Articles |
Appendix 2 Specialist Advisory Committee on Antimicrobial Resistance (SACAR)
Antimicrobial Framework
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1. Introduction |
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 Top 1. Introduction 2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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In 2000, the Chief Medical Officer set out a strategy to manage infectious diseases and control antimicrobial resistance.1 A subsequent report ‘Winning Ways’ set out the actions necessary to achieve this control and reinforced the need for prudent use of antimicrobials.2 Some of these recommendations became legal requirements through the 2006 Code of Practice for the prevention and control of healthcare-associated infections (Health Act 2006).3 Antimicrobial prescribing is now one of the indicators used by the Healthcare Commission to audit the management of medicines.4 In order to support local activities to meet these requirements, the Specialist Advisory Committee on Antimicrobial Resistance (the predecessor to the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections), has developed this framework to support the safe and appropriate use of antimicrobials.
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2. Background |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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The Code of Practice (Health Act 2006) requires all NHS trusts to have antimicrobial prescribing policies.3 Each NHS body is expected to have systems in place sufficient to apply evidence-based protocols and practices and to comply with the relevant provisions of the basic code. Section 10 of the code lays out the duty of NHS bodies to adhere to policies and protocols applicable to infection prevention and control. The Code states that ‘an NHS body, must in relation to preventing and controlling the risks of Health Care Associated Infections, have in place the appropriate core policies concerning antimicrobial prescribing’. The code also states that ‘the sufficiency and suitability of any policy must be monitored by the Clinical Governance System, and there must be evidence of a rolling programme of audit, revision and update. All policies must be marked with a review date’. Annex II of the Code of Practice states that:
- Local prescribing should, wherever possible, be harmonized with that in the British National Formulary
- All local guidelines should include information on drug, regimen and duration
- Procedures must be in place to ensure prudent prescribing
- The medicines and prescribing committee (the Drugs and Therapeutics Committee or equivalent) should take into account patterns of resistance to antimicrobials
- As part of its infection control work, the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) should promote the sharing of national and local benchmarking data from routine data collection as well as point prevalence audits. National co-ordination of this data collection should be undertaken centrally by an appropriate body
- Trusts should ensure that the checking and provision of advice on antimicrobial prescribing is routinely undertaken by clinical pharmacy staff, working through a multi-disciplinary antimicrobial team or similar expert group in accordance with hospital antimicrobial policies
- Trusts should report local clinical, microbiological and financial outcomes arising from the Department of Health-led investment to support prudent use of antimicrobials and secure recurrent investment to ensure that the benefits realized are sustained
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3. Principles of prudent antimicrobial prescribing |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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- 3.1 Antimicrobials should be used after a treatable infection has been recognized or there is a high degree of suspicion of infection.2 In general, colonization or contamination should not be treated. Antimicrobials should be used for the prevention of infection where research has demonstrated that the potential benefits outweigh the risks. Long-term prophylaxis should be avoided unless there is a clear clinical indication (for example, rheumatic fever and post-splenectomy).
- 3.2 The choice of antimicrobial should be determined by the sensitivity of the identified causative organism when this is known. Empiric therapy, for the likely causative organism (s) should be governed by local guidelines that have been informed by recent information about trends in antimicrobial sensitivities. Where possible a second-line therapy should be recommended, for individuals who have contra-indications (including allergy) or adverse reactions to the first-line choice.
- 3.3 Targeted therapy should be used in preference to broad-spectrum antimicrobials unless there is a clear clinical reason (for example, mixed infections or life-threatening sepsis). The prescription of broad-spectrum antimicrobials should be reviewed as soon as possible and promptly switched to narrow-spectrum agents when sensitivity results become available. Mechanisms should be in place to control the prescribing of all new broad-spectrum antimicrobials.
- 3.4 The timing, regimen, dose, route of administration and duration of antimicrobial therapy should be optimized and documented. The indication for which the patient is being prescribed the antimicrobials should be documented in the drug chart and case notes by the prescriber. Consideration should be given to creating a separate section on the drug chart for antimicrobials to include the indication.
- 3.5 Wherever possible, antimicrobials should be given orally rather than intravenously. Clear criteria should be defined for when intravenous therapy is appropriate. As soon as possible the prescription should be switched to an oral equivalent. The intravenous prescription should be reviewed after 48 hours as a minimum.
- 3.6 Antimicrobial treatment should be stopped as soon as possible. A stop date or review date should be recorded by the prescriber on the drug-chart. In general, antimicrobial courses should be reviewed within 5 days.
- 3.7 To ensure rapid treatment and infection control, mechanisms should be in place to ensure that patients receive antimicrobial drugs in a timely manner.
- 3.2 The choice of antimicrobial should be determined by the sensitivity of the identified causative organism when this is known. Empiric therapy, for the likely causative organism (s) should be governed by local guidelines that have been informed by recent information about trends in antimicrobial sensitivities. Where possible a second-line therapy should be recommended, for individuals who have contra-indications (including allergy) or adverse reactions to the first-line choice.
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4. Implementation |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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- 4.1 Each Trust should develop an antimicrobial management policy and strategy for its implementation. The policy should be developed and available, preferably electronically, in all wards and other clinical areas. A printed quick reference guide should be given to all prescribers. The policy should be given an expiry date and reviewed routinely. Adherence to the policy should be audited regularly and the results fed back to clinical teams.
- 4.2 An antimicrobial formulary should be developed that stipulates whether the drugs are unrestricted, restricted (approval of a specialist is required) or permitted for specific conditions. Criteria for alert antimicrobials include spectrum of activity, potential toxicity, misuse or cost. The HCC has recommended that ‘the medicines and prescribing committee should take into account patterns of resistance for antimicrobials’.
- 4.3 The antimicrobial policy should be supported by guidelines for treatment and prophylaxis of specific conditions. These guidelines should be evidence-based and prepared in line with best practice recommendations for treatment guidelines.5 Each guideline should be given an expiry date and routinely updated. Adherence to these guidelines should be audited regularly and the results fed back to clinical teams.
- 4.4 The Trust should develop a clear strategy for implementing the antimicrobial policy, formulary and guidelines. A culture of awareness, adherence to guidelines, appropriate prescribing, checking, de-escalation and stopping should be encouraged.
- 4.5 An expert antimicrobial group (EAG) should therefore be established to address effective and safe antimicrobial use. The group should consist of specialist pharmacists, microbiologists, infection-control nurses and medical staff as appropriate. The EAG should maintain responsibility and supervision for the formulary, antimicrobial management policy, strategy and guidelines. The EAG should have clear responsibilities and ways of working with the Drugs and Therapeutics Committee (DTC)/Medicines Management Committee (MMC) and Infection Control Committees and should report to the Chief Executive via the Director of Infection Prevention and Control (DIPC)/Infection Control Manager (ICM) or DTC/MMC.
- 4.6 Clear lines of accountability should be defined between the Chief Executive, DIPC, ICM (Scotland), the EAG and the DTC/MMC.
- 4.7 Antimicrobial prescribing should be facilitated and monitored routinely by antimicrobial pharmacists working in conjunction with prescribers and microbiologists. Mechanisms for providing specialist advice should be developed. For example, microbiology and pharmacy helpdesks, and referral mechanisms. The HCC has recommended that ‘trusts should ensure that the checking and provision of advice on antimicrobial prescribing is routinely undertaken by clinical pharmacy staff, working through a multi-disciplinary antimicrobial team or similar expert group in accordance with hospital antimicrobial policies’.
- 4.2 An antimicrobial formulary should be developed that stipulates whether the drugs are unrestricted, restricted (approval of a specialist is required) or permitted for specific conditions. Criteria for alert antimicrobials include spectrum of activity, potential toxicity, misuse or cost. The HCC has recommended that ‘the medicines and prescribing committee should take into account patterns of resistance for antimicrobials’.
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5. Audit |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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- 5.1 Qualitative and quantitative data should be used to monitor and audit antimicrobial prescribing.
- 5.2 Quantitative data should use the Anatomical Therapeutic Chemical (ATC) classification in conjunction with the World Health Organisation definitions of Defined Daily Doses (DDDs).6 The results should be expressed as DDDs per 100 or 1000 bed days reported at least every 3 months.
- 5.3 Regular (yearly or 6 monthly) point prevalence studies should be undertaken (for example, community-acquired pneumonias, surgical prophylaxis, and intravenous to oral switches) and further in-depth audit performed if necessary.
- 5.4 The qualitative and quantitative information should form part of each trust's audit programme and the results of audits should be fed back to local clinical teams for action.
- 5.5 The HCC has recommended that ‘the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) should promote the sharing of national and local benchmarking data from routine data collection as well as point prevalence audits’. It is anticipated that an appropriate body will be identified to carry out the national coordination of data collection centrally.
- 5.2 Quantitative data should use the Anatomical Therapeutic Chemical (ATC) classification in conjunction with the World Health Organisation definitions of Defined Daily Doses (DDDs).6 The results should be expressed as DDDs per 100 or 1000 bed days reported at least every 3 months.
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6. Education |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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- 6.1 Trusts should work with organizations that are responsible for and provide undergraduate and postgraduate training to ensure that all healthcare professionals who recommend, prescribe, handle and administer antimicrobials receive adequate training and education in the proper use of antimicrobials.
- 6.2 The trust should provide mandatory training in the local antimicrobial policies to all relevant new employees. Education updates should be repeated throughout the duration of employment to ensure familiarity with current policies. This is in accordance with the Level 3 NHS Litigation Authority Risk Management Standards for Acute Trusts.7
- 6.2 The trust should provide mandatory training in the local antimicrobial policies to all relevant new employees. Education updates should be repeated throughout the duration of employment to ensure familiarity with current policies. This is in accordance with the Level 3 NHS Litigation Authority Risk Management Standards for Acute Trusts.7
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7. Minimum recommended guidelines |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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It is recommended that, as minimum, guidelines for treatment or prophylaxis should be available for the conditions listed below.
- Urinary tract infections
- Upper respiratory tract infections
- Lower respiratory tract infections including, community and hospital acquired pneumonia and exacerbations of chronic obstructive pulmonary disease
- Soft tissue infections including injuries or bites, cellulitis, chronic ulcers and necrotizing fasciitis
- Central nervous system infections: bacterial meningitis, viral encephalitis
- Gastro-intestinal infections: food poisoning and intra-abdominal sepsis
- Genital tract infections
- Blood stream infections
- Eye, ear, nose and throat infections
- Sepsis of unknown origin
- Specific confirmed infections: for example, treatment regimens for methicillin-resistant Staphylococcus aureus and Clostridium difficile and tuberculosis
- Endocarditis
- Prevention of bacterial endocarditis (procedure-specific criteria should be agreed to identify which patients should receive prophylaxis)
- Endoscopic procedures [details should be given of which individuals, considered at high risk, should receive prophylaxis (for example neutropenic patients)]
- Surgical prophylaxis (recommendations should be made for all common surgical interventions including timing of initial dose and exceptional circumstances for repeat doses)
- Splenectomy patients (provide details of both the immunization and antimicrobial prophylaxis requirements)
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8. Template |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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Antimicrobial guidelines should be evidence-based and prepared in line with best practice recommendations for treatment guidelines.4 The provision of costing information within the guideline should be discussed locally. The following are additional recommendations for the content and detail of local antimicrobial policies.
- Name of policy
- Specify the condition and patient group where appropriate
- Date
- Version
- Review date
- Authors
- Contact details for enquiries for normal hours and out of hours
- Contact details for microbiological and pharmacological information
- Details of electronic availability
- Statement as to whether the guideline is mandatory or for guidance only
- Contents
- Guidance on the local procedure for microbiological samples
- Abbreviations used in the text
- Reference should be made to guidance in the British National Formulary under Prescription writing.8 These notes lay out a standard for expressing strengths and encourage directions in English not Latin abbreviations.
8.3 Summary list of available antimicrobials
The antimicrobials that are recommended in the guidelines should be listed, with clear indications to the route of administration and should state whether they are:
- Unrestricted
- Restricted (approval of a specialist is required)
- Permitted for specific conditions (for example, co-trimoxazole for Pneumocystis)
8.4 Regimens for treatment of common infections
- First-line recommendation
- Second-line recommendation
- Timing
- Dose
- Route of administration
- Duration of treatment
- Rules for intravenous to oral switch
- First-line recommendation for empirical therapy
- Second-line recommendation for empirical therapy
- Dose
- Timing of initial dose
- Route of administration
- Details of repeat dosing if required
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References |
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Top1. Introduction2. Background3. Principles of prudent...4. Implementation5. Audit6. Education7. Minimum recommended...8. TemplateReferences |
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1 Department of Health. Getting Ahead Of The Curve – A strategy for infectious diseases (including other aspects of health protection) London. (2002) 15 March 2007. Department of Health 2002. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4007697&chk=t0v3Uu.
2 Department of Health. Winning Ways: working together to reduce healthcare associated infection in England. (2003) 15 March 2007. London, DH. Report from the Chief Medical Officer 2003. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4064682&chk=Vqjhyn.
3 Department of Health. The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections (2006) 15 March 2007. London. Department of Health 2006. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4139336&chk=6oAPfi.
4 Healthcare Commission. The best medicine: The management of medicines in acute and specialist trusts. (2007) 15 March 2007. Available at: http://www.healthcarecommission.org.uk/_db/_documents/The_Best_Medicine_acute_trust_tagged.pdf.
5 Appraisal of Guidelines Research and Evaluation. 20 June 2007. http://www.agreecollaboration.org/.
6 Norwegian Institute of Public Health. WHO Collaborating Centre for Drug Statistics Methodology. 22 March 2007. http://www.whocc.no.atcddd.
7 NHS Litigation Authority. Risk Management Standards for Acute Trusts. (2007) 20 April 2007. Available from: http://www.nhsla.com/NR/rdonlyres/51F986A4-2C32-439B-B7FD-CF868C2EB085/0/NHSLARiskManagementStandardsforAcuteTrusts200708website.doc#detailed_standards_12.
8 20 June 2007. British National Formulary 53 (March 2007). http://bnf.org.bnf/.
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