Shared learning database

Cardiff University /SCRIPT at University of Birmingham
Published date:
March 2019

The project was undertaken to address a gap in antimicrobial stewardship (AMS) education in UK healthcare professional undergraduate programmes. The resource [1], an AMS competency framework applicable to the UK health and social care setting, was developed through a commonly used formal consensus method, i.e. a modified Delphi technique. This technique used two on-line survey rounds to gather the opinions of a panel of 21 UK experts. The framework developed from this work is offered as a model for undergraduate AMS education for all healthcare professions, and a means by which to standardise curricula, boost the impact of AMS education, and improve clinical practice. The primary users of the resource are undergraduate healthcare professional students. Secondary users may include those working in new roles such as Nursing and Physician Associates. The resource may also be used by those working in specialists and advanced practice roles.

  1. Courtenay M, Lim R, Castro-Sanchez E,et al. Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education. J Hosp Infect.2018 Nov;100(3):245-256. doi: 10.1016/j.jhin.2018.06.022. Epub 2018 Jun 30.

This project was a joint initiative between Professor Molly Courtenay at Cardiff University and Sarah Pontefract (Lecture in Clinical Pharmacy and Therapeutics and SCRIPT Editorial Lead), Hannah Vallance and Julie Mason  (SCRIPT eLearning Managers) from SCRIPT at the University of Birmingham.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Aim: To provide United Kingdom national consensus on a common set of AMS competencies appropriate for undergraduate healthcare professional education.

The AMS competencies that were developed from this work support the optimal use of antibiotics. These competencies also support the implementation of recommendations in the NICE guideline on antimicrobial stewardship (NG15) and statements 1, 3 and 4 in the NICE quality standard for antimicrobial stewardship (QS121)

Reasons for implementing your project

Antimicrobial resistant infections cause approximately 700,000 deaths each year globally and this figure is predicted to rise to 10 million, alongside a cumulative cost of $100 trillion, by 2050 if no action is taken. [1] Antimicrobial stewardship (AMS) is defined as 'an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.' [2]

The education of undergraduate healthcare professional students on antimicrobial stewardship (AMS) is a key activity for the containment of antimicrobial resistance. [3] However, UK undergraduate healthcare professional students receive disparate stewardship education, [4] and there is a need to adopt a comprehensive approach with standardised content. [4] A shift toward assessment of quality and outcomes of care has meant that healthcare professional curricular content is now associated with competencies. [5] Competency based education (CBE) recognizes that quality of care is not improved simply by accumulating and disseminating the best available evidence, [6] but instead, with the increasing emphasis on person-centred care, it is necessary for clinicians to respond to patients’ needs in a compassionate, knowledgeable, and coordinated fashion. [7] Although AMS competencies have been developed for United Kingdom (UK) prescribers, [8] specific competencies designed to address the spectrum of AMS activities (such as the administration and supply of antibiotics, and monitoring of patients for effectiveness of treatment and adverse effects), in which those healthcare professionals who do not prescribe are involved, have not been established. Undergraduate education provides an important opportunity to prepare healthcare professionals for these activities. Furthermore, it will become increasingly important to strengthen AMS in undergraduate healthcare professional education as less experienced healthcare professionals are able to access shortened post registration prescribing programmes. [9]


  1.  HM Government (2019) Tackling antimicrobial resistance 2019-2024 – The UK’s five-year national action plan. Accessed 11 February 2019
  2. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE 2018
  3. Global action plan on antimicrobial resistance, 2016
  4. Castro-Sánchez, E., Drumright, L.N., Gharbi, M., Farrell, S., Holmes, A.H. Mapping Antimicrobial Stewardship in Undergraduate Medical, Dental, Pharmacy, Nursing and Veterinary Education in the United Kingdom. PLoS ONE 2016,11(2): e0150056. doi:10.1371/journal.pone.0150056 
  5. Gruppen, L.D., Mangrulkar, R.S., Kolars, J.C. The promise of competency-based education in the health professions for improving global health. Human Resources for Health 2012,10(1),43.
  6. Rathert, C., Wyrwich, M.D., Boren, S.A. Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review 2012, 70(4), 351-379. doi: 10.1177/ 1077558712465774.
  7. Gachoud, D., Albert, M., Kuper, A., Stroud, L., Reeves, S. Meanings and perceptions of patient-centredness in social work, nursing and medicine: a comparative study. Journal of Interprofessional Care 2012, 26, 484-490
  8. Antimicrobial prescribing and stewardship competencies. London: PHE. 2013 ref 8
  9. Standards for prescribing programmes. 2018

How did you implement the project

SCRIPT is a web-based eLearning programme delivering a portfolio of modules to improve prescribing competency.  The SCRIPT portfolio contains three modules relating to the management of infection for Foundation trainee doctors across England, Wales and Northern Ireland: 1) Principles of prescribing in Infection; 2) Infection in Secondary Care; and 3) Sepsis.  The modules are also available to 14 UK Medical schools to facilitate the delivery of therapeutics teaching and to help students prepare for the national Prescribing Safety Assessment.  Additionally, variants of the modules are available to Paediatric Specialist Trainees, General Practitioners, Nurses, Paramedics and non-medical prescribing Pharmacists, adapted specifically for each audience.

Project aim

Upon publication of the antimicrobial stewardship competencies, the SCRIPT team mapped the competencies to their module content to determine if there were any gaps in content taught that needed to be resolved. The aim of this submission is to describe this mapping process so that those involved in the development of curricula for healthcare professionals will be encouraged to review their current AMS teaching and adjust this accordingly.  In addition, healthcare organisations may be encouraged to review the mandatory training they provide for staff on AMS and adapt their content to ensure the competency descriptors are met.

Key findings

The 54 competency descriptors were assessed independently by two members of the SCRIPT Editorial team to determine if they were covered in the learning content of one or more of the three infection modules, or if they were covered by any other module in the SCRIPT portfolio.  Each competency was scored for each module as either green (outcome covered); amber (outcome partially covered); or red (outcome not covered).  Any descriptors assigned as an amber were checked by a second editor and any disagreement discussed. The Editorial Lead for the SCRIPT team then ran an independent check on the results. A total of 21/54 competencies were scored as green and 9/54 as amber, giving 59.3% (n=31/54) of competencies covered or partially covered by the content in the three modules.  A further 9/54 were covered by modules elsewhere in the SCRIPT portfolio, for example, ‘Explain why it is essential that an accurate diagnosis of an allergy to an antimicrobial is based on history and laboratory tests’ is covered in the Drug Allergy and Anaphylaxis module and ‘Demonstrate an understanding of the rationale and use of perioperative prophylactic antimicrobials to prevent surgical site infection’ in the Perioperative Prescribing module.

Since the SCRIPT modules relate to prescribing and therapeutics, the Editorial team then reviewed all 54 of the outcomes to determine whether they should potentially be included in the module content or whether they were not applicable to the overall aims of the learning portfolio. A total of 6/54 were considered not applicable. Out of the 48 for potential inclusion, 6 were already partially included in the content, but 12 were not included at all.  These 18 were sent to three editors to independently review whether they should be included in one of more of the three infection modules.  A total of 9/19 were considered applicable for inclusion, four of which were partially included in the content already, leaving five to be incorporated into the module content (Table 1).


Table 1: Competency descriptors to be included in SCRIPT eLearning module content

Competency descriptor

Module title

Describe the national guidance on completion of a course of antimicrobials

Principles of Prescribing in Infection

Describe what is meant by delayed prescribing

Principles of Prescribing in Infection

Discuss how inappropriate antimicrobial use (including non-adherence to treatment regime) may lead to antimicrobial resistance*

Principles of Prescribing in Infection

Explain why self-limiting bacterial or viral infections are unlikely to benefit from antimicrobials

Principles of Prescribing in Infection

Describe and demonstrate the self-management strategies required to treat self-limiting infections (i.e. analgesia/rest/fluids)

Principles of Prescribing in Infection

Demonstrate an understanding of the factors that need to be considered when choosing an antimicrobial (including site of infection and type of bacteria likely to cause an infection at a particular site)*

Principles of Prescribing in Infection


Infection in Secondary Care



Understand the appropriateness of antimicrobial administration models such as outpatient parenteral antimicrobial therapy (OPAT)*

Infection in Secondary Care

Discuss patient/carer expectations or demands of antimicrobials and the need to use antimicrobials appropriately

Principles of Prescribing in Infection


Discuss factors that can influence antimicrobial prescribing and the implications for antimicrobial stewardship programmes*

Principles of Prescribing in Infection


Infection in Secondary Care

*Competencies partially covered by the eLearning content in one or more of the three infection modules


It is important to note that using the modality of eLearning, competencies such as ‘demonstrate’ and ‘communicate’ cannot be achieved or assessed, however the content relating to these descriptors can certainly be discussed.  For example, Demonstrate an understanding of the roles, responsibilities, and competencies of other health professionals involved in antimicrobial treatment policy decisions, can be approached by discussing the roles and responsibilities of those involved in the process. 



Achieving the missing competencies

For each of the competencies in Table 1, content has been authored by the Editorial team as either case vignettes, activities or text content to ensure each are appropriately covered.  An example has been provided for incorporating ‘delayed prescribing’.


Describe what is meant by delayed prescribing

A case vignette has been added to the Principles of Prescribing in Infection module to discuss when a delayed prescription may be appropriate.  The case also discusses self-management strategies to treat the self-limiting infection (i.e. analgesia/rest/fluids), which touches on a second competency in (see Table 1).


Major Title

Sore Throat

Page Subtitle

Case Vignette


A 4-year-old boy presents to his GP with a three day history of a sore throat. His mother reports no other symptoms. He is apyrexial and has no known drug allergies. On examination, his tonsils appear normal but he has a very red posterior pharyngeal wall. Which of the following treatment options are most appropriate to prescribe? (Select all that apply)

  • Oral co-amoxiclav 125/31 suspension, 5 ml three times a day for 5 days
  • Oral ibuprofen  150 mg three times a day Correct answer
  • Oral paracetamol 240 mg four times a day Correct answer
  • Oral phenoxymethylpenicillin 125 mg four times a day for 10 days



  • Generally, upper respiratory tract infections are viral infections and antibacterial treatment is not indicated in most patients.
  • Most children can be managed using simple analgesia to relieve pain and/or fever. Paracetamol and/or ibuprofen are routinely recommended providing there are no contraindications. Other interventions may include salt water gargling or medicated anaesthetic sprays, and the patient should be encourage to maintain an adequate fluid intake.
  • The NICE guidelines on ‘Sore throat (acute): antimicrobial prescribing’ recommend using the FeverPAIN or Centor criteria to determine which patients are most likely to benefit from antibacterial treatment. 
  • FeverPAIN criteria 
    • FeverPAIN criteria
    • Fever (during previous 24 hours)
    • Purulence (pus on tonsils)
    • Attend rapidly (i.e. seek medical attention within 3 days of symptom onset)
    • Severely inflamed tonsils
    • No cough or coryza

Each criteria scores one point. The higher the score the more likely a bacterial infection is present. (NICE NG 84, 2018).

  • Centor Criteria. The four Centor criteria are:
    • Presence of tonsillar exudate.
    • Presence of tender anterior cervical lymphadenopathy or lymphadenitis.
    • History of fever.
    • Absence of cough (NICE NG 84, 2018).
  • NICE recommendation on when antibacterials are recommended for the management of sore throats based on FeverPAIN or Centor criteria:
    • No antibacterials: patients with a FeverPAIN score of 0 or 1, or Centor score of 0, 1 or 2.
    • Consider no antibacterials or delayed prescription: patients with a FeverPAIN score of 2 or 3.
    • Consider immediate antibacterials or delayed prescription: patients with FeverPAIN score of 4 or 5, or Centor score of 3 or 4.
  • If a delayed antibacterial prescription is indicated, relative/carers should be counselled not to commence unless symptoms have not improved within 3-5 days or if the patient’s symptoms significantly deteriorate at any time.
  • This prescription can be given to the patient or their relatives/carers to take away with them or, prepared for collection from pharmacy (or the Paediatric Assessment Unit (PAU)) and the patient’s relatives/carers asked to collect should symptoms deteriorate.
  • In addition, patients should be immediately prescribed antibacterial treatment if they have:
    • Systemic symptoms; or
    • Signs and symptoms of a more serious illness; or
    • Are at high-risk of serious complications (e.g. valvular heart disease, immunocompromised patient).
  • In this scenario, the patient has a FeverPAIN score of 1, therefore antibacterials are not indicated. Provide reassurance to the patient’s relative/carers and advise them to seek medical attention if the child’s condition deteriorates



Key learning points

In the context of eLearning, it is important to ensure that information presented to the learner is up-to-date and comprehensive. The AMS competencies provided an opportunity to assess the completeness of our portfolio of content in relation to infection, to ensure that we are achieving agreed standards for undergraduates (and therefore postgraduates).  Like any field of medicine, both the eLearning content and the competencies require regular review to ensure these reflect current practice, the prescribing landscape and any global health concerns.

We would recommend our approach in the review of undergraduate curricular and associated teaching content to determine whether schools or programmes are providing the learning needed to meet the competencies. In addition, healthcare organisations could use the competencies to review the mandatory training they provide on the topic.  Ideally, such reviews should be conducted independently with more than one person and verified by a third to ensure a robust review process.

Contact details

Molly Courtenay / Sarah Pontefract
Professor / Lecturer in Clinical Pharmacy and Therapeutics and SCRIPT Editorial Lead
Cardiff University /SCRIPT at University of Birmingham
Email: /

Is the example industry-sponsored in any way?