The sharing of key health service data on the use of antibiotics is “disappointingly” low with frontline nurses and other staff, a progress report on antimicrobial stewardship in England has warned.
The report, published by Public Health England, criticises trusts for failing to engage with clinicians deemed “pivotal” to boosting antimicrobial stewardship and reducing consumption of the drugs.
“Other behavioural change strategies are needed to ensure engagement with clinicians”
PHE, the government arm’s-length body, today published the fourth annual report from the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR).
It provides an update on trends in antimicrobial resistance, antibiotic prescribing and national initiatives aimed at tackling the issue.
The report’s findings also coincide with the launch of a new public awareness campaign, called Keep Antibiotics Working.
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In particular, the report looked at the impact of national incentive payments available to trusts, under the Commissioning for Quality and Innovation (CQUIN) framework, for good practice.
The aim was to reduce antibiotic “consumption”, encourage a focus on so-called “antimicrobial stewardship” and ensure antibiotic prescriptions were reviewed within 72 hours of commencing.
Part of the CQUIN payment was reserved for submission of consumption data to PHE for the years 2014-15 to 2016-17, while payment was also given for a reduction of 1% or more in total antibiotic consumption, carbapenem use or piperacillin/tazobactam use, compared to 2013-14 levels.
In addition, the CQUIN required that a specific percentage of antibiotic scripts were reviewed within 72 hours per 50 antibiotic prescriptions taken from a sample across sites and wards.
“We need to create new antibiotics before infections become untreatable”
According to the report, half of trusts felt that the CQUIN had “changed” their antimicrobial stewardship activity and a third felt that it would help reduce antibiotic consumption.
However, the report highlighted there was no significant change in the numbers of whole-time equivalent staff, including pharmacists, nurses, and data analysts, employed to carry out antimicrobial stewardship work at trusts following the introduction of the CQUIN.
In addition, the report said the number of trusts accessing local indicators on antimicrobial stewardship via Public Health England’s “fingertips” website – launched in April 2016 – was “encouraging”.
It suggested that antimicrobial stewardship teams were increasingly interested in understanding trust prescribing patterns in order to best inform local practice, said the report.
But it added: “Disappointingly this data does not appear to be commonly shared with trust boards, frontline clinicians, nurses and pharmacists working at acute trusts who are pivotal in carrying out antimicrobial stewardship and successfully achieving the CQUIN.
“This suggests that other behavioural change strategies are needed to ensure engagement with clinicians and to assist trusts in achieving their CQUIN aims in 2017-19,” stated the report.
It also revealed progress on PHE’s antibiotic guardian campaign, which was launched in 2014 to encourage healthcare professionals and the public to make pledges in support of antimicrobial stewardship.
The report said nearly 20% of health professionals who had signed up to be guardians were nurses, making them the second most numerous professional group after pharmacists.
Meanwhile, the number of nurses of had become antibiotic guardians had increased from 922 in 2014 to 1,796 in 2016, said the report.
There had also been a significant increase in the proportion of guardians who were either students or educators, which it said reflected “increased engagement from universities”.
In addition, the report set out overall data on national progress towards meeting targets on antimicrobial stewardship, noting that halving the numbers of healthcare-associated Gram-negative bloodstream infections by March 2021 was a “key government ambition”.
The report said “encouragingly” the proportion of such infections resistant to key antibiotics had “remained broadly stable” over the last five years, which was in contrast to many other countries.
The reasons “most likely reflects” good antimicrobial stewardship and rare use of cephalosporins and quinolones in community settings in England, according to the report.
During 2016, it said the commonest cause of bloodstream infections was Escherichia coli, of which 41% were resistant to the commonest antibiotic used to treat them in hospitals, co-amoxiclav.
In addition, almost one in five were resistant to at least one of the other key antibiotics, though multi-drug resistance remained “uncommon”.
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This trend suggested patients with severe infections, including sepsis, who have risk factors for resistant bacteria may require a combination of a β-lactam antibiotic and an aminoglycoside for the first 24 hours, while waiting for laboratory results to “guide the choice of optimal therapy”.
Risk factors for resistant bacteria included patients who have received prior antibiotic courses, had a history of recent or recurrent hospital admissions and the elderly, especially those living in long-term care facilities, noted the report.
It highlighted the importance of taking clinical samples, especially blood and urine, prior to commencing antibiotics in patients presenting with infections in accident and emergency or while an inpatient, in order to inform antibiotic treatment after the first 24-48 hours.
Meanwhile, the report said data indicated that resistance was common in the more than one million urinary tract infections (UTIs) caused by bacteria identified in NHS laboratories in 2016.
Trimethoprim resistance was “very common” in laboratory processed urine samples, but the current recommended first line treatment, nitrofurantoin, was “currently effective”, it added.
‘Disappointingly’ few trusts sharing antibiotics data with nurses
“This supports the PHE infections guidelines to switch from trimethoprim to nitrofurantoin as empiric treatment for UTI before laboratory results are available,” stated the report.
Overall, between 2012 and 2016, it said prescribing reduced by 5%, with declines across the majority of antibiotic groups, but warned that “significant regional variation” in use continued to occur.
The number of prescriptions dispensed in primary care settings decreased by 13% between 2012 and 2016, largely driven by reductions in use of penicillins.
In contrast, PHE warned that, despite some progress observed in 2015, secondary care settings had not achieved a sustained reduction in total antibiotic prescribing.
However, it noted a fall in use of the ultra-broad spectrum antibiotics piperacillin/tazobactam and carbapenems between 2015 and 2016, which it described as the “first step” in cutting antibiotic use in hospitals.
A study would report “shortly” on the impact of CQUIN and a similar scheme for primary care, called the Quality Premium, on infection-related admissions, length of stay and mortality, it added.
Over the first two years of the Quality Premium, 88% of clinical commissioning groups reduced antibiotic consumption and 83% reduced broad-spectrum antibiotic use to the target level.
In 2016-17, the first year of the CQUIN, 37%, 33% and 52% of acute trusts met their targets to cut total antibiotic, piperacillin/tazobactam and carbapenem use to 2013-14 levels, respectively.
But significantly more reduced their consumption of piperacillin/tazobactam and carbapenem, compared to 2015-16 levels – 66% and 67%, respectively.
NICE working on guidelines on antibiotics for common infections
Despite the positive tone of the report, Professor Colin Garner, chief executive of Antibiotic Research UK, said it showed “we are heading at speed towards a ‘post-antibiotic apocalypse’”.
He called for the formation of a “grand alliance” of UK stakeholders to “work much more closely together” on tackling antibiotic resistance.
“We would like to see PHE engage with us. There is far too much fragmentation in tackling resistance, claimed Professor Garner.
“As well as improving an understanding of antibiotic use, we need to create new antibiotics before infections become untreatable,” he said.
“Only two new antibiotic classes have been introduced in the last 40 years so we don’t have new drugs to fight antibiotic resistant bacteria in our armoury,” he said. “This is of great concern.”
Dr Neil Wigglesworth, president of the Infection Prevention Society and a nurse by background, said: “The cost of inappropriate use of antibiotics is clear and is becoming ever more serious.
neil wigglesworth photo
“Ensuring effective infection prevention practices in all health and care settings is an essential way of preventing infection from developing and spreading and there is clear evidence that early intervention through infection prevention saves lives as well as significant cost to the NHS,” he said.
“Effective infection prevention stops the spread of resistant organisms and every infection that is prevented is one more person who doesn’t need a course of antimicrobial treatment,” he added.