Quality statement 1: Antimicrobial stewardship

Quality statement

People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Rationale

Antibiotic resistance poses a significant threat to public health, particularly because antibiotics underpin routine medical practice in both primary and secondary care. To help prevent the development of current and future bacterial resistance, it is important to prescribe antibiotics according to the principles of antimicrobial stewardship, such as prescribing antibiotics only when they are needed (and not for self-limiting mild infections such as colds and most coughs, sinusitis, earache and sore throats) and reviewing the continued need for them. These principles should be set out within local antibiotic guidelines and pathways and be consistent with the local antibiotic formulary. Local antibiotic formularies should indicate a range of antibiotics for managing common infections, and permit use of other antibiotics only on the advice of the microbiologist or physician responsible for the control of infectious diseases.

Quality measures

Structure

a) Evidence of local antibiotic formularies governing the use of antibiotics to ensure that people are prescribed antibiotics appropriately.

Data source: Local data collection.

b) Evidence that local antibiotic formularies are reviewed regularly.

Data source: Local data collection.

c) Evidence of local audits of the appropriateness of antibiotic prescribing.

Data source: Local data collection.

Outcome

Antibiotic prescribing rates (primary and secondary care).

Data source for primary care: National prescribing comparator data available from the Information Services Portal hosted by the Health and Social Care Information Centre, specifically the number of prescription items for antibacterial drugs per Specific Therapeutic Group Age-sex weightings Related Prescribing Unit (STAR-PU), and the number of prescription items for cephalosporins and quinolones as a percentage of the total number of prescription items for selected antibacterial drugs (British National Formulary [BNF], section 5.1).

Data source for secondary care: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they have antimicrobial stewardship initiatives in place, including local antibiotic formularies for antibiotic prescribing.

Healthcare professionals ensure that when they prescribe antibiotics they do so in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Commissioners ensure that they commission services that have antimicrobial stewardship initiatives and in which people are prescribed antibiotics in accordance with local antibiotic formularies.

What the quality statement means for patients, service users and carers

People are offered antibiotics according to local guidance about which ones are most suitable. This includes not being offered antibiotics if they don't need them (for example, if they have a cold, a sore throat, most coughs or earache). This is to try to reduce the problem of antibiotic resistance, which is when an infection no longer responds to treatment with one or more types of antibiotic and so is more likely to spread and can become serious.

Source guidance

  • Respiratory tract infections – antibiotic prescribing (NICE clinical guideline 69), recommendations 1.3 and 1.4.

  • Expert consensus.

Definitions of terms used in this quality statement

Local antibiotic formulary

A local antibiotic formulary is a local policy document produced by a multi‑professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement. [Surgical site infection – full guideline (NICE clinical guideline 74)].

A local antibiotic formulary is defined as 'the output of processes to support the managed introduction, utilisation or withdrawal of healthcare treatments within a health economy, service or organisation. [Developing and updating local formularies (NICE medicines practice guideline 1)]

Local policies often limit the antibiotics that may be used to achieve reasonable economy consistent with adequate cover, and to reduce the development of resistant organisms. A policy may indicate a range of antibiotics for general use, and permit other antibiotics only on the advice of the medical microbiologist or physician responsible for the control of infectious diseases. [BNF, section 5.1]

Antimicrobial stewardship

Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. [Adapted from the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)'s antimicrobial prescribing and stewardship competencies]

The approach to prescribing in line with the principles of antimicrobial stewardship recommended for secondary care is as follows:

  • Do not start antibiotics without clinical evidence of bacterial infection.

  • If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt, effective antibiotic treatment.

  • Document the following on the medicines chart and in the person's medical notes: clinical indication, duration or review date, route and dose.

  • Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.

  • Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be effective.

  • Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first antibiotic dose and make a clear plan of action – the 'Antimicrobial Prescribing Decision'. The 5 Antimicrobial Prescribing Decision options are: Stop, Switch IV (intravenous) to Oral, Change, Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT).

  • Clearly document the review and subsequent decision in the person's medical notes. [ARHAI's guidance on antimicrobial stewardship 'Start smart – then focus']

The approach to prescribing in line with the principles of antimicrobial stewardship recommended for primary care is as follows:

  • Prescribe an antibiotic only if there is likely to be a clear clinical benefit.

  • Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.

  • Limit prescribing over the phone to exceptional cases.

  • Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, co-amoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective, because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and antibiotic‑resistant urinary tract infections.

  • Avoid widespread use of topical antibiotics (especially those that are also available as systemic preparations, such as fusidic acid). [Adapted from the Health Protection Agency's management of infection guidance for primary care]