JAC Advance Access originally published online on October 9, 2006
Journal of Antimicrobial Chemotherapy 2006 58(6):1230-1237; doi:10.1093/jac/dkl405
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Antimicrobial practice |
Impact of the Hospital Pharmacy Initiative for promoting prudent use of antibiotics in hospitals in England
1 Pharmacy Department, St Mary's NHS Trust London W2 1NY, UK 2 Pharmacy Department, Hammersmith Hospitals NHS Trust, London W12 OHS, UK
*Corresponding author. Tel: +44-207-886-1078; Fax: +44-207-886-2083; E-mail: hayley.wickens{at}st-marys.nhs.uk
Received 18 May 2006; returned 7 June 2006; revised 11 September 2006; accepted 12 September 2006
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Abstract |
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Objectives: In July 2003, the UK Department of Health announced an allocation of £12 million to hospital pharmacists to improve the monitoring and control of anti-infective use over the ensuing 3 year period (the Hospital Pharmacy Initiative, or HPI). Chief Pharmacists were asked to use this money for developments to promote prudent antibiotic use and monitoring of antimicrobials within their Trusts. This study aimed to evaluate the impact of the HPI funding, which at the time had been in place for nearly 2 years, on pharmacy activities in this area.
Methods: A postal questionnaire was sent to the pharmacy department of each acute hospital Trust in England, aiming to provide a descriptive overview of the activities of hospital pharmacy staff in the field of anti-infectives and to explore the extent to which these activities were made possible by the HPI funding.
Results: One hundred and forty-one specialist antimicrobial pharmacy staff were employed in 130 responding Trusts; 89% were pharmacists, 7% pharmacy technicians and the remainder administrative staff. Three-quarters of these staff had been employed due to the funding, resulting in review of antimicrobial prescribing guidelines, antibiotic audit projects and multidisciplinary work with Microbiology/Infectious Diseases staff. Thirteen Trusts gave details of drug acquisition cost savings; over the course of a year, these Trusts saved £1.1 million in total.
Conclusions: The HPI funding has facilitated greater interaction between Pharmacy and Microbiology/Infectious Diseases departments than was previously possible. Significant reductions in antibiotic acquisition costs have been demonstrated, though further work is warranted to fully establish the impact of pharmacy activities on clinical and microbiological outcomes.
Keywords: antibacterials , antibiotic pharmacist , antibiotic policy , antibiotic management , pharmacist
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Introduction |
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UK hospital pharmacists amend up to a quarter of all inpatient prescription charts on their daily ward visits in order to promote safe, appropriate and cost-effective use of medicines1,2 and so the extension of pharmacist activities in the area of antibiotic control seems logical. Once susceptibility reports are available, the pharmacist can match these against an empirical prescription and intervene if necessary,3–6 but it has been argued that the role of the pharmacist extends beyond checking sensitivity results. Pharmacists with a strong background in microbiology are increasingly recognized as an integral part of the infection management team and can offer specialist advice on optimal antimicrobial therapy, as well as providing education, audit and feedback to prescribers, and writing evidence-based guidelines for antimicrobial prescribing.7–14
In July 2003, the UK Department of Health announced an allocation of £12 million to hospital pharmacists in England to improve the monitoring and control of anti-infective use over the ensuing 3 year period (the Hospital Pharmacy Initiative—HPI).15 Chief Pharmacists were asked to use this money for developments to promote prudent antibiotic use and monitoring of antimicrobials within their Trusts, concentrating particularly on key themes such as clinical pharmacy services in areas of high antibiotic use, antibiotic use in surgical prophylaxis and children, infection control and developing evidence-based antibiotic prescribing policies. At the time of this study, funding had been in place for nearly 2 years, but its impact had not been evaluated.
The objectives of the study were as follows:
- To provide a descriptive overview of the activities of hospital pharmacy staff in the field of anti-infectives within hospitals in England.
- To explore the extent to which these activities were made possible by the Department of Health Hospital Pharmacy Initiative funding.
- To describe the outcome measures, if any, each Trust was attempting to use to describe the results of enhanced pharmacy activity in this field.
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Methods |
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Overview
The study was conducted as a postal questionnaire, sent to all secondary and tertiary care acute Trusts in England. Responses were recorded on a database and analysed for trends in usage of the funding and outcomes recorded. (MREC reference 05/MRE10/17).
Questionnaire design
The questionnaire was designed and piloted with reference to principles of good questionnaire design,16–19 and was largely ‘tick box’ in design [the questionnaire is available as Supplementary data at JAC Online (http://jac.oxfordjournals.org)]. The questionnaire included four main sections:
- Your hospital—information on the size and type Trust the respondent worked in.
- You and your pharmacy department—concerning the size of pharmacy department and the nature of any posts within the department specializing in anti-infectives.
- Activities to monitor and control use of antimicrobials—requesting information on activities of anti-infective specialist staff within pharmacy, and whether these activities had been made possible by the HPI funding.
- Measuring outcomes—requesting information on whether the Trust was monitoring outcomes of enhanced pharmacy activities in this field of anti-infectives, and details of any benefits shown.
The potential activities of specialist pharmacy staff detailed in Section (iii) were based on a consensus statement of the activities of an anti-infective specialist pharmacist drawn up by the North West London Antibiotic Pharmacists Group in 2003 [the consensus statement is available as Supplementary data at JAC Online (http://jac.oxfordjournals.org)]. Provision was made within the questionnaire to detail the role of multiple anti-infective specialists within one pharmacy department, as anecdotal reports indicated that Trusts with a specialist pharmacist/technician in post before June 2003 may have employed additional staff.
Responses were recorded on a Microsoft Excel database (Microsoft Corporation, USA). For purposes of data protection, respondents were only identified by their tracking number.
Questionnaire mailing
A list of all acute hospital Trusts in England was compiled from national directories including the NHS website (www.nhs.uk/england/authoritiestrusts/acute/list.aspx, accessed 10 February 2005). The HPI funding was allocated to hospitals within England, therefore hospitals outside England were excluded.
The Chief Pharmacist at each Trust was listed as the default contact; the names of these pharmacists were obtained from the Chemist and Druggist Directory 2004/5 (137th ed. CMP Information Ltd., Tonbridge, UK) and by searching the Internet using Google (www.google.co.uk). This list was then cross-referenced with the membership list of the United Kingdom Clinical Pharmacy Association Infection Management practice interest group (UKCPA-IMG; www.ukcpa.org.uk). Where an appropriate specialist member of staff, or non-specialist with an interest in infection management was listed for a given Trust, they were used as the contact in place of the Chief Pharmacist. Where it was not possible to identify a specialist or the Chief Pharmacist by name, the paperwork was marked ‘for the attention of the Chief Pharmacist’.
As Trusts often comprise several hospitals that may be covered by a single specialist pharmacist, and the questionnaire was designed to focus on the activities of that pharmacist, only one questionnaire was required to be filled in per Trust. The list of hospitals was therefore edited to remove duplicates within the same Trust.
Of the 183 questionnaire packs sent out, 66 were sent to antibiotic specialist pharmacists, 21 were sent to non-specialist pharmacists with an interest in microbiology (as identified by membership of the UKCPA-IMG) and the remainder to Chief Pharmacists, three-quarters of whom were named.
A postage-paid envelope was included with the questionnaire as this is known to increase rates of return.20 Provision was made on the front of the questionnaire for those not wishing to participate in the study to give a reason for this and return the form blank, as this increases the chance of return.20
Each questionnaire carried the tracking number in order to allow for follow-up of forms that were not been returned by the deadline. A telephone call was made to the 81 hospitals who had not responded by the closing date, and duplicate questionnaires were sent out via post or e-mail where required.20 Sixteen Trusts requested further copies of the questionnaire; twelve questionnaires from this second mailing were returned. If there was no response a further 2 weeks after the telephone call, the hospital was classed as a non-responder.
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Results |
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Of 183 questionnaires, 138 (75.4%) were returned, 13 of which (9.4% of those returned) were not completed. Of these non-completed forms, 5 (3.6% of respondents) ticked the box saying they had no specialist pharmacist and did not wish to complete the form themselves. Of the remaining 8 (5.8%), half were mental health or small community hospitals, so were not in the target population for the funding; the remaining 4 were duplicate forms where a pharmacist at another hospital within the same Trust was filling in the form for that organization. One further Trust declined to take part as the Chief Pharmacist would not give their permission.
All analyses that follow are therefore based on 125 completed questionnaires received from the 130 Trusts who responded. Where participants left some questions blank, the relevant number of responses is given.
Type of Trust and bed numbers
Of the 124 respondents that categorized their workplaces, 56% worked in a District General Hospital, 36% in a Teaching Hospital and 6% in specialist units. The remaining 2% (3 hospitals) classified themselves as ‘other’ (‘Acute Referral Unit’, ‘Tertiary care centre’ and ‘Associate University Teaching Hospital’). Most Trusts comprised between 500 and 1000 beds (range from <250 to >1500).
Numbers of pharmacy staff specializing in antimicrobials and their qualifications
In total, 141 antimicrobial specialist pharmacy staff were employed in the 130 responding Trusts (including 5 Trusts who did not wish to complete the questionnaire but returned the form with minimal details); 114 (88%) of the Trusts had at least one specialist member of staff, and 27 (21%) had more than one specialist.
Of the 141 posts, 126 (89%) were pharmacists; 10 (7%) posts were held by pharmacy technicians and 5 (4%) by other staff, including administrative assistants and an audit facilitator based within the hospital audit department. Trusts employed antibiotic specialist staff amounting to an average of 0.07 whole time equivalents (WTE) per 100 beds, compared with an average of 2.98 general pharmacist WTEs per 100 beds.
Overall, the 141 staff held 280 qualifications, 152 of which were postgraduate; 27 staff held postgraduate master's degrees and 9 held doctorates.
Financing and tenure of antimicrobial posts
At the time of the survey, the HPI funding had been available for 22 months; over half of pharmacy antimicrobial specialists responding to the survey had been in post between 1 and 2 years and 86% for <2 years. Three-quarters of specialist posts had been funded to some extent by the HPI allocation (data not shown), but nearly half of these post-holders (50 posts in 41 Trusts) were employed on fixed-term contracts set to lapse once the funding ceased in April 2006 (Figure 1).
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Uses of the HPI funding
The majority of respondents (91%) were able to describe how the funding had been used. In those Trusts that had received funding, the most common use was to employ new staff (mentioned by 63% of respondents—76/120) and/or expand the roles of current staff (23%—28/120). Purchase of books or other resources was mentioned by 9% of respondents, and an equal number had used the money to purchase antimicrobial training, for instance by sending staff to the MSc in Infection Management run by Imperial College and the Health Protection Agency. Acquisition of computer hardware or software was mentioned by 7% of respondents, and 1% had purchased non-antimicrobial training; 17.5% said they had spent the money on other items, including the production of antibiotic training materials and providing locum pharmacist cover to free up existing staff to take on antimicrobial projects.
Four of the responding Trusts (3%) had not received the money; the Strategic Health Authority was reported to have withheld the funding on two occasions, and in a further incident, one Trust used the funding to offset debt.
Activities to monitor and control use of antimicrobials
Formularies and prescribing guidelines.. An antimicrobial formulary was in place in 89% of responding Trusts (109/123); in over a quarter of cases, this document had been written or updated as a result of the funding (Figure 2). Over 90% of respondents (113/123) reported having local antimicrobial usage or empirical therapy guidelines; one in three Trusts had written or updated these due to the funding (Figure 2).
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Ninety percent of respondents felt that the funding had facilitated the interaction between Microbiology and Pharmacy in the writing or review of antibiotic guidelines (data not shown).
Sixty-nine percent of respondents (82/119) had reserve antimicrobial guidelines, 69% (85/123) had intravenous (iv) to oral antimicrobial switch guidelines and 87% (105/122) had surgical antimicrobial prophylaxis policies or guidelines in place (Figure 2). In each case the HPI funding had increased provision, or enabled revision and updating of these documents; 24% had updated their reserve list, 35% had updated their iv-oral switch guidelines and 26% stated that funding had enabled them to update their surgical prophylaxis guidelines (Figure 2).
Ninety-four percent of respondents (117/124) reported that the pharmacy department was involved in decision-making in relation to introducing new anti-infectives to the formulary; a quarter of respondents said that this was made possible or improved by the allocation of the funding.
Antimicrobial education and advisory services.. The newly employed staff appear to have had a large effect on the provision of antimicrobial education by pharmacy departments, in particular to nurses, doctors and pharmacists, and to a lesser extent to other staff, such as physiotherapists and patients. One-third of departments were providing antimicrobial education to each of the nurses, doctors and pharmacists prior to the funding; this was increased to 68%, 73% and 89%, respectively (Figure 3).
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Nearly half of the Trusts (49%—59/121) reported keeping specialist, up-to-date reference sources on microbiology and infectious diseases in their pharmacy; just under half of these Trusts had purchased these resources using HPI funding (Figure 3). Sixty-one percent of the Trusts (75/122) reported having a pharmacy antimicrobial specialist available via pager or phone for complex patient referral, and 40% (49/122) reported that their antimicrobial specialist attended ward rounds on specialities of high antibiotic use (e.g. Infectious Diseases ward(s), Intensive Care); these activities had been made possible by the funding in two-thirds of the cases.
Joint microbiology/pharmacy ward rounds, a recent innovation in the NHS,14,21 were conducted in 
35% of Trusts (41/119; Figure 3). The patients seen on these ward rounds were referred by other pharmacists in 34% of cases, by clinicians in 20%, by microbiologists in a quarter and by others, such as nurses, in 2%. The HPI funding has increased activities in this area 3-fold (Figure 3).
Surveillance of anti-infectives and organisms.. Traditionally, UK hospital pharmacy systems have been set up to report on drug use in terms of expenditure, but a surveillance measure gaining in popularity is the defined daily dose (DDD) (Collaborating Centre for Drug Studies Methodology—www.whocc.no/atcddd).
Most pharmacy departments provided regular reports on anti-infective usage in terms of expenditure (86/118—73%) or volume (62/111—56%). Forty-six percent of departments (51/112) reported regularly in terms of DDDs. Activities in the area of anti-infective surveillance have been markedly improved by the HPI funding; 35% of respondents had been enabled to report expenditure, 30% to report volume used and 38% had begun to report DDDs, a 4-fold increase in activity (Figure 4).
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Fifty-eight percent of Trusts (70/121) undertook regular point prevalence surveys of antimicrobial use and 80% of this activity had been made possible by the HPI funding (Figure 4).
Forward planning and other activities to improve monitoring and control.. Respondents were asked about their activities in terms of forward planning around anti-infective issues: 39% of pharmacy departments (46/118) produced a ‘Horizon scanning’ document for anti-infectives, whilst 56% (68/121) had a multidisciplinary Antibiotic Review Group in place and 75% (92/123) reported that pharmacy had representation on the Infection Control Committee. The HPI funding increased activity in these areas. Fourteen percent had been enabled to provide or update their ‘Horizon Scanning’ document, and in half of those Trusts with an Antibiotic Review Group, its formation had been made possible by the funding. In a third of Trusts, pharmacy participation in the Antibiotic Review Group and Infection Control Committee, respectively, was dependent on the funding.
Fifty-two Trusts reported undertaking an additional initiative to improve monitoring and control of anti-infectives that were not addressed elsewhere in the survey (Table 1). Of these, 69 projects in 43 Trusts were made possible by the HPI funding, and 14 projects in 11 Trusts were independent of the funding.
Measuring outcomes
Respondents were asked whether they were monitoring selected outcomes associated with their activities in controlling antibiotic use.
Drug acquisition costs.. A traditional measure of pharmacy activities is reduction in drug acquisition costs; 77% of Trusts (89/116) were monitoring antimicrobial expenditure, and a third of these claimed to have shown a benefit associated with the HPI funding (Figure 5). Methods used to achieve this included restriction of high cost or iv antibiotics, promoting the choice of lower-cost, microbiologically equivalent agents, introducing guidelines resulting in reduced drug acquisition costs and audit of specific drugs (e.g. linezolid) resulting in decreased usage and expenditure. One-third of those showing benefit (12 Trusts) mentioned that this was due to restriction of iv ciprofloxacin and encouraging early switch to the oral form; at current prices, the iv agent is 60 times more expensive than the oral form.
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Thirteen Trusts detailed the magnitude of cost savings attained; these varied from £23 000 to £500 000 per year, and amounted to an approximate total saving of £1.1 million over these 13 Trusts in 1 year.
Volume of antimicrobials used.. Three-quarters of Trusts were monitoring overall antimicrobial usage in terms of volume. HPI-associated reductions in usage were reported by 26% of respondents (22/86; Figure 5); again, restriction of iv and high cost drugs was a major theme. Only one Trust attempted to quantify the magnitude of this reduction, stating that ‘DDDs [had] reduced from 40 000 to 30 000 per month, trend continuing as more initiatives implemented’. No denominator, such as occupied bed days, was given.
Inappropriate antimicrobial prescribing.. Seventy-eight per cent of Trusts were monitoring levels of inappropriate antibiotic prescribing, such as prescription without indication, prolonged use of iv agents, where an oral agent could be safely substituted, unnecessarily long courses of peri-surgical antimicrobial prophylaxis, or unnecessarily broad-spectrum prescribing. In just under half of cases (44% of Trusts overall—40/90), the HPI funding was felt to have had a beneficial effect on this indicator (Figure 5). Of the 40 Trusts in this group, 35 gave further details of their achievements, citing schemes such as antimicrobial stewardship programmes, drug chart stickers to prompt review of antimicrobial prescriptions and educational activities; however only one respondent put a figure on levels of appropriate prescribing, quoting 70% compliance with local antibiotic policy.
Antimicrobial resistance and clinical outcome.. Relatively few Trusts reported monitoring levels of antimicrobial resistance and clinical outcome with respect to the impact of the HPI funding (33% and 22% of respondents, respectively). Around 5% of Trusts claimed to have shown benefits in terms of reduced antimicrobial resistance and improvement in clinical outcome solely due to pharmacy activities. Unfortunately these were universally unsubstantiated beyond vague statements; one reported achieving ‘clarithromycin and trimethoprim resistance control’ and another that ‘antibiotic resistance has remained stable’. One pharmacy technician considered DDD measurement a tool to monitor clinical outcome: ‘currently monitoring consumption in DDD/100 bed days ... which will demonstrate a reduction in length of stay’, highlighting an educational requirement surrounding the use of DDDs and monitoring effectiveness of interventions.22
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Discussion |
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The HPI funding has had a demonstrable impact on the activities of hospital pharmacy departments in monitoring and controlling the use of antibiotics. Trusts have been encouraged to focus on improving antimicrobial stewardship following the publication of documents such as Winning Ways23 and, more recently, the Scottish Antimicrobial Prescribing Policy and Practice recommendations.24 As hospitals are increasingly being assessed on their activities in this area under initiatives such as the Healthcare Commission's Acute Hospitals Portfolio,25 the funding became available at an opportune time.
The majority of HPI funds have been used to employ highly specialist pharmacists; three-quarters of the staff were employed at senior grades (Whitley Council grades D or higher), perhaps indicating the importance with which the posts were perceived within Trusts. As it is likely that such specialist pharmacists will be required to lead on antimicrobial initiatives,4,6,7,9,10,13 a degree of management experience and ability to interact with senior clinicians on a credible level will be necessary, skills which are arguably more likely to be found in senior pharmacists applying for high-level posts.
As a result of the funding, pharmacists reported great enhancements in development and review of evidence-based antimicrobial prescribing guidelines, provision of antimicrobial education programmes to clinical staff, reporting of antimicrobial use through traditional means and point-prevalence methodology.
That the largest increases in activity attributable to the HPI funding were in such potentially labour-intensive areas implies that such activities may define the working day of a typical specialist antimicrobial pharmacist.
An antimicrobial formulary or usage guidelines was in place in approximately 90% of responding Trusts, in accordance with the findings of Woodford et al.26 However, in a recent study of UK hospital pharmacy departments, only 78% reported having a general hospital formulary in place,27 implying that restriction of antimicrobials is a relatively high priority. That the prevalence of iv-oral switch and reserve antimicrobial guidelines, both before and after the HPI, was lower than empirical or surgical prophylaxis guidelines, may indicate that these are seen as lower priority areas for Trusts.
Pharmacy departments were involved in writing anti-infective guidelines and policies in 94% of Trusts, and 54% of respondents reported that this had been facilitated by the funding, one of the largest effects seen in the survey. Again, this is likely to reflect the increased numbers of specialist staff available to undertake the work. Employing a specialist pharmacist appears to have enhanced multidisciplinary working between pharmacists and microbiology/infectious diseases clinicians; 90% of respondents reported that this was occurring as a result of the funding, as opposed to the findings of Woodford et al.28 in 2004, who found little evidence of co-operation between Pharmacy and Microbiology departments.
The dramatic improvements in the number of Trusts reporting on antimicrobial usage in terms of expenditure, volume and DDDs seem likely to be the result of increased staff provision within Pharmacy, either by employment of a specialist, or by ‘freeing up’ time for existing staff to work on the analysis. Calculating DDDs is time-consuming as many UK hospital pharmacy departments use systems that cannot generate these figures automatically; however, this measure has been used successfully to report on the effects of interventions to improve antimicrobial prescribing.29 In order to benchmark across Trusts, it will be necessary to incorporate multiple confounding factors, such as number of paediatric beds, presence of a renal or oncology speciality and number of high dependency beds, and this may be prohibitively complicated.30
Two key activities of microbiology specialist pharmacists are audit, which is helpful in assessing adherence to prescribing guidelines, and feedback of these data to prescribers.7–14,31 An example of audit conducted by UK microbiology pharmacists is the point-prevalence methodology developed in west London.32 This typically consists of a yearly or six-monthly snapshot audit of antimicrobial prescriptions throughout a hospital and provides data on number of anti-infectives prescribed, course length, appropriateness of therapy and route, duration and combinations. Data are collected manually and are used to target the activities of the specialist pharmacist; the data can also be fed back to clinicians as part of an Infection Control performance management system.33
On the negative side, it is worrying that 4 of 138 Trusts had not received the funding: on the basis that Trusts who have employed specialist staff using the HPI funding were more likely to respond to the questionnaire, it is possible that there are more Trusts in England that have had their funding withheld in a similar way.
Further work is required in order to fully quantify outcomes associated with specialist antimicrobial pharmacy activity; whilst the majority of Trusts were monitoring antibiotic expenditure, overall usage and degree of appropriate use, only few researchers attempted to follow clinical or microbiological outcomes associated with pharmacy activity in this area. The fact that only one Trust felt able to give figures pertaining to improvements in appropriate antibiotic usage, whilst 13 were able to quote impressive cost savings associated with the HPI funding, perhaps reflects the emphasis that has historically been placed on cost-containment activities within Pharmacy. The cost savings reported, approximating to a total of £1.1 million over 13 Trusts in 1 year, are comparable to savings generated by the activities of specialist microbiology pharmacists in the US, of between $70 000 and $800 000 per year.34
Where details of the strategies used to achieve this were given, one-third of Trusts had restricted iv ciprofloxacin and advocated early switch to the much cheaper oral form. This is a well-described intervention:35–37 the high bioavailability of oral ciprofloxacin may give pharmacists confidence in making this switch, and therefore makes a good target for an initial antimicrobial intervention in Trusts where there had previously been little activity in this area. However, such savings cannot be assumed to be recurrent; in Trusts where specialist staff have been employed in Pharmacy for some time, cost savings may be high initially, and then tail off as the ‘easy targets’ are exhausted.
There are difficulties in demonstrating clinical outcome, partly due to the labour-intensive nature of following each patient affected by pharmacy intervention through to discharge and beyond; as the NHS IT development agenda progresses, this may become more feasible. Linking antimicrobial resistance rates and prescribing data is currently rare in UK hospitals, but may also become routine, though linking any reduction or change in resistance rates to antimicrobial intervention alone is fraught with problems.
The methodology employed in this study relied on self-reporting of achievements, and as such may overestimate the impact of the HPI funding; different results may have been obtained if service users and managers had been surveyed. How and whether the appointment of specialist antimicrobial pharmacists has improved antimicrobial stewardship, leading to improved clinical and microbiological outcomes, will need to be assessed in future studies. Further study is also required to assess the impact of pharmacy interventions on antimicrobial prescribing and outcomes, including on key indicator measures such as Clostridium difficile, MRSA and surgical site infection rates. However, at a time when Trust Chief Executives and board members are being actively encouraged to improve antibiotic control, the employment of specialist antimicrobial pharmacy staff may help to drive forward this agenda through their activities in promoting evidence-based medicine, greater multidisciplinary interaction and improving surveillance of antimicrobial use. More outcome data associated with the funding may yet be forthcoming, as several respondents who did not feel that they were able to currently show a benefit stated they that were in the process of following the impact of their activities. However, up to a third of posts that have been created using the HPI funding may have disappeared at the end of the 3 year period; the impact of this loss has yet to be evaluated.
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None to declare.
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Supplementary data |
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The questionnaire and consensus statement are available as Supplementary data at JAC online (http://jac.oxdfordjournals.org).
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Acknowledgements |
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Thanks to all the pharmacy staff in England who took part in this survey. This work was undertaken in part fulfilment of the requirements for the MSc in Infection Management for Pharmacists at Imperial College London; thanks to Professor B. Dean-Franklin, Dr K. Hand and the management committee for their helpful comments and support. This MSc was supported financially by St Mary's NHS Trust. Preliminary results from this study were presented at the SACAR/UK National Prescribing Centre/UK Department of Health meeting ‘Resistance is futile’ held at the Royal Pharmaceutical Society of Great Britain in July 2005.
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References |
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