3Antimicrobial use in healthcare
38.Progress in developing new antimicrobial treatments is urgently needed. But as our witnesses pointed out to us, the development of new antimicrobials will not change the situation within the next five years, the lifetime of the new AMR strategy, and it is therefore essential to maintain a strong focus on looking after and preserving the effectiveness of existing antimicrobials.
39.Prevention is key. Prevention includes vaccination, as well as stopping or reducing transmission, both in hospital settings—through measures to improve cleanliness and control MRSA—and also in the community. Our evidence emphasised the importance of continued focus on prevention.43 Variation in practice also needs to be addressed.
40.We also heard that progress was also being made in reducing antibiotic prescriptions. The Government’s advisory Committee has estimated that around 20% of UK prescriptions are inappropriate. The Government aims to halve inappropriate prescribing. However, it is not clear that this target is sufficiently challenging, as we were told that antibiotic prescription rates in the UK remain approximately double those seen in the Netherlands, Sweden and the Baltic states.44
41.In primary care, there has been a 13% reduction in prescriptions in the past five years. However, in secondary care there has been less progress. PHE report that:
Secondary care, despite some progress observed in 2015, has not had a sustained reduction in total antibiotic prescribing. However, from 2015 to 2016 hospitals reduced their use of the ultra-broad spectrum antibiotics piperacillin/tazobactam and carbapenems (both -4%). This is the first step in reducing antibiotic use in hospitals and focussing on using these antibiotics appropriately is key to preventing the emergence and spread of carbapenem-resistant Gram-negative bacteria.45
42.Efforts to educate prescribers have included the Antibiotic Guardian campaign,46 run by PHE, and supported by public awareness campaigns, which are designed to support prescribers in reducing antibiotic prescription.47 NICE has also developed guidance in this area.48 We are supportive of public education campaigns to promote antibiotic stewardship.
43.We heard that in secondary care much lower target reductions, of around 1–2%, have been set. This is because many people requiring hospital admission are acutely ill and are prescribed an antibiotic on admission as an appropriate safety measure while tests are run. The focus of efforts to change antibiotic prescribing in secondary care will be on encouraging prescribers to review antibiotic use at 24 hour intervals to check that the antibiotic is still needed and that the correct one has been used.49 Given that there is also rightly a focus on rapid recognition and treatment of possible sepsis, it is important that staff are not deterred from early action.
44.Many decisions to prescribe antimicrobial medicines are made in the absence of a positive diagnosis of the cause of the infection, potentially leading to inappropriate prescriptions. For example, as we note above, although only 10 per cent of sore throats benefit from antibiotic treatment as most are viral, antibiotics are still prescribed in as many as 60 per cent of cases. Lord O’Neill argued strongly for the increased availability of rapid diagnostic testing, and, ultimately, for all antimicrobial prescribing to be tied to diagnostic testing.50 Practical difficulties were raised with this, including the fact that it is far cheaper to prescribe an antimicrobial than to carry out a diagnostic test.51 We also heard that the widespread use of diagnostic tests could in fact increase rather than decrease inappropriate prescribing. This is because, even if a patient tests positive for a certain bacteria, that does not mean that antibiotics are required, as in many cases the illness will be self-limiting and the person’s own immune system will manage to fight it off without antimicrobial treatment.52
45.We were told that decision-making algorithms could in some cases be as effective or more effective than diagnostic tests in improving prescribing, and far cheaper.53 However, implementing evidence-based best practice in this area appears to be a major challenge, even when the evidence base is long established and well known. Professor Michael Moore, Professor of Primary Health Care Research at the University of Southampton, told us:
The research is published, but it just does not get into practice. You are saying ‘why isn’t there a thing coming up on my screen to say ‘is it an antibiotic? What are you prescribing it? Is there a clinical score?’ Then you do not label it properly. NICE guidance said that all antibiotic prescription should be associated with an indication. That is just a simple programming thing, and it has not happened to date.
There is a how body of work around delayed prescribing: why isn’t that easy to do? It was around the mid-1990s when we first published on delayed prescribing. There is no delayed prescribing button on your IT system that says ‘how long do you want to delay the prescription for?’ and prints the information on the other side of the prescription.
We know that for one [diagnostic test]–CRP testing–there is good evidence that it reduces prescribing. The NICE guidance for pneumonia recommended the use of that, but it is simply not being implemented. It is three and a half years since the NICE pneumonia guidelines came out. What happens is that the costs of those tests are met in primary care, and the antibiotics are paid for at the CCG level. If you say to a general practice, which is a small business, “We want you to use this test,” they say that it costs £10 a go, whereas it costs them nothing not to use it. If they are doing 100 of those tests a year, you are asking them to spend £1,000 on that testing. That is an implementation problem. It is about getting the resource in the right place to get these things implemented.54
46.When we put this issue to Public Health England, they told us that best practice evidence on responsible prescribing of antimicrobial medicines–including the use of delayed prescriptions–was now at the forefront of newly available NICE guidelines, and that work was taking place to improve IT systems.55
47.Digital health tools for clinicians and policymakers have the potential to greatly increase the quality, safety, and cost effectiveness of clinical care and reduce the threat of antimicrobial resistance. Technology can and does exist to support prescribing. For example OpenPrescribing.net56 is a suite of tools that shows prescribing in every individual NHS practice, every month. Research carried out by DataLab using prescribing data shows that when PHE guidance on treatment of urinary tract infections was published, recommending a change in the first line antibiotic, and a quality premium was introduced to promote the change, changes in prescribing rates did occur, and were more rapid after the introduction of the quality premium. However there was considerable variation in the implementation of new guidance between CCGs. These graphs show the changes in the three highest and three lowest CCGs (all marked in red, with the blue dotted line representing the median):
48.DataLab argue that whilst software exists that supports prescribing, its use to support antimicrobial and other prescribing is variable, and that better co-ordination is needed at a national level:
The NHS invests heavily in ‘Clinical Decision Support Systems’. They are, put simply, computer software that aims to prompt a clinician a the point of prescribing to ensure the prescription they give to a patient works, is as safe as possible, and gives the best value to the NHS and tax-payer. Practically this is normally done by generating a pop-up box for the prescriber before they finally issue a prescription.
Despite extensive knowledge and work in this area it is unclear to us where the ultimate responsibility for the content of these systems lies in the NHS. It appears that there are diverse arrangements and diffuse responsibility for procurement and assuring that these systems are high quality, and providing front line health clinicians with support based on the best evidence and latest national guidance. We believe that there could be better national coordinated approach by the NHS and arms-length bodies for ‘Clinical Decision Support Systems’ to implement change and help eliminate the kind of wide variation we have identified through OpenPrescribing.57
Conclusions
49.In order to preserve the effectiveness of current antimicrobial medicines for as long as possible, it is essential that they are prescribed appropriately. Improvements to date in prescribing practices are promising but need to continue. As UK prescribing levels are still approximately double that of the Netherlands, Sweden and the Baltic states, more challenging targets for primary care, and for rapid review and withdrawal of clinically unnecessary secondary care prescribing are needed.
50.Despite a growing body of research about the appropriate use of antimicrobials, and the availability of NICE guidance in this area, we were told that there are still fundamental problems with implementation–the guidance ‘just does not get into practice’.
51.As prescriptions are now issued electronically, introducing prompts to prescribers which require them to ensure that correct algorithms, diagnostic tests and reviews have been followed before antimicrobials are prescribed should be a simple matter, making appropriate prescription of antibiotics the default option. Instead, we heard that 20 years on, simple, low cost interventions such as issuing delayed prescriptions, which have proven efficacy in safely reducing antibiotic use, can still be very difficult to put into practice on standard GP prescribing systems.
52.Antimicrobial resistance has not been sufficiently addressed in a joined-up way—although research and guidance is clear, frontline clinicians still lack the tools to implement it easily because it has not been included in IT specifications. We welcome NICE’s development of evidence-based guidelines on antimicrobial prescribing, but we expect to see rapid and concerted action by NHS England to ensure that prescribing systems in all care settings make responsible prescribing of antimicrobials the default option.
53.Digital health tools for clinicians and policymakers have the potential to greatly increase the quality, safety, and cost effectiveness of clinical care and reduce the threat of antimicrobial resistance. The variation in uptake of best practice is unacceptable and there is good evidence of how this could be addressed. A single organisation should be given responsibility for co-ordinating clinical decision support systems across the NHS, and ensuring they prompt evidence based prescribing of antimicrobials, as well as other medicines.
54.We heard a range of views about the importance of rapid diagnostic testing in antimicrobial prescribing, with some arguing that no antibiotic should be prescribed without one, while others felt that this could have unintended consequences, and that in some cases algorithms were a better aid to prescribing. Rapid diagnostic tests are already recommended by NICE for certain infections, but we heard that often these are not used because the cost of the test—which is far higher than the cost of antibiotics—falls on individual GP practices rather than the CCG.
55.Encouraging the development of rapid diagnostic testing should be considered alongside the action to promote the development of new antimicrobials, but use of diagnostic tests should be based on NICE guidance. Where testing is clinically appropriate and recommended by NICE, action should be taken to address the perverse financial incentives which may discourage their use.
45 ESPAUR report, Public Health England, October 2017, p6
Published: 22 October 2018