Nurses should be able to question the antimicrobial prescribing practices of colleagues when these are not in line with guidelines, according to the National Institute for Health and Care Excellence.
NICE has today published high profile guidance for clinicians to “promote and monitor the sensible use of antimicrobials”.
“We need to encourage an open and transparent culture that allows health professionals to question antimicrobial prescribing practices”
It encouraged health and social care practitioners across “all care settings” to work together to support antimicrobial stewardship.
The institute called on health professionals to communicate and share “consistent messages” about antimicrobial use, and learning and experiences about antimicrobial resistance and stewardship.
It also suggested that clinicians consider setting up local networks to share best practice, as well as developing local processes for peer review of prescribing.
In addition, NICE called on organisations to encourage an “open and transparent culture” that allowed clinicians to challenge the practices of other prescribers.
Professor Mark Baker, director of the NICE Centre for Clinical Practice, said: “We need to encourage an open and transparent culture that allows health professionals to question antimicrobial prescribing practices of colleagues when these are not in line with local and national guidelines and no reason is documented.”
Though mostly directed at GPs, the guidance also covers prescribing by suitably qualified nurses and pharmacists.
When prescribing antimicrobials, the guideline reminded clinicians to follow local or national guidelines on prescribing the “shortest effective course, the most appropriate dose and route of administration”.
Prescribers should not issue an immediate prescription for an antimicrobial to a patient who is likely to have a self-limiting condition, states the guidance.
In addition, they should not issue repeat prescriptions for antimicrobials unless needed for a particular clinical condition or indication.
“It’s often patients themselves who… may put pressure on their doctor to prescribe an antibiotic when it is not indicated and they are unlikely to benefit from it”
It adds that prescribers should avoid issuing repeat scripts for longer than six months without review and ensure adequate monitoring for patients to reduce adverse drug reactions and to check whether continuing an antimicrobial is “really needed”.
Although a new infectious disease has been discovered nearly every year over the past 30 years, NICE noted that very few new antibiotics have been developed.
Overall, antibiotic prescribing in England has been steadily increasing over several years. Nationally, 41.6 million antibiotic prescriptions were issued in 2013-14 at a cost to the NHS of £192m.
The institute highlighted that, despite considerable guidance that prescribing rates of antibiotics should be reduced, surveys suggested nine out of 10 GPs felt pressured to prescribe antibiotics and 97% of patients who asked for antibiotics were prescribed them.
As well as providing guidance for individual prescribers, NICE said commissioners and service providers should ensure antimicrobial stewardship programmes were in place locally.
It also recommended setting up multi-disciplinary antimicrobial stewardship teams working across all care settings.
Such teams should be able to review prescribing and resistance data frequently and feed this information back to prescribers.
They should also be able to work with prescribers to understand the reasons for very high or increasing volumes of antimicrobial prescribing, as well as challenging prescribers who issue antimicrobials scripts outside of local guidelines where it is not considered justified.
But Professor Baker added that it was “not just prescribers” who should be questioned about their attitudes and beliefs about antibiotics.
“It’s often patients themselves who, because they don’t understand that their condition will clear up by itself, or that perhaps antimicrobials aren’t effective in treating it, may put pressure on their doctor to prescribe an antibiotic when it is not indicated and they are unlikely to benefit from it,” he said.
Professor Baker added: “Many people think that it is their body which becomes resistant, rather than the bacteria that cause antimicrobial-resistant infections. This often makes it feel that the issue of resistance is someone else’s problem.”
He called on clinicians to “take time” to discuss with patients the likely nature of their condition, the benefits and harms of antimicrobial prescribing, alternative options such as watchful waiting and why an antimicrobial may not be the best option, for example, if they have a self-limiting respiratory tract infection.
Meanwhile, a patient safety alert has been issued today to healthcare professionals about the “alarming” rise in antimicrobial resistance over the past 40 years.
Sent out jointly by NHS England, Public Health England and Health Education England, the alert highlights inappropriate use of antimicrobials as being a key factor to the increase in resistance.
It stated that from 2010 to 2013, total antibiotic prescribing in England increased by 6%. This included a 4% rise in general practice and 12% increase in hospital inpatient prescribing.