Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus

Abstract

There has been dramatic change in antibiotic use in English hospitals. Data from 2004 and 2009 show that the focus on reducing fluoroquinolone and second- and third-generation cephalosporin use seems to have been heeded in NHS secondary care, and has been associated with a substantial decline in hospital Clostridium difficile rates. However, there has been a substantial increase in use of co-amoxiclav, carbapenems and piperacillin/tazobactam. In primary care, antibiotic prescribing fell markedly from 1995 to 2000, but has since risen steadily to levels seen in the early 1990s. There remains a 2-fold variation in antimicrobial prescribing among English General Practices. In 2010, the NHS Atlas of Variation documented a 3-fold variation in the prescription of quinolones and an 18-fold variation in cephalosporins by Primary Care Trusts across England. There is a clear need to improve antimicrobial prescribing. This paper describes the development of new antimicrobial stewardship programmes for primary care and hospitals by the Department of Health's Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection: Antimicrobial Stewardship in Primary Care Initiative. The secondary care programme promotes the rapid prescription of the right antibiotic at the right dose at the right time, followed by active review for all patients still on antibiotics 48 h after admission. The five options available are to stop, switch to oral, continue and review again, change (if possible to a narrower spectrum) or move to outpatient parenteral antibiotic therapy. A range of audit and outcome tools has been developed, but to maintain optimal antimicrobial usage, monitoring of local and national quantitative and qualitative data on prescribing and consumption is required, linked to the development of key performance indicators in primary, secondary and tertiary care.

Molecular Epidemiology of Clostridium difficile Infection in a Major Chinese Hospital: an Underrecognized Problem in Asia?

“…China has the right setting for C. difficile infection, with heavy antibiotic prescribing, with the production of antibiotics being recently quoted as 210,000 tons per annum, approximately half being used in human medicine (22). The per capita use in China based on this production figure is approximately 10 times that of England, according to data from 2009 (23). The frequency of use of nonprescribed antibiotics in the community in China has been reported as 36% of individuals per annum, compared to 3% in the United Kingdom (24).…”

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

“…They may contribute to the delivery of key health-care strategies and directives such as Equity and Excellence: Liberating the NHS, 16 Creating a Patient-led NHS, 17 Your Health, Your Care, Your Say 18 and Start Smart then Focus. 19 As yet, no national policy in this area exists, although we understand that there have been meetings between members of the British Society for Antimicrobial Chemotherapy (BSAC) OPAT steering group and the Department of Health regarding further service development. Health-care providers mainly use the current system of tariffs provided through NHS England Payment by Results system, which can be interpreted in a number of different ways, thus making the commissioning process complex.…”

Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam

“…[21][22][23] This approach accommodates the need to initiate broad-spectrum therapy during periods of clinical uncertainty when the relevant pathogen is yet to be identified while encouraging more specific treatment after microbiologic data become available and the clinical scenario is better defined and can be either restrictive or persuasive, depending on its design and implementation.…”