Antimicrobial Stewardship from Policy to Practice: Experiences from UK Antimicrobial Pharmacists

Feedback of consumption data is a key element of an AMS program [28]. In order to engage prescribers, data are needed [29] and lack of it is a barrier to effective implementation of AMS [30, 31]. In the UK, consumption data have been available since 1991 for community prescribers. It is captured as part of the reimbursement of community pharmacists for dispensing NHS prescriptions [32], but will not include antibiotics supplied by any other method, e.g. private prescriptions or packs given out in clinics. The data are used to compare rates of prescribing within localities using a standardized method to account for differences in the local population. For example, the use of Specific Therapeutic Group Age–sex weightings Related Prescribing Units (STAR-PUs) as a denominator allows more accurate and meaningful comparisons within a specific therapeutic group by taking into account the types of people who will be receiving that treatment [33]. These data can be used to drive improvements in antimicrobial prescribing rates, total antibiotic consumption and broad-spectrum antibiotic consumption (cephalosporins, fluoroquinolones and amoxicillin/clavulanate) [34, 35]. From 2005 until 2013, overall antimicrobial consumption had been increasing in the community, but significant reductions were seen in the use of cephalosporins and fluoroquinolones [32]. Although there has been no explicit linkage between increasing AMR rates and increasing consumption of specific antimicrobials or classes, in 2014, the Department of Health’s expert advisory committee, the Advisory Committee on Antimicrobial Resistance and Healthcare Acquired Infections (ARHAI), proposed that total antimicrobial consumption should reduce to 2010 levels in the community [36, 37] and that the proportion of antibiotics from cephalosporin, quinolone or amoxicillin/clavulanate classes should reduce by 10% from the 2013/2014 value or to less than the 2013/2014 median, whichever is the smaller reduction. In 2015–2016, a Quality Premium [38] (financial reward) was introduced to achieve this goal, along with a national reporting tool to monitor it [39].

In Scotland, a similar national quality indicator was introduced in 2013 aimed at reducing unnecessary antibiotic use for self-limiting respiratory infections. This uses a ‘best in class’ approach so that at least 50% of practices in each region will be at or below the 25th percentile of Scottish practices (using January–March 2013 as the baseline) or will have made the minimum acceptable reduction toward that level. In 2013–2014, there were 276,383 (6.5%) fewer prescriptions for systemic antibacterials in primary care in Scotland than in 2012–2013 and 57.5% of practices achieved the national quality indicator. Since 2008, there has been a focus on reducing the use of cephalosporins, quinolones and amoxicillin/clavulanate in the community and this has led to year-on-year reductions in the use of these agents [40].

For English hospitals, a detailed and comprehensive report published by the English Surveillance Program for Antimicrobial Utilization and Resistance (ESPAUR), set up by Public Health England in response to the five-year AMR strategy, provided the very first national data on antimicrobial consumption [41]. This report covered the period 2010–2013 and used consumption data derived from hospital pharmacy stock management systems for drugs dispensed to both individual patients and ward stocks. This type of data has to be used because electronic prescribing (EP) in hospitals in England is very much in its infancy [41]. Using hospital pharmacy stock management systems prevents the reporting of detailed consumption data down to doctor or clinical team level, and neither of the two main pharmacy accounting systems used in the UK includes a reporting tool as standard. A worldwide survey of hospital AMS showed that 92% of UK hospitals reported antimicrobial usage data, but only 52% reported defined daily doses (DDDs) to specialty level, and even fewer were able to link consumption data to resistance or infection rates (31% and 33%, respectively) [42, 43].

The ESPAUR report [41] showed an increase in overall antibiotic consumption in hospital inpatients of 11.9% over the 4-year period (an average year-on-year increase of 3.5%, equivalent to 2.3–2.5 DDD per 1000 inhabitants per day). The data were reported at area level only, so did not allow benchmarking between hospitals.

ARHAI in England also proposed (although these proposals may be subject to further refinement) that total antibiotic consumption be reduced by 1% per annum over 2015–2019 (as measured by DDD per 1000 admissions per year), and total carbapenem consumption be reduced to 2010 consumption levels (as measured by the same method), corresponding to an average reduction of 20–25% [36, 37]. Again, there has been no explicit linkage between increasing antimicrobial consumption and increasing AMR, but the ESPAUR report does show increases in both elements over the reporting period, and controlling antimicrobial consumption is recognized as a key element of the AMR strategy [41]. In 2015–2016, consumption data are being validated by hospitals as part of the Quality Premium [38]. In addition, 65% of NHS hospitals are also using a specific software package (Rx-Info Define) to benchmark hospital medicines consumption [44].

Since 2008, SAPG has published annual reports on antimicrobial use and resistance in humans [45] utilizing national data marts which collate data from hospital Pharmacy and Microbiology systems and prescriptions for antibiotics dispensed by community pharmacists. In Wales, the Welsh Antimicrobial Resistance Program Surveillance Unit (WARP-SU) [46] currently reports antimicrobial usage and resistance data. Finally, within Northern Ireland, the COMPASS system [47] provides data on primary care antibiotic prescribing with the national AMR dataset currently being developed.

There are two national AMS toolkits for England: Start Smart then Focus for hospital care [25, 26] and the Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) Antibiotics toolkit for community care [24]. Wales [48] and Scotland [49] have their own versions of the guidance. In addition, national guidance on AMS is due for publication in August 2015 by the National Institute for Health and Care Excellence (NICE) [50].

The Scottish Antimicrobial Prescribing Group has produced national guidance [49] on AMS and infection management to support antimicrobial teams and prescribers across hospital and community care settings. All regions have a centrally funded antimicrobial pharmacist position in addition to locally funded positions to support local delivery of stewardship and drive quality improvement in antimicrobial prescribing.

A large proportion of antimicrobial pharmacist time is currently dedicated to optimizing prescribing practice, as described later in this article.

Education and training is essential to optimizing prescribing and AMS, and, in order to drive consistency in practice, performance standards need to be set. The first national antimicrobial prescribing and stewardship competences were published in 2013 and these are currently being developed to include in Health Education England work streams [51]. The competences consist of five dimensions, and each dimension includes statements that describe the activity and outcomes that prescribers should be able demonstrate. The five dimensions are:

Antimicrobial pharmacists are central to the delivery of education on stewardship for healthcare staff, and in 2014 an expert curriculum [52] was developed to support specialist Infectious diseases and antimicrobial pharmacists in this role, as well as providing professional development opportunities. The 4-year pharmacy degree contains variable amounts of teaching and training in AMS and there are limited postgraduate opportunities for pharmacists to gain specialist training in infection management and AMS [53]. The expert curriculum provides the first opportunity to develop some form of credentialing in this area.

The TARGET antibiotic toolkit [24] includes educational materials for prescribers in primary care. A similar initiative has also been developed in Wales: the ‘Stemming the Tide of Antibiotic Resistance’ educational program (STAR) [54, 55]. This includes resources for clinicians to share with the public during consultations and is reported to have helped deliver changes in local prescribing practices and reduce unnecessary antibiotic use [56]. In Scotland, a similar program, the Scottish Reduction in Antimicrobial Prescribing (ScRAP) [57], was launched in October 2013 as an educational resource to help prescribers to meet a government target to reduce unnecessary prescribing of antibiotics. In 2015, SAPG, in collaboration with NHS Education for Scotland, launched a stewardship resource for nurses and midwives in the form of an interactive electronic workbook [58].

Since 2008, the UK has actively promoted ‘European Antibiotic Awareness Day’ (EAAD) which is held in November each year to raise awareness among health professionals and the public of AMR and appropriate prescribing and antimicrobial use. In 2014, to move from raising awareness to engagement, and as a marker for behavior change, a new campaign, Antibiotic Guardian, was developed which called on everyone in the UK to choose a pledge on the website http://​www.​antibioticguardi​an.​com. The pledges were developed using the behavior change strategy ‘if–then’ approach. In the first two months, 11,998 healthcare professionals and members of the public chose a pledge and became antibiotic guardians.

Although there is an extensive literature on the positive contribution that electronic systems (such as computerized clinical decision support, computerized physician order entry or full EP) can provide to AMS, the bulk of this originates from the USA, South East Asia, and Australia, where such systems have been in use for many years [64‐68]. EP is not yet widely implemented in the UK, although a handful of pathfinder hospitals have had experience with EP systems for a considerable time [69]. Furthermore, although the potential benefits from introduction of EP have long been recognized [70, 71], little work has so far been published on the actual impact of these systems on antimicrobial usage and resistance. Four small case studies have reported on the impact of electronic systems in AMS in the UK [72‐75] demonstrating decreased levels of antimicrobial usage [72], increased identification of patients requiring intervention [73], avoidance of clinically significant drug interactions [74] and improvements in documentation of key antimicrobial indicators (such as indication and duration, which feature in the Start Smart, Then Focus toolkit) [75].

Around 15 different providers of EP systems are active within the UK market, and these products are being used in about 20% of NHS Trusts, with an expectation that 40–50% of Trusts will have a plan for implementation of EP in place by 2016 [76]. With this large number of different solutions and timelines for implementation, there will inevitably be significant variation in how EP is used to support AMS. There is an on-going research program investigating how EP is introduced into NHS Trusts which will include work looking at effectiveness (primarily safety considerations around drug–drug interactions or allergy awareness) and outcomes [76]. Work is beginning, with the formation of ESPAUR, to help guide NHS Trusts in their procurement and implementation plans for EP, with specific reference to their use in AMS. It is to be expected that, as EP systems and their use in stewardship matures within the UK, an increasing evidence base will become available, highlighting additional beneficial outcomes (and potential pitfalls).

A further step change in the benefits of EP for stewardship will be achieved by implementation of mobile technologies harnessing EP, biochemical and microbiological results, patient observations, radiology, and clinical decision support in a single point-of-care device. There are a large number of antimicrobial smartphone apps available within the UK, commonly providing information on preferred antimicrobial choices for specific indications, but, as this field also matures, the exciting possibilities provided by linking these apps with the many data sources available to support clinical decision making will drive innovation and research in this area.

Despite the low incidence of invasive fungal infections compared to bacterial infections, for some specialist centers antimicrobial expenditure is dominated by antifungal use. While strategies have focused on the prudent use of antibiotics, antifungal stewardship is less well defined. This is primarily due to a lack of effective diagnostics to guide therapy, of therapeutic drug monitoring to guide dosing and of knowledge of the funding arrangements for antifungals. Antifungal stewardship initiatives are gaining momentum in the UK at present with pharmacists driving the agenda. One such program [77] has suggested savings of approximately £180,000 over a 12-month period by rationalizing and reviewing therapies, while another two programs [77, 78] found stepping down and stopping unnecessary empiric therapy was common.

Over recent years, there has been a drive to treat patients closer to their own home, facilitating early discharge or even avoiding admission altogether. For antimicrobials, outpatient parenteral antimicrobial therapy (OPAT) offers a safe and effective (clinically and financially) [79] means to deliver treatment outside the inpatient setting, providing good clinical governance and AMS practices are in place [80, 81]. Pharmacists have been cited as core members of the OPAT team in both the adult and pediatric UK OPAT good practice recommendations [81, 82]. This has led to a number of pharmacists taking national roles in this area, particularly addressing the stewardship dilemma that OPAT presents where the convenience of dosing antimicrobials to suit OPAT may take precedence over the spectrum of activity [80].