What’s new in antimicrobial stewardship?

In this article, we report the highlights of the event.

NHS England’s AMR priorities

Dr Kieran Hand, Prescribing & Clinical Lead for AMR at NHS England, outlined their priorities for the coming year. These included:

• increased use of prognostic tools such as STARWAVe, a tool to predict future hospitalisation among children who have presented to in-hours primary care with acute cough and respiratory tract infection 
• judicious use of point of care testing in Primary Care and Community, such as CRP testing for respiratory tract infections
• increased use of digital decision support tools, such as the APMO digital decision tool
• intelligent use of data, such as accurate diagnosis coding

Initiatives to manage gram-negative urinary tract infections more effectively

A 2022 Department of Health policy paper introduced four new commitments to reduce UTIs in support of the national action plan ambition to halve healthcare associated gram-negative blood stream infections by 2024. To support organisations and healthcare staff to meet these ambitions, access to national and local data is available:

• AMR local indicators
• Future NHS
• Model Health System, a data-driven improvement tool (see AMR dashboard system/Region view)

England

Approximately 1.9 million emergency admissions for bacterial infection and/or sepsis were recorded in England in 2022-23. Around 18 percent (approximately 335,000 admissions) were coded as UTI at any point during the admission spell. 

Areas with greater admission numbers were associated with greater deprivation, and two-thirds of admissions coded for UTI were in people aged 70 years and over, with an average length of stay of 17 days. 

To support the improved management of UTIs in hospital, the 2022-23 CQUIN for appropriate antibiotic prescribing for UTI in adults aged 16+ was introduced. Case compliance requires:

• documented diagnosis of specific UTI based on clinical signs and symptoms 
• diagnosis excludes use of urine dip stick in people aged 65 years and over, and in all urinary catheter-associated UTI (CAUTI) 
• empirical antibiotic regimen prescribed following NICE guidance or local guidelines 
• urine sample sent to microbiology as per NICE requirement 
• for diagnosis of CAUTI, documented review of urinary catheter use is made in the clinical record.

The burden of UTIs in primary care in 2022-23 suggested that approximately 18 percent of all antibiotics prescribed in primary care were to treat lower or recurrent UTI, and 39 percent of all trimethoprim and nitrofurantoin items were prescribed for people aged 70 years and over. 

The NHS England Quality Premium FY 2017-2019 Reducing gram negative bloodstream infections and inappropriate antibiotic prescribing in at risk groups incentivised CCGs to improve patient health outcomes, reduce inequalities and improve access to services. Case compliance required:

• 10-20 percent reduction or greater in all E.coli blood stream infections on 2016 performance
• 10 percent reduction or greater in the Trimethoprim:Nitrofurantoin prescribing ratio in FY 2017-2018
• 10-30 percent reduction or greater in the number of trimethoprim items prescribed to patients aged 70 years and over.

For community pharmacy in England, the Pharmacy Quality Scheme Responding to Urinary Tract Infection Symptomsforms part of the community pharmacy contractual framework. During 2022-23, the PQS incentivised the use of the TARGET Treating Your Infection leaflet to respond to UTI symptoms for women under 65 years presenting in community pharmacies during October 2022 and March 2023. Over 8000 community pharmacies submitted data for more than 100,000 women presenting with UTI symptoms:

• 77 percent of women presented with none or only one of the three strongly predictive symptoms of UTI: dysuria, new nocturia, cloudy urine, and/or vaginal discharge and, therefore, were less likely to have a UTI
• The findings suggested that most women presenting to community pharmacies with urinary symptoms were likely to have self-limiting symptoms and could be suitably managed with self-care, pain relief, and appropriate safety netting
• One-third of women were managed by community pharmacy team members without the need for referral to a pharmacist while one in five women presented with escalation symptoms and were signposted to other healthcare settings.

Future initiatives in England to reduce UTIs include regional hydration pilot projects and a UKHSA UTI communication campaign.

Wales

The NHS Wales General Medical Services (GMS) contract guidance 2019-2022 included
multidisciplinary antimicrobial stewardship for urinary tract infection. This quality improvement project aimed to incentivise GP collaboratives to review the diagnosis and management of adults with suspected UTIs.

Four audits are available:

• Healthcare professionals do not use dipstick testing to diagnose UTI in adults with urinary catheters
• People prescribed an antimicrobial for UTI have the clinical indication documented in their clinical record
• Review of urinary prophylaxis (PHW UTI standards, NICE NG112)
• Adults with a UTI not responding to initial antibiotic treatment have a urine culture.

Scotland

The Healthcare Improvement Scotland Scottish Antimicrobial Prescribing Group launched the Scottish Reduction in Antimicrobial Prescribing (ScRAP) educational toolkit which includes:

• Acute Urinary Tract Infection Audit Tool
• Acute Urinary Tract Infection (UTI) Audit Tool Data Collection

The NHS Pharmacy First Scotland UTI service incentivised:

• women aged 16 to 65 years with uncomplicated UTIs can access free advice or treatment
• a pharmacist will undertake a clinical assessment
• triaged to advice only, refer if required, or supply antibiotics via Patient Group Direction
• trimethoprim 200mg twice daily for three days
• nitrofurantoin 100mg MR twice daily for three days
• by the end of 2020 over 16 percent of all prescriptions for trimethoprim were written by community pharmacists.

Useful resources for UTI treatment

• TARGET Urinary Tract Infection Resource Suite
• SAPG Urinary Tract Infections
• Model Health System Antimicrobial Resistance

Strategies for successful AMS interventions 

Delegates shared tools and resources they found useful in changing prescribing practice and antimicrobial stewardship:

• Apps e.g. Microguide, Tendible for care bundles
• ARK charts
• Local or regional resistance data
• TARGET antibiotics toolkit
• Other professionals
• Clinical AMS champions, especially from the same professional group or speciality 
• Having a dedicated email address for AMR and AMS queries.

Professor Diane Ashiru-Oredope (Pharmacist lead for AMR/AMS UKHSA) and Frances Kerr (Project lead for Scottish Antimicrobial Prescribing Group) also shared some valuable resources:

• Start Smart then Focus, with significant updates published in August 2023
• National antimicrobial intravenous-to-oral switch (IVOS) criteria for early switch
• Hospital Antibiotic Review Programme (HARP) resources
• Prescribing competencies framework with significant updates published in August 2023
• World AMR Awareness Week resources

Using data for action

Collecting data is important, but using data to implement actions is vital. Using data for action could include asking what it means and using insights as a focus for improvement. Examples of data to access:

• NHS Scotland Discovery Dashboard
• UKHSA AMR local indicators
• NHS England AMR Data Workstream Antimicrobial Resistance Programme

COPD and acne: How to achieve effective antimicrobial stewardship over the long term

Acne vulgaris is a common and multi-factorial skin disease, affecting 85 percent of adolescents and young adults.Complications of acne include skin changes such as scarring, post-inflammatory hyperpigmentation or depigmentation and psychosocial problems such as depression and anxiety. 

Cutibacterium acnes, formerly Propionibacterium acnes is the dominant component of the skin microbiome in the pilosebaceous unit. Overuse of antibiotics prescribed for acne is a concern for the development and spread of antibiotic resistant bacteria.

There are specific criteria for referring patients to specialist dermatology services; however, these services have long waiting lists which means that primary care has an increasingly important role for management of patients with acne. 

Good practice includes:

• Do not use an oral antibiotic monotherapy; combine oral antibiotic with a topical nonantibiotic treatment to treat acne. 
• Aim to limit the duration of systemic antimicrobial treatment to three months, followed by maintenance therapy with topical retinoid and/or antiseptic for 12 weeks (then review whether to continue)  
• If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either: another 12-week course of the same treatment; or, an alternative 12-week treatment  
• For unresponsive moderate to severe acne, consider an option that includes an oral antibiotic. If the current option included an oral antibiotic, then referral to a consultant dermatologist-led team can be considered. 
• If acne recurs on cessation of antimicrobial therapy despite topical treatment, consider a systemic retinoid (via dermatology referral to secondary care) if rapid relapse, or intermittent three-month courses of systemic antimicrobial if a longer remission was achieved. 
• Treatments including topical or oral antibiotics should only last longer than 6 months in exceptional circumstances, with review at 3-monthly intervals: the aim being to discontinue the antibiotic as soon as possible.

Useful resources for acne

• How to manage and review adults and children over 12 years of age on long-term and repeated antibiotics for the prevention and treatment of acne vulgaris
• NICE CKS Acne vulgaris
• NICE Guidance (NG198): Acne vulgaris: management
• Nouioui I et al, 2018. Genome-based taxonomic classification of the phylum actinobacteria. Front Microbiol, 2018;9:2007.

In England, 1.3 million people have a diagnosis of COPD and there are around 30,000 deaths per annum, with health inequalities in England linked to increased incidence of COPD. When reviewing a patient with COPD, it is useful to use a system-wide approach and quality improvement toolkits such as the TARGET booklet on COPD. 

Useful resources for COPD

• GOLD report for COPD
• NICE Guidance (NG115): COPD diagnosis and management

A holistic, evidence-based approach to the management of patients who report penicillin allergy

Penicillin allergy records are common, often incorrect and limit antibiotic treatment options for patients. Evidence suggests that patients with infections who report allergy to penicillin have increased morbidity and mortality compared to those who don’t.

There are a variety of practices for de-labelling patients who report penicillin allergy, from those who discuss with colleagues in their local teams but do not yet have commissioned services, to those who are leading services that de-label or de-sensitise patients. 

Recent work on de-labelling includes a Royal Cornwall Hospitals NHS Trust initiative led by Daniel Hearsey and Neil Powell on a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital.

In addition, Rashmeet Bhogal at the University Hospitals Birmingham NHS Foundation Trust has set-up a study across three large NHS Teaching Trusts. It is designed in such a way to support pharmacist-led screening, risk stratification and, where appropriate, direct penicillin challenge. 

Useful resources

• Penicillin allergy de-labelling toolkit
• Guidelines for de-labelling services

This article was co-authored by Stephen Hughes, Professor Diane Ashiru-Oredope and Jonathan Snape.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.