Implementation: getting started

This section highlights interventions for changing prescribing practice (education and feedback, and information systems to support data collection and feedback), as these could have a big impact on practice and be challenging to implement. We identified these with the help of healthcare practitioners including GPs and pharmacists, commissioners and Guideline Development Group (GDG) members.

The challenge: changing prescribing practice for antimicrobials

The benefits

Reducing the use of antimicrobials where they are not indicated will:

  • slow down the emergence of antimicrobial resistance

  • ensure that antimicrobials remain an effective treatment for infection

  • improve clinical outcomes for the population as a whole

  • conserve healthcare resources.

See the World Health Organization's factsheet on antimicrobial resistance.

Using education and feedback to change prescribing practice

See recommendations 1.1.3, 1.1.6, 1.1.9, 1.1.10, 1.1.17, 1.1.18, 1.1.19

Education and feedback have been recommended as a way of changing prescribers' attitudes and supporting antimicrobial stewardship. Potential barriers that may affect prescribers acting on messages about antimicrobial stewardship include:

  • the possible risk of adverse outcomes from not treating

  • not seeing the direct impact of their prescribing on antimicrobial resistance

  • lack of critical evaluation, review and reflection on their own prescribing practice.

Managers and leads of services could support a change in prescribing practice by:

  • allocating resources for education and feedback in their local area

  • using governance processes such as audit so that prescribers follow antimicrobial guidelines

  • creating an open and transparent culture so that prescribers can question prescribing when this doesn't follow antimicrobial guidelines

  • providing regular updates across the service on individual prescribing, antimicrobial resistance and patient safety incidents

  • including antimicrobial stewardship interventions in education programmes which are designed for the setting in which they are to be used

  • encouraging prescribers to reflect on their personal practice

  • including objectives for antimicrobial stewardship in prescribers' annual reviews

  • signposting prescribers to relevant resources (see further resources for details of resources you may wish to include)

  • using the NICE baseline assessment tool to evaluate current practice and plan changes.

Commissioners could support a change in prescribing practice by:

  • using contracts to ensure that prescribers have the training and skills for antimicrobial stewardship

  • using contracts to ensure that there are programmes for education and feedback on antimicrobial prescribing and resistance, which for secondary care could include the Antimicrobial stewardship: Start Smart - Then Focus toolkit, designed to provide an outline of evidence‑based antimicrobial stewardship in the secondary care setting

  • working with NHS England primary care commissioners to use the TARGET resource for commissioners

  • ensuring that providers have data about rates and trends of antimicrobial prescribing (for example, from the NHS Business Service Authority)

  • encouraging local learning networks, possibly across clinical areas or services, linking to NHS England where required (clinical commissioning groups could lead on this).

Those responsible for planning pre- and post‑registration training for prescribers could support a change in prescribing practice by:

  • including information about antimicrobial stewardship in training courses

  • providing opportunities for prescribers to demonstrate via continuing professional development (CPD)/revalidation that they are following the principles of antimicrobial stewardship.

Using information systems to change prescribing practice

See recommendations 1.1.3, 1.1.6, 1.1.10, 1.1.11, 1.1.12

Information systems can help antimicrobial stewardship by capturing data to allow feedback on:

  • rates and trends of antimicrobial prescribing

  • rates and trends of antimicrobial resistance

  • patient use of standard and back‑up (delayed) prescriptions.

However the relevant data are not always captured or easily accessible.

Commissioners could support the use of information systems to change prescribing practice by:

  • offering a central facility, which presents national and local data on antimicrobial prescribing and resistance in a format that is easy to use

  • encouraging the introduction of electronic prescribing where systems are not in place (if a phased approach is needed, this could start with electronic prescribing for antimicrobials)

  • learning from services such as orthopaedic wound clinics, which make significant contributions to local surveillance and antimicrobial stewardship

  • commissioning the planning and designing of information systems to support antimicrobial stewardship by establishing working groups (to include IT specialists) across all services; this will need coordination and subgroup working to address differences between the various primary and secondary care services.

Commissioners and managers of services could support the use of information systems to change prescribing practice by:

  • including the information standard 'Prescriber ID' (when available) as part of the set‑up of the cost centre and registering of prescribers' codes

  • circulating the data they receive about rates and trends of prescribing within their organisation

  • using data on rates and trends of prescribing in programmes for educating prescribers about antimicrobial stewardship.

Further resources