The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use.

Although a third of the public still believe that antibiotics work against coughs and colds, simply getting the public to believe otherwise may not be enough to reduce the level of prescribing. The large Department of Health sponsored household survey demonstrated that those with a greater knowledge about antibiotics were no less likely to be prescribed an antibiotic, and although those with increased knowledge about antibiotics were more likely to complete a course they were also more likely to self-medicate and to keep left-over antibiotics. Future campaigns that are aimed at reducing the level of prescribing should be focused towards those more likely to be prescribed antibiotics at present: younger women and those with a lower level of education. They should also examine and consider modifying consultation behaviour and other behavioural components involved in patient' expectations for antibiotics. This should include delayed antibiotic prescriptions. The easiest way to reduce the use of leftovers may be to shorten the course of antibiotics prescribed to 3 or 5 days. We should also promote a 'Do not recycle antibiotics' message towards the more highly educated, young women who are more likely to store, take and share antibiotics without advice.

Qualitative interview study A sample of adult members of the public with diverse ethnicity and deprivation were opportunistically recruited in pharmacies in four areas of England. Responders who had recently had an RTI, were asked to participate in a later telephone interview.

Objectives: To assess the public's knowledge and attitudes to antibiotics, their reported antibiotic use and the relationship between them.Patients and methods: A questionnaire was included in the face-to-face Office for National Statistics Omnibus Household Survey in Britain in 2003. Of 10 981 randomly selected adults from England, Scotland and Wales, 7120 (65%) completed the questionnaire.Results: Although 79% of respondents were aware that 'antibiotic resistance is a problem in British hospitals', 38% of respondents did not know that antibiotics do not work against most coughs or colds and 43% did not know that 'antibiotics can kill the bacteria that normally live on the skin and in the gut'. Respondents with lower educational qualifications were less knowledgeable about antibiotics. In a multivariable analysis, better knowledge of antibiotics was not associated with being less likely to be prescribed any in the last year, but was independently associated with being more likely to finish a course of antibiotic as prescribed. Knowledge was also associated with being more likely to take antibiotics without being told to do so. In women, better knowledge was associated with being more likely to give an antibiotic to someone else that was not prescribed for them. Conclusions:We have shown that there is no simple relationship between increased knowledge and more prudent antibiotic use. Future national antibiotic campaigns should have a defined audience and aims in order to facilitate prudent antibiotic use by clinicians and public.

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Despite the publication of guidance for GPs on CFS/ME, confidence with making a diagnosis and management was found to be low. Educational initiatives and guidance for GPs should stress the importance of accepting CFS/ME as a recognisable clinical entity, as this is linked to having a positive attitude and could lead to improved confidence to make a diagnosis and treat CFS/ME patients.

There is little evidence that the 2008 public antibiotic campaigns were effective. The use and visibility of future campaign materials needs auditing. A carefully planned approach that targets the public in GP waiting rooms and through clinicians in consultations may be a more effective way of improving prudent antibiotic use.

Antimicrobial resistance is a global problem and is being addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) and procalcitonin, measurements to guide antibacterial prescribing in adult patients presenting to GP practices with symptoms of respiratory tract infection (RTI). Studies that were included were randomised controlled trials, controlled before and after studies, cohort studies and economic evaluations. Many studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces antibiotic prescribing by 23.3% to 36.16%. Procalcitonin is not currently available as a point-of-care testing (POCT), but has shown value for patients with RTI admitted to hospital. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. CRP POCT can better target antibacterial prescribing by GPs and contribute to national antimicrobial resistance strategies. Health services need to develop ways to ensure funding is transferred in order for POCT to be implemented.