Health Security Agency and Chair of the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR). She is also Honorary Chair and Professor of Pharmaceutical Public Health at University of Nottingham.

An antimicrobial pharmacist by background, she has led on several projects that have shaped national and international policy in tackling antimicrobial resistance, including creating the global Antibiotic Guardian campaign in 2014. From 2016 until March 2022, she was advisor and Global AMR lead for the Commonwealth Pharmacists Association.

How would you describe the current narrative around antimicrobial prescribing and stewardship in the UK? Is there a renewed sense of momentum to prioritise AMR post COVID?

The UK Government is committed to tackling AMR, publishing the UK 5 Year Antimicrobial Resistance Strategy in 2013 and the subsequent 20-year vision and accompanying action plan in 2019. The five-year national action plan (NAP) for antimicrobial resistance (2019-2024), sets out ambitions and actions for tackling AMR, in support of the UK’s 20-year vision for AMR. An addendum to the NAP was published in May 2022 outlining changes to the NAP commitments; these were required to reflect lessons learnt from COVID-19, current progress and the work towards new sector targets.

Antimicrobial prescribing levels and stewardship are considered critical components of tackling AMR in the UK. In England, national evidenced-based antimicrobial stewardship interventions have been developed for primary and secondary care (as well as community pharmacy) to support the delivery of the national action plan objectives. These include the Start Smart then Focus toolkit for hospitals, TARGET Antibiotics toolkit for primary care and community pharmacy, peer review AMS support, tools to assess the appropriateness of prescribed antimicrobials, eBUG, Antibiotic Guardian and World Antimicrobial Awareness Week /European Antibiotic Awareness Day. Each of these tools is regularly assessed for impact with findings presented in the annual English Surveillance Programme for Antimicrobial Utilisation and Resistance report.

The COVID-19 pandemic has shown us the impact an infectious disease can have on our health and way of life. The COVID-19 pandemic also affected the antimicrobial stewardship (AMS) activities undertaken across the UK. Of the AMS leads that responded to a UK-wide survey, most reported a reduction in AMS activity, with 64% (61 out of 95) reporting that COVID-19 had a negative impact on routine AMS activities.

Developing proactive antimicrobial stewardship approaches and surveillance for novel therapeutics for COVID-19 has important implications for the monitoring of new antimicrobials. New methods for communication and collaboration among stewardship teams, infection prevention programmes, and information technology departments should continue. As healthcare systems return to pre-pandemic ways of working, it is pivotal to ensure there is a concerted focus on AMR.

What are some of the key challenges when designing and implementing antimicrobial stewardship programmes across care settings?

In the UK, antimicrobial stewardship programmes are well established in hospital settings although not without challenges. Implementing AMS programmes has additional challenges in long-term facilities, outpatient clinics and community pharmacies. However, there has been an increased focus on providing relevant AMS interventions for these settings in recent years. Key challenges across settings are:

Resource constraints

Implementing effective AMS programmes requires significant resources including multidisciplinary specialist healthcare teams, engagement from frontline healthcare professionals (especially those involved in prescribing, dispensing and administration of antimicrobials), diagnostic and laboratory capacity and effective implementation, information technology infrastructure as well as education and training of healthcare professionals, patients, and the public. In settings other than acute care hospitals, there are also limited microbiology and stewardship specialists to lead AMS programmes.

Perceived additional burden and imposed limitation

Frontline clinicians who usually focus on the patients they are reviewing at any particular time can be resistant due to the perceived additional burden of implementing AMS interventions and a perceived potential limitation to their ability to provide the best care for patients. One of the main issues often reported as a source of hindering healthcare professionals from maximising the available resources is the lack of time. Healthcare professionals report having limited time with each patient and utilising the interventions often adds to the time pressure. For example, it can be challenging to add CRP point-of-care testing to the usual consultation time, many have also reported a lack of time to advise patients and many also felt that electronic tools take too long to use. General practitioners have also reported that lack of internet access among some patient groups is a barrier to using some materials as they are unable to email electronic information sheets to patients or direct them to online information, especially those who are elderly.

Although there is a wealth of data available in the UK, there are challenges across sectors in obtaining timely data on antimicrobial use and resistance to identify areas for improvement.

Coordination of care across different care settings remains challenging however the recent model of Integrated Care Systems, provides important opportunities for the future.

It is worth highlighting that in some parts of the world, there are additional challenges such as a lack of regulatory support or enforcement of regulation by regulatory bodies, and a lack of basic data infrastructure to collect and analyse data on antibiotic use and resistance.

Implementing AMS programmes has additional challenges in long-term facilities, outpatient clinics and community pharmacies. However, there has been an increased focus on providing relevant AMS interventions for these settings in recent years © shutterstock/DC Studio

Understanding the impact of ethnicity, deprivation, and regional divergence, along with potential confounders, remains a crucial avenue of enquiry, and is essential to the identification of appropriate target interventions. A multifaceted approach including education, training and awareness campaigns for both members of the public and healthcare workers, increased resources for ASPs, improved coordination across care settings, and regulatory support for antimicrobial stewardship programmes are needed.

How do levels of antibiotic dispensing and stewardship efforts in hospitals and pharmacies differ?

In England, the majority (72.1%) of antibiotics are prescribed in general practice and dispensed through community pharmacies. Hospital inpatients account for 13% of prescriptions, hospital outpatients 6%, dental practices 4% and other community settings 4%. Significant and focused stewardship efforts have been in place in UK acute hospitals and primary care for several years. In recent years, there has been increased stewardship support for community pharmacy teams including through national programmes and the development of directly relevant stewardship interventions and tools. Recently in England and Wales for example, the TARGET antibiotic checklist part of the national AMS resources for primary care, which aims to support interaction between community pharmacy teams and patients prescribed antibiotics, has been implemented nationally. The checklist, completed by the pharmacy staff with patients, invites patients to report their infection, risk factors, allergies, and knowledge of antibiotics. The TARGET antibiotic checklist was part of the AMS criteria of England’s Pharmacy Quality Scheme for patients presenting with an antibiotic prescription from September 2021 to May 2022. A total of 8374 pharmacies (88% of all community pharmacies in England) collectively submitted data from 213,105 TARGET antibiotic checklists. In total, 69,861 patient information leaflets were provided to patients to aid in the knowledge about their condition and treatment.

Do we yet understand enough about why antimicrobials are being mis- and overused?

Mis- or overuse of antimicrobials is unlikely to be intentional compared to some other drugs. Behavioural science methodologies are important to understand why and how to address mis- and overuse, we have some understanding of why antimicrobials are mis- and overused and these include:

  • Lack of awareness and knowledge about antimicrobials including what they can be used
    for. For example, there are misconceptions that all antimicrobials cure any kind of ill health or symptoms associated with infections; also, antibiotics can cure self-limiting infections usually caused by viruses e.g. colds and most coughs. Also, when they are prescribed, there can be a lack of knowledge of how to use them appropriately and when to stop;
  • Fear of patient deterioration or complications:  an EU-wide study of healthcare workers in 2019 highlighted that 31% of prescribers said they would have preferred not to prescribe an antibiotic at least once in the week before completing the survey, but did so anyway. The most common reason for this was fear of patient deterioration or complications, with prescribers reporting that this fear affected their prescribing decision at least once per week (43%), or at least once per day (11%);
  • Perceived pressure from patients and other stakeholders (such as parents or carers) has also been highlighted as contributing to inappropriate prescribing;
  • Diagnostic uncertainty as healthcare professionals sometimes find it difficult to differentiate between viral infection and bacterial infection and recommendations based on the interventions do not always agree with their clinical judgement;
  • Communication: The importance of ongoing training to enhance communication skills
    for those with direct patient contact cannot be underestimated. A cluster randomised control trial including primary care practices in five European countries representing north, south and central Europe (Belgium, the Netherlands, Poland, Spain and the UK), has previously shown that Internet-based training to enhance the communication skills of prescribers, including the use of a patient information booklet, achieved reductions in an antibiotic prescription for respiratory tract infections across language and cultural boundaries.

Quantifying the burden of AMR is challenging due to the sophisticated and novel methodologies required. UKHSA has contributed to the development of state-of-the-art analytical methods to enable the health and economic impact of AMR to be quantified. Such estimates are crucial to enable health economic evaluations of intervention and control strategies, which UKHSA undertake. UKHSA also continues to work with partner organisations to develop relevant evidenced-based interventions.

How important is it to bring public understanding into conversations about antimicrobial resistance and stewardship?

Given the influence of patients on prescribing in primary care, as well as other mechanisms through which behaviour can increase the risk of AMR, such as self-medication (e.g. through online sources or use of leftovers) and inappropriate disposal of antibiotics, it is important to increase public understanding about the risks of antimicrobial resistance and especially what actions they can and should take to mitigate the risk of antimicrobial resistance for themselves and those around them. It is worth highlighting that the complex nature of AMR creates challenges when developing a public health campaign both in determining the campaign messaging and which behaviours contribute to increased resistance. There is also a balance needed to ensure the public seek help when it is needed. We know that public health campaigns to improve public knowledge and awareness have been successful at altering behaviour relating to other aspects of public health, such as increasing cancer screening attendance, smoking cessation, and reducing alcohol consumption. However, unlike AMR, these campaigns focus on aspects of public behaviour that have a well-defined, single behaviour to target and evaluate in order to determine the campaign’s effectiveness.

A multifaceted approach including education, training and awareness campaigns for both members of the public and healthcare workers, increased resources for ASPs, improved coordination across care settings, and regulatory support for antimicrobial stewardship programmes are needed © shutterstock/fizkes

Recently in England, the interim findings from two surveys conducted with members of the public, highlighted that the restrictions imposed during the pandemic impacted health-seeking behaviours across England and led to greater self-management for respiratory tract infections (RTIs). It also highlighted the need to focus on groups with characteristics commonly associated with health inequalities, such as those with disabilities, socially deprived groups, minority ethnic groups as well as younger adults.

Previous systematic reviews have shown that the effectiveness of an intervention on antibiotic prescribing depends to a large extent on the prescribing behaviour and any barriers to change that may exist within the targeted community. In addition, multifaceted educational interventions occurring on multiple levels are only effective after addressing such local barriers to change. Educational training and communication materials for healthcare workers and the public should take this into account, and behaviour change strategies should be the aim of interventions developed.

Can you share any examples of best practice or successful antimicrobial stewardship interventions? How could these be adapted for other care settings in the UK, and further afield?

Over the last ten years, through the development of evidence-based interventions and quality-improvement initiatives by national organisations such as UKHSA, NHS England, professional bodies, ESPAUR stakeholders and the effective delivery by frontline primary and secondary health workers, total antibiotic use in England has reduced. Before this, antibiotic use had risen every year from 2008 to 2013 (+16.6%).

Examples of national AMS interventions which have contributed to driving change include:

  • Start Smart then Focus toolkit for secondary care which provides an outline of evidence-based antimicrobial stewardship activities in the secondary healthcare setting (hospitals);
  • TARGET (Treat Antibiotics Responsibly, Guidance, Education and Tool) Antibiotics toolkit for primary care which supports influencing prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use;
  • eBug – a national and international health education resource that teaches children,
    young people and communities about hygiene, the spread of infections, antibiotic use, and resistance. Established in 2006, following a European Union-wide needs assessment, the resources were launched in 2009 and are now endorsed by the National Institute for Health and Care Excellence, in guidance that recommends that all schools use e-Bug to
    educate on hygiene, infections and antibiotics, available here;
  • Evidence-based national clinical guidelines for the management of infections e.g. NICE, SIGN for managing common infections in the context of tackling antimicrobial resistance – specifically in relation to bacterial infection and antibiotic use. These guidelines also support the work of primary and secondary care settings in their antimicrobial stewardship efforts;
  • Antibiotic Guardian a global initiative that invites the public, students, educators, farmers, veterinary and healthcare workers, and professional organisations to choose a pledge on how they will make better use of antibiotics. The initiative uses a behaviour change strategy, implementation intention, and an ‘if-then’ planning approach: if X happens, then I will do Y. For example, one of the pledges for general (primary care) practitioners is ‘The next time I intend t0 prescribe antibiotics for a self-limiting infection to a patient with high expectations of antibiotic treatment, I will use a delayed/backup prescription’. The use of implementation intentions has been shown through meta-analyses to support both individuals and groups in bridging their intention-behaviour gaps. Evaluation of the Antibiotic Guardian campaign has shown that the if-then approach increased commitment to tackling antibiotic resistance in both healthcare workers and members of the public, increased self-reported knowledge, and changed self-reported behaviour. This was particularly the case among people with prior awareness of antibiotic resistance; and
  • More recently, a national consensus for IV to Oral switch criteria has been developed and published.

With thanks to Dr Neil Cunningham, National Medical Director’s Clinical Fellow, and Dr Colin Brown, Director Clinical and Emerging Infections UKHSA for their review and contributions.

This article is from issue 25 of Health Europa Quarterly. Click here to get your free subscription today.

Contributor Details

Professor Diane Ashiru-Oredope

Lead Pharmacist, HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency Honorary Chair and Professor of Pharmaceutical Public Health, University of Nottingham
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