The NICE guideline defines antimicrobial stewardship as “an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness”. Worryingly there is nothing in their definition about patients. My personal definition, which is in line with the more commonly used definitions in the literature, is “the promotion of the use of the right antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance”.
I find this new NICE guidance to be so woolly that you could read and ignore most of the document as the vast majority of the statements are “to consider this” or “you could implement that”. In true politically correct style it actually says very little in a lot of words, there is nothing new and there is little practical application for us who actually work in healthcare with a prescription pad or drug chart. With newspaper headlines of “Doctors write 10m needless antibiotics prescriptions a year” and “GPs should face disciplinary action for prescribing [inappropriate] antibiotics”, I was hoping for something with a bit more resistance to cheap “sound-bites”...So what are the main points in the guideline?
Antimicrobial Stewardship Teams
The guideline opens with a number of recommendations for organisations such as clinical commissioning groups (CCGs), acute trusts and primary care providers to fulfil in respect to antimicrobial stewardship. It puts the emphasis on the commissioners of NHS services to ensure that antimicrobial stewardship is undertaken in all of the care settings that come under their organisation. Organisations should establish antimicrobial stewardship teams including a specialist Pharmacist and Microbiologist but unfortunately there is nothing about how much time this requires in relationship to hospital workload and therefore this could allow for only nominal amounts of time, if any, to be set aside which may not actually be adequate.
Organisations are recommended to support and promote education and training in regards to the appropriate use of antimicrobials and I believe this is the key to antimicrobial stewardship but the guideline does not give this area high enough priority (5 lines in a 50 page document). In the full version of the document NICE states that the evidence suggests that undergraduate programmes do not provide enough training in antimicrobial prescribing and resistance. NICE also recognises that not all antimicrobial stewardship team members will have the prerequisite educational skills or the necessary resources to deliver relevant education to prescribers and that providing this education and training across all care settings would be challenging. However, unless healthcare staff understand how to diagnose and manage infections they are unlikely to implement antimicrobial stewardship or become better prescribers.
Audit and monitoring
Recommendation is given that prescribing is audited and monitored in relation to antimicrobial resistance and that feedback given to the prescribers including antimicrobial resistance, individual prescribing and antimicrobial-related patient safety incidents. Nice in theory but in my experience this rarely leads to a change in practise unless this data is benchmarked openly. League tables, however, are rarely popular, tend to cause conflict and don’t encourage ownership of the issue. I would prefer to see the bench marking done anonymously whilst linking it to revalidation in order that doctors are not exposed individually but given enough incentive to change their practise. Obviously this data then needs to be accurate and targeted to each individual in order to create ownership whilst not using it as yet another stick to beat us all with...!
Organisations are also encouraged to promote peer review of prescribing and the development of local networks to share best practice and facilitate communication of information about antimicrobial stewardship. Who has the authority to peer review someone like a vascular surgeon on endovascular infections? Who should be the infection expert within a speciality? Is it the vascular surgeon or an infection specialist e.g. a microbiologist? I believe it should be the specialist with a microbiologist consulting on more uncommon situations or arbitrating on any disagreements. Therefore a general surgeon should be the expert in peritonitis, an orthopaedic surgeon in joint infections, a neurologist in meningitis, a cardiologist in endocarditis and a GP in infections common to primary care etc. I believe clinical specialities should be embracing this opportunity to develop their expertise and become champions of infection within their speciality. Antimicrobial stewardship is not the “antibiotic police” as it is often seen, but an opportunity for each speciality to be inspired as to how they could use antibiotics more effectively, bring about improvement and perhaps “police” themselves.
The guideline recommends that laboratory testing follows national laboratory standard operating procedures ensuring reporting takes account of antimicrobials on local formularies while keeping in mind the priorities of the local antimicrobial stewardship teams. This is a nice idea in practice but many labs (including mine) now serve multiple separate NHS hospital Trusts and primary care facilities, all with different priorities and antimicrobial formularies, so in reality it is impossible for the lab to satisfy all-of-these all of the time.
Recommendations for prescibers
The guideline makes a number of specific recommendations for antimicrobial prescribing but these should be routine practice already:
- Use the shortest possible effective course
- Use the most appropriate dose
- Use the most appropriate route of administration
- Review IV antimicrobials at 48-72 hours with results and consider an IV to oral switch
- Assess the patient clinically before prescribing and document the reason for either starting or not starting antimicrobials
- Take samples before prescribing and review the choice of antimicrobial when results are available
- Consider delaying prescribing until results are available or to see if the patient gets better without the need for an antimicrobial
- Discuss all options with patients and carers including whether antimicrobials are actually required
- Consider potential drug interactions, dose modifications required for other clinical conditions e.g. renal failure and drug allergies
- When patients transfer to another care setting ensure information about their antimicrobial usage is included in their transfer documentation
What is not so good about the guideline?
There are also a number of recommendations in the guideline that are either potentially harmful to patient care if they are followed to rigidly or are just impractical to implement. These include:
- Consider the risk of selecting out bacteria that cause healthcare-associated infections before prescribing an antimicrobial. This is all very well BUT antibiotics do not cause healthcare-associated infections, these are caused by bacteria…. if you don’t come in to contact with the bacteria you won’t get these infections and undue worry can prevent patients being treated for the condition they have because of fear about a condition they might, but probably won’t, get!
- Take into account the risk of antimicrobial resistance to the patient and the population as a whole. Doctors treat the individual patient in front of them so the risk to the wider population is unlikely to influence their prescribing; you can’t allow a patient to come to harm for the greater good of the rest of population, that would be unethical
- Identify whether hospital admissions are linked to previous prescribing. Having done quite a few “look backs” in my time I can say it is usually impossible to be able to say that the prescribing of antimicrobial A has directly caused condition B. Trying to do this on a large scale will take a lot of NHS resource that might be better utilised elsewhere
- There is a heavy emphasis on the use of empirical guidelines which suggests that any patient not on an empirical guideline antimicrobial is being mismanaged. I find this alarming. It is important to remember that guidelines are empirical not definitive, they cover all possible causes of the infection concerned. Most guidelines say nothing about narrowing down and targeting treatment once laboratory results indicate the causative microorganism, yet this is a fundamental aspect of good infection management and antimicrobial stewardship
- Another issue I have is the emphasis on the use of IT or decision support systems which I think run the risk of dumbing down infection management. Leaving decision making to a computer means that the clinical workforce will become even more de-skilled in the management of infectious diseases and this does not support good antimicrobial stewardship. I’m not too worried as according to the BBC, Medical Practitioners are only 2% likely to be replaced with a robot, and a pharmacist is 1%, so we seem safe from technology at the moment (http://www.bbc.co.uk/news/technology-34066941)
- I am very concerned at the suggestion that antimicrobials should be dispensed in specific treatment length pack sizes in order to stop prolonged courses. I believe this promotes empirical broad spectrum treatments rather than narrowing down and targeting therapy once the specific microorganism is known. This may in fact lead to more inappropriate antimicrobial use
- There is a whole section of the guideline devoted to “horizon scanning” and the introduction and adoption of new antimicrobials more efficiently. However I thought the whole point of antimicrobial stewardship is to preserve the antimicrobials we currently have, as there are no new antimicrobials in development. I wonder if the heavy contribution from experts with financial links to the pharmaceutical industry has anything to do with this large section (30%) of the guidance, when education receives only 5 lines
So in summary, the NICE guideline on Antimicrobial Stewardship is nothing new. The summary of good prescribing principles is the most relevant to front line clinical staff and I would support the need for teaching all healthcare workers in order to improve antimicrobial use. However the guideline misses the main point of antibiotic stewardship which is: “the use of the right antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance”. This guideline does not address the main concerns and is not SMART (Specific, Measurable, Achievable, Realistic, Timed). In fact most of the recommendations are couched in terms like “consider” which appears to leave them optional when, with the post antibiotic era looming, they should be mandatory.
So I think it is as woolly as a mammoth but can I actually produce anything better? I hope I can, and that will be the content of the next blog.