Antibiotic stewardship

October 23rd 2018

Antibiotic stewardship

Misuse and overuse of antibiotics is one of the world’s most pressing public health problems. Infections and bacteria are adapting and becoming resistant to some antibiotics, making some of these important medicines ineffective; consequently, lives are being endangered.

Lesley Boler, Queens Nurse and Care UK’s head of governance and quality for secondary care, looks at the issues and reports on how Care UK’s teams are tackling the problem in their primary and secondary healthcare services.

She said: “Antibiotic resistance is one of the biggest threats facing us globally as we move into the next decade. The overuse of antibiotics in recent years means they are becoming less effective and this has led to the emergence of what newspaper headlines have referred to as superbugs.

“Actually these bugs are no different to those carried on skin and on our bodies which, if they get into the wrong places, can cause infections. However, some strains of bacteria have developed resistance to different types of antibiotics that we would normally use to treat these infections. These include:

  • Staphylococcus aureus bacteria resistant to methicillin: MRSA

  • Gram negative bacteria such as pseudomonas which are resistant to many classes of antibiotics

  • multi-drug-resistant tuberculosis

  • Carbapenemase-producing Enterobacteriaceae (CPE)

“These types of infections can be serious and challenging to treat, and they are becoming an increasing cause of disability and death across the world. The world’s overuse of antibiotics has brought about the development of these resistant bacteria and they are an unfortunate example of the success of natural selection.

“Put simply, in a large population of bacteria, there may be some that are not affected by an antibiotic. While others die, these survive and reproduce, creating more bacteria that are not affected by the antibiotic. The more people are prescribed antibiotics, the more resistant strains are created.

“Without effective antibiotics, many routine treatments such as hip and knee replacements will become increasingly dangerous and the possibility of fighting an acquired infection will be dramatically cut. This has consequences for all patients and for our wider society. People with antimicrobial-resistant infections are more likely to have longer, more expensive hospital stays, and may be less likely to recover effectively, so putting a strain on their families, social services and the NHS.

“Antimicrobial stewardship is a coordinated programme that promotes the appropriate use of antibiotics. At Care UK, we take antimicrobial stewardship very seriously.

“One of the key elements of that stewardship is preventing the misuse of antibiotics – for instance prescribing antibiotics only when they are needed and not for self-limiting mild infections such as colds and most coughs, sinusitis, earache and sore throats. It is also important that the correct antibiotic is prescribed and that their use is reviewed to determine the continued need for them.

“All our clinicians at our NHS 111, out of hours and GP services prescribe as follows:

  • Only if there is likely to be a clear clinical benefit will antibiotics be prescribed.

  • Clinicians consider a no or delayed antibiotic strategy for acute self-limiting upper respiratory tract infections.

  • We limit prescribing over the phone to only exceptional cases.

  • Our doctors prescribe only simple generic antibiotics if possible. Broad-spectrum antibiotics not only destroy more of the gut’s natural flora but growing resistance to them will also affect the efficacy of narrow spectrum drugs.

  • We avoid widespread use of topical antibiotics. Most minor skin infections are self-limiting and usually resolve without the use of an antibiotic.

“Meanwhile, the approach at our NHS treatment centres is as follows:

  • We do not start antibiotics without clinical evidence of bacterial infection.

  • We document the following on the medicines chart and in the person's medical notes: clinical indication, duration or review date, route and dose to try and ensure patients only receive the dose they absolutely need.

  • We seek to obtain cultures of bugs – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing drugs to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.

  • We review the clinical diagnosis and the continuing need for antibiotics within 48 hours from the first antibiotic dose and have a clear plan of action.

“Alongside this, our strict regimes of cleaning and hygiene protocols, as well as our careful approach to controlling and reducing antibiotic usage in line with national guidance, mean we have a track record of zero cases of hospital-acquired MRSA, MSSA, E.coli bacteraemias and C.difficile infection following surgeries at our treatment centres.

“We will seek to maintain this record by working with patients and GPs to ensure that antibiotics will be there well into the future to allow safe surgery and recovery from major, bacterial-based illness.”