A new report shows that 88 per cent of clinical commissioning groups in England have not yet fully implemented the NICE guideline on antimicrobial stewardship, says Ash Soni, president of the Royal Pharmaceutical Society.

A Freedom of Information request by the Patients Association during April to the 209 clinical commissioning groups (CCGs) across England has found that 10 per cent of the 144 that responded had no antimicrobial stewardship (AMS) programme in place.

Only 12 per cent of the CCGs had fully implemented the NICE AMS guideline, although over 80 per cent had done so in part and were hoping to increase this over the year.¹

The NICE AMS guidelines² are a set of co-ordinated strategies aimed at minimising the risk of AMR. While there are encouraging signs that a number of areas are delivering on the expectations set out by NICE, it is clear this is not the case everywhere.

Clinical commissioning groups were also asked whether a named individual was in place to oversee the implementation of their local AMS programme. Guidance from Public Health England (PHE) suggests that AMS leadership roles should be established across the local health pathway.³ Almost a third of CCGs (31 per cent) were unable to confirm that this was the case.¹

For those CCGs that did have leadership roles in place, in many cases responsibility for the role was split between several individuals, often involving a combination of the local head of medicines management, the pharmacy prescribing lead and the chief infection control nurse. Responses provided suggested that such an approach helped facilitate better joint working across the local healthcare pathway.

Despite the availability of a number of important resources designed to help CCGs put stewardship practices in place, the report shows that uptake is low. Only 23 per cent had implemented the Department of Health/PHE-endorsed RCGP TARGET antibiotics toolkit,¹ which offers a range of outcome-focused components to support local stewardship efforts.³

C-reactive protein

The TARGET toolkit also recommends the use of C-reactive protein (CRP) point-of-care testing (POCT) as an effective means of improving antibiotic prescribing practice.⁴ One of a number of diagnostic tests that can be performed in pharmacies, CRP POCT has been shown to reduce antibiotic prescribing in patients presenting with respiratory tract infection (RTI) symptoms by as much as 36 per cent.⁵

While the FOI request revealed that 19 per cent of CCGs had carried out a feasibility test on the potential introduction of CRP POCT locally, over half (51 per cent) said that they had not carried out a feasibility study and had no plans to do so.¹

Responses indicate that this is often a result of concerns around securing funding to introduce CRP POCT, especially in light of the wider financial pressures that CCGs are already under. Of those areas planning to introduce CRP testing in some capacity, several were doing so because they had received funding from external sources, such as NHS England’s Primary Care Infrastructure Fund.¹

With the latest data concluding that antibiotic prescribing rates have dropped, we should use these new findings to show how much more the situation could and must improve and consider the use of diagnostics and screening to empower clinicians and patients in the decision making for appropriate use of antibiotics.

CCGs undertaking CRP POCT pilots hoped that rolling out the use of diagnostic testing would support ambitions to achieve a reduction in the prescribing of antibiotics for lower RTIs, reduce GP appointments and fulfilment of delayed prescriptions, and achieve a decrease in costs. There was also an expectation that CRP POCT would help increase patient understanding and reassurance around their presenting condition, something that could be measured through the use of patient audits.

POCT is already part of many pharmacists’ offering. The 2015 report, Straight to the Point, argued that pharmacists should work with other healthcare professionals and CCGs to develop clinical and business plans to implement CRP POCT.⁶ For instance, it could form part of a common ailments scheme.

Pharmacists could also use CRP POCT to reduce pressure on general practice – especially out-of-hours services, where antibiotic use is rising more rapidly than in other parts of the NHS⁷ – allowing them to offer self-care advice to low-risk patients and refer high-risk patients to their GP or out-of-hours service.

Community pharmacy has an important role to play in ensuring appropriate use of antimicrobials and CRP POCT is a natural evolution of pharmacists’ clinical role. Greater emphasis needs to be placed on driving uptake of existing resources such as this, as CCGs seek to improve their AMS efforts.

Putting this extra support in place will minimise the risk of increased resistance, reduce costs for the NHS and, ultimately, help to safeguard the health of our patients.

 

 

References

<sub>1. The Patients Association. ‘Antimicrobial Resistance – a Patient Safety Issue’ report. patients-association.org.uk/reports/antimicrobial-resistance
2. NICE Guideline 15. Antimicrobial stewardship: systems and processes for effective antimicrobial medicines use. August 2015. nice.org.uk/guidance/ng15
3. Public Health England. Patient Safety Alert: addressing antimicrobial resistance through implementation of an antimicrobial stewardship programme. August 2015. england.nhs.uk/wp-content/uploads/2015/08/psa-amr-stewardship-prog.pdf
4. Royal College of General Practitioners. TARGET antibiotics toolkit. rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit.aspx
5. Public Health England. Healthmatters Tackling Antimicrobial Resistance. December 2015. gov.uk/government/collections/health-matters-public-health-issues
6. Straight to the Point! Ensuring the rational use of antibiotics in primary care using C-Reactive Protein Testing. A consensus report. June 2015.
patients-association.org.uk/wp-content/uploads/2015/06/straight-to-the-point.pdf
7. Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) (2014). gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report</sub>