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Published on 25 March 2010

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Antimicrobial pharmacists as key ambassadors of antimicrobial stewardship in England

teaser

Antimicrobial pharmacists are essential to the success of
antimicrobial management and infection prevention and control multidisciplinary teams, which ultimately aim to reduce HCAIs and antimicrobial resistance

Dr Christianne
Micallef
PhD (Clinical Bacteriology)
MPhil MRPharmS
Specialist Project
Support Practitioner
Antimicrobial Prescribing
HCAI Improvement
Programme, Department
of Health, London

Lead Specialist
Pharmacist, Infection
Prevention & Control
Service, The Queen
Elizabeth Hospital, Kings
Lynn NHS Trust, Norfolk

The Health and Social Care Act 2008 Code of Practice[1*] for health and social care on the prevention and control of infections which has been recently released, will come into force for National Health Service (NHS) institutions on 1st April 2010, and 1st October 2010 for other registered users. This document specifies that each Trust needs to have antimicrobial guidelines in place (which should be based, where possible, on the British National Formulary). In addition, ‘procedures should be in place to ensure prudent prescribing and antimicrobial stewardship’. The current Health and Social Care Act replaces the previous 2006 version, also referred to as the Hygiene Code.[2]

A number of other key documents are available for healthcare professionals, as well as to the general public and these provide information on infection control, as well as antimicrobial stewardship. Winning Ways,[3] Saving Lives [4] and Clostridium difficile: how to deal with the problem,[5] are examples of these. The latter also provides detailed information on the most appropriate approach that trusts can adopt to diagnose, treat and avoid Clostridium difficile infection (CDI). All the abovementioned documents include advice on antimicrobial prescribing, and reiterate that the avoidance of broadspectrum antibacterial agents such as cephalosporins and quinolones must be ensured.[3-5] These antibiotics may be implicated in both Meticillin-resistant Staphylococcus aureus (MRSA)[6-8] infections, as well as CDI.[6,9-13]

In Savings Lives,[4] specific guidance on antimicrobial prescribing state that the following recommendations must be considered, in order to ensure ‘good practice’, when conducting effective antimicrobial management:

  • An antimicrobial prescribing and management policy.
  • A strategy for implementation of the antimicrobial prescribing and management policy.
  • An antimicrobial formulary and guidelines for antimicrobial prophylaxis and treatment.
  • Prescribing of antimicrobials should have proper clinical justification.
  • An intravenous to oral switch policy and use of oral agents should be preferred, wherever possible.
  • Daily review of antimicrobial prescriptions.
  • Reducing the use of broad-spectrum antimicrobials.
  • Single doses for surgical prophylaxis.

Saving Lives[4] also includes the seven high-impact interventions (HIIs), or care bundles, and some have suggested that a high impact intervention should also be in place, in order to ensure safe and rational antimicrobial prescribing.[14] Others, have also developed a care bundle for local use.[15]

The HII No.8 on cleaning and decontamination of clinical equipment, as well as additional new draft guidelines on antimicrobial prescribing, aimed at pre-hospital care and the ambulance environment, have been recently launched and can be currently viewed (at the time of writing) on the clean-safe.care website.

Antimicrobial stewardship has gained increasing importance in the past decade, mainly as a direct result of the national targets introduced in England aimed at reducing, initially, MRSA bacteraemias in 2004, and later on, CDI in 2007.[16] Mandatory reporting for MRSA bacteraemias was introduced in 2001. CDI in patients over 65 years of age also had to be reported from 2004 and later on, in 2007, all CDI cases in children and adults aged 2 or more years of age.

For MRSA bloodstream infections, the aim was to reduce these by 50% based on 2003/2004 figures in acute hospital and acute foundation trusts, by March 2008.[16] This was not only achieved, but was actually surpassed, as a 57% reduction was obtained by 2008, which continued to decrease to 62% by 2009.[17,18] With CDI, the objective was to decrease the 2007/2008 figures by 30%, by the end of March 2011. A total decrease of 41% by 2008 has been achieved. However, the Health Protection Agency reported an increase of 8% of CDI, in patients aged 65 years in the final quarter of 2008-9.[17,18] The recently published National Audit Office (NAO) report17 as well as the House of Commons, Public Accounts Committee Report on Reducing Healthcare- Associated Infections (HCAIs) in England, November 2009,[18] however have clearly stated that although MRSA bacteraemias and CDI rates are decreasing, these two infections account for only 20% of HCAIs and the remaining 80% of HCAIs are actually on the increase.[17,18] Further work needs to be undertaken to fully support this statement.

Antimicrobial pharmacists are commonly seen as the essential link between the Microbiology Laboratory, Infectious Diseases (ID) physicians, pharmacy departments and clinicians in the wards.[19-21] A Department of Health initiative in 2003, which involved a circular being sent to all NHS Chief Pharmacists, Chief Executives, Medical Directors, Consultant Medical Microbiologists and Chairs of Drugs and Therapeutics Committees, as well as Chief Executives of Strategic Health Authorities, 22 announced funding for antimicrobial management initiatives. This prompted the recruitment of antimicrobial pharmacists in NHS institutions. Indeed, today, most trusts in the UK employ antimicrobial pharmacists, although they often have additional duties, other than their infection management role, largely because they are still primarily funded by pharmacy departments. Indeed, this is very different situation to specialist nurses in infection control, who are located in an Infection Control or the Microbiology Department and do not perform additional duties, other than those included in their specialty.

A similar system could be in place, where specialist antimicrobial pharmacists are incorporated fully as an essential limb of the Infection Prevention and Control body,23 whilst maintaining strong links with pharmacy departments. This would enable them to continue their essential work of:

  • Reviewing antimicrobial prescriptions
  • Advising on correct drug regimens
  • Therapeutic drug monitoring
  • Conducting antimicrobial audits and disseminating
  • findings
  • Participating in teaching activities, highlighting antimicrobial stewardship
  • Referring patients who require microbiology/ID input
  • Closely working with all clinical colleagues toensure safe and rational antimicrobial prescribing as well as,
  • Contributing to research.

This move would definitely help specialist antimicrobial pharmacists further develop their role and also possibly increase the number of consultants in this area as well as, encourage more pharmacists to take up this role. With the advent of independent prescribers, specialising in infection management, antimicrobial pharmacists can provide specialist support to the infection control and antimicrobial management team by offering their expertise to all clinical colleagues. There is a need however, to clearly define the roles of the medical microbiologists/ ID physicians and the senior lead specialist antimicrobial pharmacists.[19,21]

In primary care trusts, antimicrobial consumption is monitored using ePACT data, but in hospitals, no such system exists. Indeed, the June 2009 NAO report stated that approximately one-third of all trusts do not have a robust strategy to review antimicrobial prescriptions after a defined period. The link between antimicrobial resistance and antimicrobial prescribing is a well-known phenomenon, so if antimicrobial prescribing is not managed rigorously, antimicrobial resistance will continue to escalate. Some have indeed proposed that antimicrobial treatment be withdrawn completely: this option of course, poses strong ethical dilemmas and is impractical.[24]

A general collaborative effort is required to produce reliable, retrospective antimicrobial consumption data, in order to enable comparisons between different hospitals nationally and also on an international scale. The system commonly advocated (and this is also used internationally) is the WHO/ATC Defined Daily Doses or DDD/1000 occupied beddays.[5,20—21] Point prevalence or prospective audits20 must also be conducted and results discussed at senior clinical and managerial levels and should also be readily available for all clinical staff throughout the Trust. Antimicrobial pharmacists should help coordinate all antimicrobial prescribing audits conducted, as this offers assurance to clinical governance committees, and hence NHS institutions, that the local antimicrobial stewardship strategy is being operated successfully. This is one of the key duties which are sought for by the Care Quality Commission, when reviewing trusts.

References
1. DoH. The Health & Social Care Act 2008, Code of Practice for health and adult social care on the prevention & control of infections and related guidance. London: DoH 2009.
2. DoH. The Health and Social Care Act 2006. Code of practice for the NHS on the prevention and control of healthcare associated infections and related guidance. London: DoH 2006.
3. DoH. Winning Ways: Working together to reduce healthcare associated infection in England. London: DoH. 2003.
4. DoH. Saving Lives: Reducing infection, delivering clean and safe care. London: DoH. 2007.
5. DoH and Health Protection Agency. Clostridium difficile infection: How to deal with the problem. London: DoH. 2009.
6. Paterson DL. Clin Infect Dis 2004;38 (Suppl 4):S341-45.
7. Tacconelli E et al. J Antimicrob Chemother 2008;61:26-38.
8. Liebowitz LD, Blunt MC. J Hosp Infect 2008;69:328-36.
9. Barbut F, Petit JC. Clin Microbiol Infect 2001;61:246-53.
10. Wilcox M et al. J Antimicrob Chemother 2008;62:388-39.
11. Monaghan et al. Gut 2008;57:850-60.
12. Dubberke ER et al. Infect Control Hosp Epidemiol 2008;29:S81-92.
13. Owens JC et al. Clin Infect Dis 2008;46:S19-31.
14. Cooke FJ, Holmes AH. Int J Antimicrob Agents 2007;30:25-29.
15. Pulcini C et al. J Antimicrob Chemother 2008;61:1384-
88.
16. Duerden B. Clin Med 2008;8:140-43.
17. National Audit Office. Reducing healthcare associated
infections in hospitals in England. London. June 2009.
18. House of Commons, Public Accounts Committee. Reducing healthcare associated infection in Hospitals in England. Fifty-second report of Session 2008-9. London. November 2009.
19. Hand K. J Antimicrob Chemother 2007;60 (Suppl 1): i73-i76
20. Dellit TH et al. Clin Infect Dis 2007;44:159-77.
21. MacDougall C, et al. Clin Microbiol Rev 2005;18:638-56.
22. DoH. PL/CMO/2003/3 and PL/PhO/2003/3. Hospital Pharmacy initiative for promoting prudent use of antibiotics in hospitals. London: DoH. 2003.
23. Micallef C. Pharm J 2009;282:674.
24. Stokes DJ et al. FEMS Immunol Med Microbiol 2008;53:300-05.



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