Charlotte Eley and Professor Cliodna McNulty discuss NICE Guideline 63 on antimicrobial stewardship, and explain what steps can be taken to reduce antimicrobial prescribing
Read this article to learn more about:
- the problem of antimicrobial resistance, and why antimicrobial stewardship is crucial
- how to manage patient expectations during a consultation
- where to find and how to disseminate information on antimicrobial stewardship.
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. Earn 0.5 CPD credits
Antimicrobial resistance (AMR) has been identified as a growing serious threat to public health by the World Health Organization.1 The development of resistance occurs when a microorganism adapts so that a drug to which it was originally sensitive becomes ineffective. As a result, infections caused by resistant organisms may persist and increase morbidity and hospital stays, which in turn may also increase the risk of these infections spreading to others.1
Antimicrobial resistance is much broader than just antibiotic resistance; it also covers the resistance of other organisms including fungi and viruses. Overall, AMR is increasing and the lack of new antimicrobials to treat resistant diseases1 means that current antimicrobials should be used responsibly so that they remain effective for as long as possible.
The Chief Medical Officer, Dame Sally Davies, stated that: ’Antimicrobial resistance poses a catastrophic threat. If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics…’2
NICE Accreditation Mark
NICE Guideline 63 on Antimicrobial stewardship: changing risk-related behaviours in the general population has been awarded the NICE Accreditation Mark.
Antimicrobial stewardship is a multifaceted approach to promote the appropriate use of antimicrobials and preserve their effectiveness, including:
- prescribing antimicrobials only when they are needed
- reviewing the continued need for antimicrobials
- educating the public on:
- self-limiting illness and correct use of antimicrobial medicines
- the dangers associated with overuse and misuse
- why good hygiene is essential to reduce spread of infection
- how infections can be prevented with vaccines.
To help prevent AMR it is important that antimicrobials are prescribed according to the principles of antimicrobial stewardship (see Box 1, below).
Box 1: The main principles of antimicrobial stewardship3
Encourage everyone to take responsibility for tackling AMR through excellent hygiene and responsible antimicrobial use. This includes local authority public health teams, commissioners, prescribers, primary care and community pharmacy teams, childcare and education providers, and the general public of all ages
Ensure that antimicrobial stewardship programmes are a local priority. Local authorities and CCGs should work collaboratively towards a system-wide approach to reduce AMR with consistent information to share with the public to help reduce inappropriate antimicrobial demand and use, and advising people on how to use antimicrobial medicines
Improve people’s infection prevention knowledge and their behaviour towards antimicrobials, especially children and young people, who will be future antimicrobial users and prescribers.
NICE Guideline (NG) 63 on Antimicrobial stewardship: changing risk-related behaviours in the general population (published January 2017) aims to inform and change people’s behaviour towards antimicrobial medicines, reduce AMR, and limit the spread of infections caused by resistant microbes.3 This article will discuss the key aspects of NICE NG63 relevant to primary care.
Key priorities for implementation
The key priority for implementing NICE NG63 is to use and share resources that provide advice and information on AMR to change public behaviour and reduce antimicrobial use.
In order to reduce patient antibiotic expectations, clinician and patient communication (including information sharing) needs to be improved during the consultation.4 For example, during a consultation for a respiratory tract infection (RTI), patients should receive:5,6
- reassurance that their infection is not severe
- advice about self-care and illness duration
- information on when they should re-consult.
Patients need to feel that their concerns have been listened to and addressed, which in turn should help reduce future GP consultations and unnecessary antimicrobial prescriptions.
During a consultation, remember ‘the six Rs’ of good practice for information exchange and eliciting patient concerns and expectations:6
- Reassurance—reassure the patient about the severity of the infection
- Reasons—provide reasons if antimicrobials are not necessary. Communicate these to the patient in a clear manner
- Relief—this can be advised in the form of paracetamol for pain
- Realistic—give a realistic natural history or length of duration of illness
- Reinforce—reinforce the key message that back-up prescriptions must only be used if symptoms worsen or do not even begin to settle in the expected time
- Rescue—give safety netting advice at the end of the consultation.
Resources and training for healthcare practitioners
Prescribers, primary care practitioners, and community pharmacy teams can promote best practice through sharing advice, resources, and existing best practice principles by signposting AMR resources from national agencies such as Public Health England (PHE) and NHS Choices. For healthcare practitioners to share materials with the general public successfully, they need education, training, and information on prescribing. A range of resources for primary care healthcare practitioners are discussed below.
TARGET antibiotics toolkit
The Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) antibiotics toolkit is aimed at primary care practitioners and is designed to help influence 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, helping to fulfil CPD and revalidation requirements (see: www.rcgp.org.uk/TARGETantibiotics).7 The toolkit includes:
- a presentation/workshop for primary care staff on how to optimise management of common infections and what patient-facing materials are available
- patient leaflets to share in a consultation
- audit templates
- antimicrobial and diagnostic guidance
- educational posters and videos
- self-assessment checklist on prescribing practice
- other free e-Learning resources.
Another useful resource is PrescQIPP,8 an NHS programme aimed at supporting optimised prescribing for patients. PrescQIPP produces evidence-based resources and tools for primary care commissioners, while also providing a platform to share innovation across the NHS. A webkit on antimicrobial stewardship is available.
PHE Fingertips website
Healthcare professionals can also use the PHE Fingertips website, which provides access to a wide range of health data, categorised into thematic profiles, including a profile on AMR local indicators. This profile allows users to browse AMR indicators (such as antimicrobial resistance, antibiotic prescribing, and infection prevention and control) at different geographical levels, benchmark against the regional or England average, and export data to use locally.9
Training helps to ensure that consistent information is being provided to the public. A range of courses on antimicrobial stewardship are available for healthcare professionals, including:
- RCGP online learning on antibiotic resistance in primary care10
- TARGET webinars11
- Health Education England introductory course on reducing antimicrobial resistance12
- Centre for Pharmacy Postgraduate Education training for pharmacists13
- British Society for Antimicrobial Chemotherapy’s online course on antimicrobial stewardship.14
Signpost information on antimicrobial stewardship
Local authorities need to be proactive about implementing antimicrobial stewardship. Displaying a range of resources that provide or signpost to advice and information can help to disseminate public health messages on AMR. For example, displaying posters or leaflets about self-care are excellent methods to alert the general public to advice resources, such as NHS Choices and NHS 111. Posters can also raise awareness that community pharmacists are an easily accessible first point of contact for health advice. NICE NG 63 recommends that educational posters should also be made available in locations such as GP waiting rooms, pre-school settings, and school/college receptions, cafeterias, and public toilets to educate the general public (particularly young people) on important topics like handwashing.3
Share advice on self-care
Printed information on AMR needs to be in the most easily accessible form for healthcare professionals so that they can share it with their patients during consultations. This information should cover hygiene, self-care, safety netting advice, and antibiotic use. NICE NG63 recommends the use of computer prompts or decision support tools to prompt healthcare practitioners to share these resources such as leaflets in a patient consultation.3
Respiratory tract infections are the most common indication for community antibiotic prescriptions.5 They are particularly common in children, so sharing leaflets on RTIs in children during consultations can significantly reduce antibiotic prescribing, as this helps to reassure and enable concerned parents/carers.15
Public Health England has produced several leaflets for the TARGET website. The Treating your infection (TYI) patient leaflet can be used by clinicians during a consultation with a patient who presents with an infection that does not require treatment with antimicrobials.16,17 The pictorial version of the TYI leaflet is suitable for people with lower literacy and language needs, and emphasises how to manage an infection through self-care. The TARGET Urinary tract infection (UTI) patient leaflet is designed to be used during consultations with women who have urinary symptoms suggestive of non-complicated UTIs. All of the above leaflets are available to download for free via the RCGP website. There are also leaflets to share with parents including When should I worry18 and Caring for children with coughs.19
Back-up antimicrobial prescriptions
Back-up (or delayed) antimicrobial prescriptions are used when a clinician issues a prescription to a patient to collect or use at a later date, if the patient feels that their symptoms have not improved, or have worsened after several days. Research has shown that backup prescriptions reduce antibiotic use, change people’s beliefs and behaviours towards antibiotics, and overall symptom control in most people who are given a back-up prescription is similar to having an immediate antibiotic prescription.20,21 Most patients lack an understanding on what a back-up prescription is,22 therefore, when offering a back-up prescription it is important for practitioners to effectively communicate to patients what this means. Practitioners should also share information on self-care so that the patient can manage their symptoms, give safety netting advice, and instruct the patient on recognising signs that suggest they need to use their prescription; this can be done with one of the leaflets.
Barriers to implementing antimicrobial stewardship
One of the main barriers to implementing antimicrobial stewardship programmes in primary care is the time available to GPs,23 who only have a 10-minute consultation to make the right decision about prescribing. General practitioners’ perceptions of patient views significantly influence the antibiotic prescribing decision; a study of patients patients with acute cough revealed that patients expecting, or hoping for, antibiotics were prescribed them more frequently than those who were not expecting antibiotics.24 The study also highlighted that patient views are not associated with illness severity, therefore it is important to address the way patients view antibiotics.24 Having a discussion with patients on why they need (or do not need) antibiotics will mean that they will be less likely to ask for an antibiotic the next time they have an infection, and in the long term this will help to free up a GP’s time.
Prognostic uncertainty and concerns about complications remain important reasons for antibiotic prescribing.25 General practitioners tend to prescribe antibiotics for sicker patients and for patients from socioeconomically deprived backgrounds.26 Most patients (and if applicable, their parents/carers) want reassurance that their illness does not require further treatment, and to be given advice on how to self-care.5 Therefore, establishing patient expectations at the start of the consultation can help the healthcare practitioner to manage these expectations appropriately. Ask the patient if they require reassurance and/or self-care advice, and give reasons on why they do or do not need antibiotics or a back-up prescription.
NICE NG63 provides a comprehensive programme of support and endorses two externally developed resources to help the general public, outreach workers in the community, and educational organisations to learn more about hygiene and antibiotics and implement the guideline recommendations:27
Germ defence is an effective online tool that can be used to educate the general public about protecting themselves against cold and flu. This online tool suggests hand-washing pledges to change behaviour and reduce colds and flu. A large randomised control trial found that participants who were given access to the Germ defence website (and the people they lived with) reported fewer colds, flu, and stomach upsets, than the participants who were not given access to the website.28 General practitioners can signpost or promote this educational tool and the general public are encouraged to read further information on AMR at home and to change their behaviour.
NICE NG63 recommends that all children should be taught in an age-appropriate way about hand, respiratory, and food hygiene, and appropriate antimicrobial use.3,27 Resources are available for free on PHE’s e-Bug website (www.e-Bug.eu), including educational games for children on microbes, hygiene, and antibiotics, which can be played at home or at school. These resources, including a new community hygiene and self-care course called Beat the bugs, could be delivered in antenatal and postnatal classes or to community nurses. Links to the e-Bug website could be used on GP newsletters or posters.
Linking to awarenessraising initiatives
Public health teams should link to national awareness campaigns. This could include encouraging patients, colleagues, friends, and family to become part of the nationwide PHE Antibiotic Guardian campaign to increase awareness of antibiotic use. Supporting international campaigns such as World Antibiotic Awareness Week and European Antibiotic Awareness Day can also raise awareness of inappropriate antimicrobial demand and use. Social media channels such as Twitter and Facebook can provide a rapid and relatively easy means of reaching the general public (particularly younger generations) and alert them to these national campaigns.
Provide facilities for washing and drying hands
Increasing the public’s intention to wash their hands will make little difference to the spread of infection if there are inadequate washing facilities. All healthcare providers including general practices, hospitals, community pharmacies, nurseries, and schools should consider providing appropriate facilities for washing hands with liquid soap and running water. This will facilitate the general public washing their hands after using the toilet, and before eating.
Everyone has a responsibility in helping to tackle the public health threat of AMR. Establishments should work collaboratively towards a local, system-wide approach to share consistent messages with the general public on antimicrobial stewardship.
During a consultation where infection is suspected, practitioners should determine patient and/or carer expectations as this is key to informing patient management. If necessary, share information on expected duration of illness, self-care, safety netting advice, and appropriate antibiotic use. Educating the general public on infection prevention is an essential part of any antimicrobial stewardship programme, especially children and young people as they are our future antibiotic users and prescribers.
NICE NG63 provides practitioners and commissioners with the knowledge and confidence to implement antimicrobial stewardship programmes at a local level. The guidance highlights the importance of educating the public on using antimicrobial medicines responsibly, and about self-limiting infections; it also provides evidence-based recommendations on implementing this education. Resources available to healthcare practitioners cover training, sharing advice on self-care, and using back-up prescriptions.
A limitation of NICE NG63 is that practitioners are not provided with advice on how they can measure their antimicrobial prescribing rates, and how this compares on a local and national level; however, as mentioned in this article, practitioners can refer to the PHE Fingertips website or the PrescQIPP website to access this data. Although NG63 aims to change people’s behaviour to reduce antimicrobial resistance and the spread of resistant microbes, it does not explain how practitioners can help to measure any behaviour change, which is something that needs to be explored further.
- Everyone has a responsibility to help prevent infections by teaching through example, and educating about hygiene and vaccination
- Healthcare professionals need to work collectively towards a local system-wide approach in general practice, out-of-hours services, pharmacies, hospitals, schools, and other healthcare premises, to share consistent antimicrobial stewardship messages with the general public
- Healthcare professionals should:
- know how they can deliver antimicrobial stewardship messages within a routine consultation. This could include sharing Public Health England’s TARGET resources. Advice on good practice should be shared with colleagues
- establish patient expectations and share information with patients on the expected duration of their illness, strategies for selfcare, and safety netting advice using patient leaflets and verbal communication
- shortcuts to patient information leaflets should be placed on practice computers, and printed copies should be readily available so they can be shared easily
- increase the use of back-up prescriptions. If antibiotics are necessary, advise patients to take them as prescribed, never share antibiotics, and return any leftovers to the pharmacist
- signpost to NHS information resources (e.g. community pharmacies, NHS 111, and NHS Choices) and educational resources such as the University of Southampton’s Germ defence website to learn about how to reduce future infections, and Public Health England’s e-Bug website, which is suitable for children of all ages, to learn about hygiene and antibiotics
- encourage all members of the practice team to be involved in national and local antimicrobial stewardship campaigns including Antibiotic Guardian and World Antibiotic Awareness Week
- ensure that there are appropriate handwashing and drying facilities for patients in the practice surgery
- audit prescribers’ antimicrobial stewardship activities including antibiotic use, self-care advice, and leaflet provision.
TARGET=Treat antibiotics responsibly, guidance, education, tools
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- Commissioners should work with their local Departments of Public Health to consider a strategy for antimicrobial stewardship:
- this strategy should ideally be built into the local health and wellbeing strategy, to ensure that all agencies who can assist with antimicrobial stewardship are identified, particularly education services in schools and healthcare providers
- Information on levels of antimicrobial prescribing for each GP practice are available through prescribing data and the Primary care web toola and can be used by commissioners to target their interventions to specific areas
- Local formulary sites should identify links to useful resources to inform shared decision making with patients that can be printed off and used in patient consultations
- Commissioners could use CQUIN quality incentive schemes to encourage antimicrobial stewardship with local providers and similarly prescribing incentive schemes with local GP practices.
a NHS England. Primary care web tool. Available at: www.primarycare.nhs.uk
CQUIN=Commissioning for quality and innovation
Read the Guidelines summary of NG63 on Antimicrobial stewardship: changing risk-related behaviours in the general population for more advice on changing behaviour to slow the development of antimicrobial resistance
- World Health Organization. Antimicrobial resistance: Global report on surveillance. 2014. Available at: www.who.int/drugresistance/documents/surveillancereport/en/
- Dame Sally Davies. Antimicrobial resistance poses ‘catastrophic threat’, says Chief Medical Officer. Department of Health, 2013. www.gov.uk/government/news/antimicrobial-resistance-poses-catastrophic-threat-says-chief-medical-officer–2 (accessed 3 March 2017).
- NICE. Antimicrobial stewardship: changing risk-related behaviours in the general population. NICE Guideline 63. NICE, 2017. Available at: www.nice.org.uk/guidance/ng63
- Cabral C, Ingram J, Lucas P, et al. Influence of clinical communication on parents’ antibiotic expectations for children with respiratory tract infections. Ann Fam Med 2016; 14 (2): 141–147.
- McNulty C, Nichols T, French D, et al. Expectations for consultations and antibiotics for respiratory tract infection in primary care. Br J Gen Pract 2013; 63 (612): 429–436.
- Little P. Delayed or back-up prescriptions for respiratory tract infections. Presented at: TARGET Webinars; 2016. Available at: www.target-webinars.com/webinars/back-up-prescriptions/ (accessed 3 March 2017).
- RCGP. TARGET Antibiotics Toolkit. www.rcgp.org.uk/targetantibiotics (accessed 10 April 2017).
- PrescQIPP. www.prescqipp.info/ (accessed 3 March 2017).
- Public Health England. AMR local indicators. Available at: fingertips.phe.org.uk/profile/amr-local-indicators
- RCGPLearning. Antibiotic resistance in primary care. elearning.rcgp.org.uk/course/info.php?popup=0&id=167 (accessed 7 April 2017).
- TARGET Webinars. TARGET antibiotic training modules. Available at: www.target-webinars.com/
- NHS Health Education England. e-Learning for healthcare: reducing antimicrobial resistance. Available at: www.e-lfh.org.uk/programmes/antimicrobial-resistance/
- Centre for Pharmacy Postgraduate Education. Antibacterial resistance—a global threat to public health: the role of the pharmacy team. Available at: www.cppe.ac.uk/programmes/l/antibacres-p-01/
- Future Learn, University of Dundee, the British Society for Antimicrobial Chemotherapy. Antimicrobial stewardship: managing antibiotic resistance. Available at: www.futurelearn.com/courses/antimicrobial-stewardship
- Francis N, Butler C, Hood K et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009; 339: b2885.
- Bunten A, Hawking M, McNulty C. Patient information can improve appropriate antibiotic prescribing. Nursing In Practice 2015; 82: 61–63
- TARGET Antibiotic Toolkit. Leaflets to share with patients: Treating your infection patient leaflet. Available at: www.rcgp.org.uk/clinical-and-research/toolkits/~/link.aspx?_id=9FCF9DA4B4A045519593320478D FD9E7&_z=z
- Department of Primary Care and Public Health, Cardiff University. When should I worry—your guide to coughs, colds, earache and sore throats. Available at: www.whenshouldiworry.com/
- University of Bristol. Caring for children with coughs. Available at: child-cough.bristol.ac.uk/
- Little P, Moore M, Kelly J et al on behalf of the PIPS Investigators. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014; 348 (7949): g1606.
- Little P, Stuart B, Hobbs R et al for the DESCARTE Investigators. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infecti Dis 2014; 14 (3): 213–219.
- McNulty C, Lecky D, Hawking M et al. Delayed/back up antibiotic prescriptions: what do the public think? BMJ Open 2015; 5 (11): 1–7.
- Pakyz A, Moczygemba A, Vanderwielen L et al. Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study. Am J Infect Control 2014; 42 (10): 257–263.
- Coenen S, Francis N, Kelly M et al on behalf of the GRACE Project Group. Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough. PLOS ONE 2013; 8 (10): e76691.
- Cabral C, Lucas P, Ingram J et al. ‘It’s safer to…’ parent consulting and clinican antibiotic prescribing decisions for children with respiratory tract infections: an analysis across four qualitative studies. Soc Sci Med 2015; 136–137: 156–164.
- Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ 2003; 326 (7381): 138–144.
- NICE. Antimicrobial stewardship: changing risk-related behaviour in the general population. NICE Guideline 63: Tools and resources. NICE, 2017. Available at: www.nice.org.uk/guidance/ng63/resources
- Little P, Hobbs FDR, Moore M et al. An internet-delivered handwashing intervention to modify influenza-like illness and respiratory infection transmission (PRIMIT): a primary care randomised trial. The Lancet 2015; 386: 1631–1639.