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    Antibiotic stewardship: how to improve implementation and patient outcomes?


Intro

Primary care accounts for 80% of all antibiotics prescribed and while the introduction of new antibiotics has allowed medicine to stay one step ahead of resistance, the development of new antibacterial agents is critical to fighting infections in the future (1). Since 2010, only one new antibiotic has been approved by the FDA whilst the threat posed by bacterial infections has only continued to increase (2). As a consequence, it has become greatly important to optimise the use of antimicrobials through antimicrobial stewardship programs (ASPs) by prescribing shorter courses of antibiotics to improve patient adherence.

Figure 1: Antibacterial pipeline (3)

Figure 1: Antibacterial pipeline (3)

ASPs advocate multifaceted educational interventions, combined with other effective antibiotic stewardship strategies to drive change. Quality information, such as the ‘TARGET’ antibiotic toolkit developed by Antimicrobial Stewardship in Primary Care (ASPIC) in association with the Royal College of General Practitioners (4), is available online, although the possibility of improving patient outcomes and reducing the emergence of antibiotic resistance is only achievable if these ASPs are effectively implemented.
A study published by the British Journal of General Practice in July 2013 found that 97% of patients who requested antibiotics during consultations had them prescribed (5). This demonstrates that, whilst GPs may have increased awareness and/or knowledge of antibiotic stewardship principles, they are not changing their prescribing behaviour sufficiently. This may be due to a lack of practical guidance on the implementation of these systems.

Figure 2: Antimicrobial resistance costs (6)

Figure 2: Antimicrobial resistance costs (6)

Interviews conducted with 15 pharmacists and 6 physicians found that the major barriers to the implementation of ASPs are those of culture and resources. Communication between GPs and their patients is key to avoiding the perception that their refusal to prescribe antibiotics was driven by cost-saving initiatives. The findings also demonstrated a lack of sufficient staff and technology to collect and report data making it difficult to track interventions/outcomes (7–8). Insufficient funding of staff also served as a barrier according to a nationwide survey (9). Evidence suggests that the use of clinical decision support tools and patient notifications, such as real-time alerts, can improve the implementation of these systems and aid patient compliance (7–8).

Figure 4: Real-time alert (10)

Figure 4: Real-time alert (10)

 

Short courses of antibiotics

We are all familiar with the prescription instructions advising that we complete the full course of antibiotics as prescribed by our doctor, however, there is a paradoxical view which suggests that shorter courses are as effective at clearing up the infection and could, in fact, reduce antibiotic resistance (11).

How long should we take antibiotics for? According to some studies, for as little time as possible to initially give your body a helping hand in fighting the infection, but leaving the remaining bacteria to be dealt with by your immune system. Taking the full course of antibiotics could actually increase the risk of infection and promote antibiotic resistance as they could make it easier for drug-resistant bacteria to compete over their host’s resources, while shorter courses intentionally allow some susceptible bacteria to survive in order to help suppress any resistant pathogens (12). The length of antibiotics regimens varies greatly with a minimum course of 5 days being prescribed for urinary tract infections, although there is evidence to show that a 3-day course is sufficient for an uncomplicated infection (13).

Studies suggest that GPs could gauge when to end the course of antibiotics by measuring levels of procalcitonin in the bloodstream. Procalcitonin concentrations are increased when an infection is thriving and so reducing levels may signify that the antibiotics have done their job and the infection is becoming more manageable for the immune system to fight alone (14).

Point-of-care procalcitonin tests are now available such as Radiometer that enable rapid testing in the GP practice. This advantage could lead to more structured interaction, patient education and treatment course compliance paving the way to reduced resistance and improved patient outcomes.


References:
  1. Beech E. Promoting appropriate antimicrobial prescribing in primary care [Internet]. NHS England. 2015 [cited 20 June 2016]. Available from: https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/04-cdi-promoting-antibiotic-prescribing-pc2.pdf
  2. Bassetti M, Merelli M, Temperoni C, Astilean A. New antibiotics for bad bugs: where are we? Annals of Clinical Microbiology and Antimicrobials. 2013;12(1):22.
  3. Team: Lethbridge Canada/project – 2014hs.igem.org [Internet]. 2014hs.igem.org. 2016 [cited 17 June 2016]. Available from: http://2014hs.igem.org/Team:Lethbridge_Canada/project
  4. TARGET Antibiotics Toolkit [Internet]. RCGP. 2015 [cited 17 June 2016]. Available from: http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit.aspx
  5. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use | Guidance and guidelines | NICE [Internet]. NICE. 2015 [cited 17 June 2016]. Available from: https://www.nice.org.uk/guidance/ng15
  6. Griffiths L, Shaw N. Antibiotic prescribing update. Prescribing Points [Internet]. 2013 [cited 17 June 2016];22.10. Available from: http://www.oxfordshireccg.nhs.uk/wp-content/uploads/2013/08/Prescribing-Points-Vol-22-10-November-2013.pdf
  7. Health matters: Antimicrobial resistance – GOV.UK [Internet]. GOV. 2015 [cited 17 June 2016]. Available from: https://www.gov.uk/government/publications/health-matters-antimicrobial-resistance/health-matters-antimicrobial-resistance
  8. Pakyz AL. Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study. – PubMed – NCBI [Internet]. Ncbi.nlm.nih.gov. 2016 [cited 17 June 2016]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25239719
  9. Tamma P. Antimicrobial Stewardship. An Issue of Infectious Disease Clinics. London: Elsevier Health Sciences; 2014.
  10. Notifications & Alerts – Trailer Tracking [Internet]. Trailer Tracking. 2016 [cited 4 July 2016]. Available from: http://www.trailertracking.com/signaltrack/notifications-alerts/
  11. Doron S. A nationwide survey of antimicrobial stewardship practices. – PubMed – NCBI [Internet]. Ncbi.nlm.nih.gov. 2013 [cited 17 June 2016]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23795573
  12. Kucharski A. Stop Taking Antibiotics When You Feel Better? [Internet]. Discover Magazine. 2014 [cited 20 June 2016]. Available from: http://discovermagazine.com/2014/oct/8-stop-taking-antibiotics-when-you-feel-better
  13. Dillner L. Can I stop taking antibiotics as soon as I feel better? [Internet]. The Guardian. 2015 [cited 20 June 2016]. Available from: http://www.theguardian.com/lifeandstyle/2015/mar/15/can-i-stop-taking-antibiotics-as-soon-as-i-feel-better
  14. Carr J. Procalcitonin-guided antibiotic therapy for septic patients in the surgical intensive care unit. Journal of Intensive Care. 2015;3(1).

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