Articles |
Report of the Prescribing Subgroup of the Specialist Advisory Committee on Antimicrobial Resistance (SACAR)
Pharmacy and Medicines Management, University Hospital of South Manchester NHS Foundation Trust, Manchester M23 9LT, UK
* Corresponding author. Tel: +44-161-291-4195; Fax: +44-161-291-2285; E-mail: jonathan.cooke{at}smtr.nhs.uk or jonathan.cooke{at}manchester.ac.uk
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Abstract |
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 Top Abstract BackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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This report describes the work of the Human Prescribing Subgroup of the Department of Health (DH) Specialist Advisory Committee on Antimicrobial Resistance over a period of 3 years from 2003. It describes the coordination and outputs from the DH Pharmacy Initiative for promoting prudent use of antibiotics in hospitals. The production and dissemination of a template have supported this and have provided a format for acute hospitals to develop antimicrobial guidelines. Engagement with key stakeholders has enabled antimicrobial use and resistance to be highlighted as an important policy issue. Work with the Healthcare Commission has informed the development of high-level indicators that have been incorporated into national audits of acute hospitals and recommendations in a national report ‘The Best Medicine’. The development of a quantitative database of antimicrobial usage has been an important feature of this work. Three annual national multidisciplinary conferences have been organized where work has been presented.
Keywords: antimicrobial stewardship , antimicrobial management , clinical pharmacy , antibiotic pharmacist , healthcare-acquired infection
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Background |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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The Prescribing Subgroup (PSG) of the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) was established in 2003 to focus on the prudent prescribing of antimicrobials initially in hospitals but subsequently across the whole of the national health service (NHS). The group, which met 13 times between 2003 and January 2007, has as its remit:
- to advise SACAR on the prudent use of antimicrobials in humans;
- to promote good practice in the use of antimicrobials;
- to ensure recommendations are consistent with a strategy that lowers the risk of antimicrobial resistance.
Some of the activities and outputs of the PSG are described below.
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The Hospital Clinical Pharmacy Initiative |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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One of the first tasks for the PSG followed an announcement by the Chief Medical and Pharmaceutical Officers in June 2003 that around £12 million would be provided over a 3 year period to promote prudent antibiotic prescribing through enhanced clinical pharmacy services in hospitals.1 Clinical pharmacy activities have developed widely in the UK and evidence is available to show that these activities are cost-effective and lead to improved patient care and better use of medicines.2 Hospital chief pharmacists were asked to plan developments to improve the prudent use and monitoring of antibiotics in their hospitals.3 The funding was distributed through English Primary Care Trusts over a period of 3 years starting in June 2003.
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Template for hospital antimicrobial guidelines |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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Previous research had demonstrated marked variation in the content and format of antimicrobial guidelines being used within the NHS.4 In order to support chief pharmacists who had been tasked with improving and monitoring the prudent use of antibiotics and to promote a uniform approach to antimicrobial prescribing, the PSG prepared and published an evidenced-based template for antimicrobial guidelines. The template, which was supported by the SACAR Board and has been promulgated to the Department of Health (DH), the Health Protection Agency, the British Society for Antimicrobial Chemotherapy (BSAC), the Royal Pharmaceutical Society of Great Britain (RPSGB) and the UK Clinical Pharmacy Association (UKCPA),5 has recently been updated and the current version appears in Appendix 2 of this supplement.
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Lateral engagements with key stakeholders |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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Key stakeholders have included the DH, the National Audit Office,6 the Hospital Infection Society, the BSAC, the RPSGB, the Medicines and Healthcare Products Regulatory Agency (MHRA), the Healthcare Commission (HCC), the National Institute for Health and Clinical Excellence (NICE) and the UKCPA.
Evidence was provided during the consultation process concerning the widening of prescribing rights to include certain non-medical clinicians7 and effective antimicrobial management in nursing homes (see http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4135521&chk=bV9She).
Medicines and Healthcare Products Regulatory Agency
Members of the PSG offered input and advice to MHRA consultations on a number of antimicrobial medicines that were being considered for Medicines Act declassification from Prescription Only Medicines to Pharmacy (P) and from P to General Sales List. The Pharmacist Lead represented SACAR as an observer at the Committee on Safety of Medicines meeting, and a case has been made about why management of antimicrobial medicines needs to differ from that of other pharmaceuticals.
UKCPA, BSAC, RPSGB and Hospital Infection Society
Supportive links and education and training programmes have developed with all of these organizations and PSG members have joined expert groups and contributed to meetings and conferences.
Initial discussions with the HCC enabled antimicrobial management to be included within 21 medicines management indicators that were used to assess hospitals in the Acute Hospitals Portfolio (AHP) audits that took place in 2005.8 These have replaced the ‘star ratings’ of hospital trusts. During a series of audits of 173 acute and specialist hospital trusts that were carried out in 2005 as part of the AHP, the HCC sought to examine the impact of the Hospital Pharmacy Initiative.9 It found that hospitals had used the resources allocated to partially fund a pharmacy post at an average of 0.54 whole time equivalent staff working on the prescribing of antimicrobials. In the autumn of 2005, trusts reported that they had received £7.1 million, although 12 trusts reported having received no funding.
In an assessment of antimicrobial management, 94% of hospitals reported that guidelines for the use of antimicrobials for clinical indications had been produced and 95% reported guidelines were available for surgical prophylaxis. Clinical pharmacists were reported to be working closely with microbiologists to identify local issues, and 76% of trusts had undertaken audits looking at the emergence of problem organisms and looking at how these may relate to prescribing practices (63% of trusts had audited current antimicrobial prescribing practices).
Two types of audits of the use of antimicrobials were commonly undertaken, namely, qualitative audits using point prevalence methodology10 and quantitative techniques using either costs or WHO Defined Daily Doses (DDDs).11 Sixty-three per cent of trusts had undertaken point prevalence audits in which staff had audited patients across the hospital in order to identify any issues with their antimicrobial medication. Two of the key returns from the AHP audits were the number of patients receiving intravenous antibiotics who should have been switched to oral antibiotics (which tend to be cheaper as well as involving less risk) and patients who have been receiving antibiotics for a longer period than is necessary. Forty-two per cent of trusts reported auditing daily doses, whereas 85% reported auditing antimicrobial costs. Some trusts reported both.9
A number of hospitals have reported considerable savings in their expenditure on antimicrobials over this period.12 The overall expenditure on antimicrobials in English acute hospitals over a 5 year period is seen in Figure 1. These data represent hospital dispensing information provided by Intercontinental Medical Statistics (IMS). They are based on information collected by IMS from 97% of hospitals in England and are presented for each calendar year. A linear regression line has been plotted for the data points from 2001 to 2004 and a reduction in expenditure of around £8 million occurred in 2005. These data are not corrected for increased throughput of patients within NHS hospitals during this period. The difference between the regression line and the actual observer figure for 2005 is around £30 million; however, this observation will not meet the criteria for a robust interrupted time series until data for 2006 and 2007 are included.13
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HCC recommendations |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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The HCC made a number of recommendations in their report:9
- that SACAR should promote the sharing of national and local benchmarking data on antimicrobial prescribing arising from routine local data collection as well as point prevalence audits;
- that an appropriate body should carry out the national coordination of data collection centrally;
- trusts should ensure that clinical pharmacy staff check and provide advice on antimicrobial prescribing routinely, working through a multidisciplinary antimicrobial team or similar expert group in accordance with hospital antimicrobial policies.
Trusts should report local clinical, microbiological and financial outcomes arising from the DH-led investment, in order to support the prudent use of antimicrobials and secure recurrent investment to sustain the benefits.
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Database of antimicrobial usage in acute hospitals |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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National data for antimicrobial usage in secondary care have always proved difficult to obtain.14 In the UK, hospital pharmacy computer systems provide their issue data to IMS who are the world's leading source of information and analytics for pharmaceuticals. Permission to analyse these data has been obtained, conditionally, by the DH and the HCC and although not patient-linked, these data offer the most comprehensive analysis that has been obtained to date.9 These data have been obtained for the calendar years 2003–2005 inclusive and represent distribution of antimicrobial usage from around 150 acute hospitals within England covering a population of around 50 million.
Examples of some of the outputs from the database are shown in Figures 2 and 3. There is a 5-fold variation in the use of antimicrobials between the hospitals within the database, ranging from under 50 to almost 200 DDDs per 100 bed days (Figure 2), and a 2-fold variation in the proportion of antimicrobials given orally (Figure 3). Analysis and final validation are currently ongoing and will seek to examine relationships between specific antimicrobial usage and the mandatory reports of MRSA and Clostridium difficile rates within acute hospitals. Previous observations have noted a link between fluoroquinolones and C. difficile diarrhoea.15
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Patient-linked data will become more widely available once electronic prescribing and administration systems are in place. Given the importance of linking susceptibility reports and clinical diagnostic data, these developments will be eagerly awaited.
There is a need to report and analyse data at the hospital level in a way that will allow assessment of the effect of interventions using Effective Practice and Organization of Care methodology.16 A template for use by local acute hospital trusts to facilitate collection of these data is being developed in conjunction with the European Surveillance of Antimicrobial Consumption (ESAC) group. This is being piloted in key sites within member countries. An automatic electronic collection of antimicrobial usage system that utilizes the data files held on each hospital pharmacy computer would be a useful tool for analysis and would enable data to be aggregated at a regional and national level. The PSG is also investigating how to facilitate the routine feedback of antimicrobial prescribing data to general practitioners.
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Educational initiatives |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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The PSG has produced and run three national conferences.
‘Resistance is Useless’(2004)
This conference dealt with the problems of antimicrobial resistance, antimicrobial surveillance methodology and a review of ways to change prescribers' behaviour.
‘Resistance is Futile’ (2005)
Here, the focus was on the structure, content and evidence base of prescribing guidelines; the knowledge and skills required for optimizing antimicrobial use; team-working to address antimicrobial resistance and a review of antimicrobial use in hospitals.
‘Resistance to Change’ (2006)
The 2006 conference looked towards activities to tackle antimicrobial resistance through improving the use of antimicrobials. The agenda incorporated a wider perspective that included a European dimension through ESAC, a general practice viewpoint and results from the recent HCC audits in English hospitals.
These conferences enabled pharmacists and microbiologists to meet and discuss important issues and methodology, with attendees additionally being encouraged to present their work in the form of posters. Examples of topics presented at these meetings are shown in Tables 1 and 2.
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Key recommendations to SACAR and future work plans |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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- Seek support to encourage hospital trusts to continue funding the local initiatives of the hospital clinical pharmacists and to provide tools to support their activities.
- Promote a coordinated effort to obtain funding for the establishment of local and national monitoring of antimicrobial consumption in acute trusts.
- Continue to actively engage with the MHRA, the office of the Chief Pharmacist, national guideline bodies and other stakeholders to ensure that antimicrobial resistance is taken into account within the wider pharmaceutical public health agenda and broader aspects of medicines management.
- Develop the current prudent antimicrobial prescribing programme to engage primary care clinicians.
- Work with other stakeholders in the development and use of evidence-based guidelines for the appropriate use of antimicrobials in both hospital and primary care settings.
- Work with other stakeholders in the development and use of audit tools for the appropriate use of antimicrobials for use by individual organizations.
- Identify areas of research into the appropriate use of antimicrobials and to prioritize and seek funding for specific projects.
- Work with NHS IT ‘Connecting for Health’ to ensure that databases and information support tools are developed to ensure the optimal use of antimicrobials.
- Work with other internal and external agencies to develop and promote appropriate strategies to educate and train users of antimicrobials.
- Continue to develop links with external agencies such as the HCC, NICE and the National Electronic Library for Infection.
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Transparency declarations |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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Professor Cooke has received funds for research studies, advisory boards or speaking at symposia organized by the European Association of Hospital Pharmacists, Imperial College London, the Royal Pharmaceutical Society of Great Britain, Trinity College, Dublin, the United Kingdom Clinical Pharmacy Association, the University of Manchester, the University of Aston, the University of York. Abbott, Altana, Ashley Communications, AstraZeneca, Bayer, Chiron, GSK, Hayward Medical Communications, Janssen-Cilag, Menarini, MSD, Munro and Forster Healthcare, Pfizer, Roche, Sanofi-Aventis, Ted Butler and Associates, Wyeth.
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References |
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TopAbstractBackgroundThe Hospital Clinical Pharmacy...Template for hospital...Lateral engagements with key...HCC recommendationsDatabase of antimicrobial usage...Educational initiativesKey recommendations to SACAR...Transparency declarationsReferences |
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1 Department of Health 2003. PL/CMO/2003/3. PL/PhO/2003/3. Hospital Pharmacy Initiative for Promoting Prudent use of Antibiotics in Hospitals. http://www.dh.gov.uk/en/PublicationsAndStatistics/LettersAndCirculars/ProfessionalLetters/ChiefMedicalOfficerLetters/DH_4004614 (22 March 2007, date last accessed).
2 Child D, Cantrill JA, Cooke J. The effectiveness of hospital pharmacy in the UK: methodology for finding the evidence. Pharm World Sci (2004) 26:44–51.[CrossRef][Web of Science][Medline]
3 Cooke J. Antimicrobial management—the role of clinical pharmacists. Hosp Pharm (2003) 10:392–400.
4 Wiffen PJ, Mayon-White RT. Encouraging good antimicrobial prescribing practice: a review of antibiotic prescribing policies used in the South East Region of England. BMC Public Health (2001) 1:4.[CrossRef][Medline]
5 SACAR. UK Template for Hospital Antimicrobial Guidelines. http://www.advisorybodies.doh.gov.uk/sacar/hospital-antimicrobial-guidelines-template-may05.rtf (22 March 2007, date last accessed).
6 National Audit Office 2004. Improving Patient Care by Reducing the Risk of Hospital Acquired Infection: A Progress Report. pp. HC 876. Session 2003–2004, London. www.nao.org.uk/publications/nao_reports/03-04/0304876.pdf (22 March 2007, date last accessed).
7 Department of Health. Medicines Matters—A Guide to Mechanisms for the Prescribing, Supply and Administration of Medicines. www.prescribing.swest.nhs.uk/DH_Medicines%20Matters%200706.pdf (22 March 2007, date last accessed).
8 Healthcare Commission. Medicines management indicators for the annual health check. In: Acute Hospital Portfolio Reviews 2005/6. London: Healthcare Commission. 17. http://www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/acutehospitalportfolio/medicinesmanagement2005/2006.cfm (22 March 2007, date last accessed).
9 Healthcare Commission. The Best Medicine—The Management of Medicines in Acute and Specialist Trusts. London: Healthcare Commission. 1–72. www.healthcarecommission.org.uk/_db/_documents/The_best_medicine__acute_trust_report.pdf (22 March 2007, date last accessed).
10 Dean BLW, Jacklin A, Rogers T, et al. The use of serial point prevalence studies to investigate anti-infective prescribing. Int J Pharm Pract (2002) 10:121–5.
11 Norwegian Institute of Public Health. WHO Collaborating Centre for Drug Statistics Methodology. http://www.whocc.no/atcddd (22 March 2007, date last accessed).
12
Wickens HJ, Jacklin A. Impact of the hospital pharmacy initiative for promoting prudent use of antibiotics in hospitals in England. J Antimicrob Chemother (2006) 58:1230–7.
13 Mol PGM, Wieringa JE, NannanPanday PV, et al. Improving compliance with hospital antibiotic guidelines: a time-series intervention analysis. J Antimicrob Chemother (2005) 55:5507.
14 Kritsotakis EI, Gikas A. Surveillance of antibiotic use in hospitals: methods, trends and targets. Clin Microbiol Infect (2006) 12:701–4.[Web of Science][Medline]
15 Pepin JSN, Coulombe MA, Alary ME, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile—associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis (2005) 41:1254–60.[CrossRef][Web of Science][Medline]
16
Ramsay C, Brown E, Hartman G, et al. Room for improvement: a systematic review of the quality of evaluations of interventions to improve hospital antibiotic prescribing. J Antimicrob Chemother (2003) 52:764–71.
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