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Friday, August 21, 2015

Antibiotics stewardship

On Aug 18, the National Institute for Health and Care Excellence (NICE) in the UK released its firstguideline on antimicrobial stewardship, after a draft was published earlier this year. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use is aimed at all health and social care practitioners (hospital and care home staff, general practitioners [GPs], dentists, podiatrists, pharmacists, and community nurses), commissioning and provider organisations, and users, although next year NICE will release more specific advice on antimicrobials for the general public.
The main recommendations are designed to promote and monitor sensible antimicrobial use through stewardship teams to review prescribing and resistance data and to provide feedback, education, and training to prescribers. Specific guidance is given on clinical assessment and documentation of diagnosis, obtaining microbiological samples, watchful waiting or delayed prescribing, and taking the time to discuss with patients the likely cause of their symptoms. Above all, prescribers need to ensure “the right antibiotic, at the right dose at the right time”, when a prescription is needed, and must resist pressure to prescribe unless warranted. According to NICE, “9 out of 10 GPs say they feel pressured to prescribe antibiotics, and 97% of patients who ask for antibiotics are prescribed them”.
Practical recommendations on antibiotic prescribing are sorely needed and this NICE guideline is a good start. It is a pity, however, that it has taken until August, 2015, to be released, when the need has been present for decades. In 1945, in fact, Alexander Fleming in his Nobel Lecture warned of the danger of over-reliance on antibiotics and the threat of bacteria developing resistance. Poor prescribing is at the heart of antibiotic resistance.
The Lancet Infectious Diseases Commission on antibiotic resistance, led by Otto Cars, warned that “we are at the dawn of a postantibiotic era”, with the arrival of untreatable strains of carbapenem-resistant Enterobacteriaceae. Antibiotic resistance is a global crisis now, threatening people's lives, livestock, and the economy. Strict monitoring of the use of antibiotics, legislation to prevent over-the-counter sales, audit feedback on prescribing, and regular revision of treatment guidelines are some of the measures recommended by the Commissioners.
Will the NICE guideline improve prescribing and reduce antimicrobial resistance? The UK is a long way behind Sweden, for example, where many of the recommendations in the NICE report have been implemented for some time and proved sound and helpful. In 1995, the Swedish Strategic Programme against Antibiotic Resistance (STRAMA) was launched, which has gone on to develop systems to review, update, and implement local antimicrobial guidelines informed by local prescribing data and resistance patterns. Swedish physicians are able to receive data on how their individual prescribing compares with anonymised data for their colleagues. Visualisation of variations in antibiotic prescribing together with data from medical records on diagnosis-linked prescriptions improves antibiotic use.
A strength of the NICE guideline is that it encompasses all health-care settings, but weaknesses include a lack of advice for vulnerable groups such as the very young, old, or immunocompromised, and not enough direction and clarity about leadership, accountability, resourcing, and education. On Sept 28, a massive open online course (MOOC) on antimicrobial stewardship launches, which might help health-care professionals further.
In November, to coincide with Antibiotic Awareness Week, a new Lancet Series will examine antimicrobial access and resistance. The evidence behind what works to reduce patient demand, to improve prescribing behaviour, to combat resistance, and to control infection will be presented in the Series. Concrete examples of national policies on responsible antibiotic use—what works and what does not—will be of particular relevance, as will implementing the WHO global action plan on antimicrobial resistance.
Time is running out in infection prevention and management. The antibiotic development pipeline is worryingly short and growing resistance threatens the medicines that we do have. Only two new classes of antibiotic have been marketed since the 1970s. Improving the standard of hygiene in society is not to be forgotten worldwide—simple handwashing can do much to prevent infection in all settings. Tailoring of prescribing to ensure appropriate antibiotic use is essential. The NICE guideline is a belated, but welcome, addition to antibiotic stewardship. Prescribers themselves now need to take more responsibility for antibiotic use and ensure that every prescription is evidence based. If every prescriber took the time to stop, think, weigh up the evidence, and consult if unsure, then antibiotic efficacy would be preserved for longer, and more patients' lives saved.

For the Editorial on draft NICE guidance see Lancet 2015; 385: 746

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