Introduction

This quality standard covers the effective use of antimicrobials (antibacterial, antiviral, antifungal and antiparasitic medicines) to reduce the emergence of antimicrobial resistance (loss of effectiveness of antimicrobials). It covers all settings, all formulations of antimicrobials (oral, parenteral and topical agents) and is for health and social care practitioners, organisations that commission, provide or support the provision of care, as well as people using antimicrobials and their carers. For more information see the antimicrobial stewardship topic overview. NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as legislative changes and antimicrobial licensing, are therefore not covered by this quality standard.

Why this quality standard is needed

In the 2013 annual report, Professor Dame Sally Davies, Chief Medical Officer, said 'Antimicrobial resistance poses a catastrophic threat. If we don't act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can't be treated by antibiotics'.

In the past 50 years, a wide array of antimicrobials has been developed. However, microorganisms are emerging with resistance to many of these, rendering them ineffective. The development of new antimicrobials has slowed substantially and it is possible that in the future infectious diseases and infections that were previously easy to control will become significant threats to health. Standard surgical procedures could become riskier, as could treatments that result in immunosuppression (chemotherapy or organ transplantation), which rely on being able to treat infections in vulnerable patients.

Since 1998, when the World Health Assembly agreed the first resolution on antimicrobial resistance, there has been increasing national and international awareness of the need to use antimicrobials appropriately. In May 2015, the World Health Organization published a global action plan on antimicrobial resistance.

It is difficult to achieve a balance between using antimicrobials when they are really needed and reducing use when they are not indicated. There are concerns about possible harm to people if antimicrobials are not given, but there is agreement about the need to raise awareness that an increase in antimicrobial resistance is associated with antimicrobial prescribing. Antimicrobial stewardship requires a system-wide approach with individuals and organisations working together to preserve antimicrobial effectiveness.

In 2015, the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) published a report reviewing prescribing patterns for antimicrobials in different care settings between 2010 and 2014. This showed that:

  • total consumption of antibiotics in primary and secondary care increased by 6.5%, from 21.6 defined daily doses (DDD) per 1,000 inhabitants per day in 2011 to 23.0 DDD per 1,000 inhabitants per day in 2014

  • combined community and hospital prescriptions increased by 6%

  • general practice consumption increased by 6.2%

  • prescribing to hospital inpatients increased by 11.7%

  • prescribing to hospital outpatients increased by 8.5%

  • dental prescribing increased by 2.8%

  • 'other community prescribing' increased by 5.5%.

Antibiotic prescribing in primary care has been shown to directly affect antimicrobial resistance[1].

Between 2010 and 2014, most antimicrobial prescribing occurred in general practice. In 2014, 74% of antimicrobial prescribing was in general practice, with 11% and 7% for hospital inpatients and outpatients respectively, 5% for patients seen in dental practices and 3% in other community settings.

The quality standard is expected to contribute to improvements in the following outcomes:

  • antimicrobial resistance

  • mortality from infectious disease

  • mortality among people who are immunosuppressed.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

1b Life expectancy at 75

1c Neonatal mortality and stillbirths

Improvement areas

Reducing premature mortality from the major causes of death

1.2 Under 75 mortality rate from respiratory disease*

1.4 Under 75 mortality rate from cancer*

Reducing mortality in children

1.6 i Infant mortality*

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Improvement areas

Reducing the incidence of avoidable harm

5.2 Incidence of healthcare associated infection (HCAI)

i MRSA

ii C. difficile

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Public Health Outcomes Framework

* Indicator is shared

Indicators in italics in development

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

3 Health protection

Objective

The population's health is protected from major incidents and other threats, whilst reducing health inequalities

Indicators

3.5 Treatment completion for TB

3.7 Comprehensive, agreed inter-agency plans for responding to public health incidents and emergencies

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.1 Infant mortality*

4.5 Under 75 mortality rate from cancer*

4.7 Under 75 mortality rate from respiratory diseases*

4.8 Mortality rate from communicable diseases

Alignment with NHS Outcomes Framework

* Indicator is shared

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering antimicrobial stewardship across healthcare settings.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to people using services. Quality statements on these aspects of patient experience are not usually included in topic-specific quality standards. However, recommendations in the development sources for quality standards that affect people's experience of using services and are specific to the topic are considered during quality statement development.

Coordinated services

A whole system, integrated approach to antimicrobial stewardship is fundamental to preserving the effectiveness of antimicrobial medicines.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services.

This quality standard is very closely related to the NICE quality standards on surgical site infection, infection prevention and control, antibiotics for neonatal infection and healthcare-associated infections, and should be read alongside them. Other quality standards that should also be considered when promoting and monitoring the judicious use of antimicrobials are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All prescribers of antimicrobials should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people using antimicrobials. If appropriate, healthcare professionals and social care practitioners should ensure that family members and carers are given advice on the judicious use of antimicrobials and the adverse consequences of overusing them.