CURRENT PLEDGES: 216887
Shared Learning 2025 – Diagnostic Stewardship
Organisation
Commonwealth Pharmacists Association
Project title: Diagnostic resource development to aid clinical integration of microbiology services in lower-and-middle income countries
Project Overview
Lower-and-Middle-Income Countries are disproportionately affected in implementing strategies to overcome antimicrobial resistance (AMR) due to challenges including inadequate infrastructure, limited access to quality medicines, vaccines and laboratory diagnostics and insufficient staff capacity and capability. High-quality, timely access to clinical microbiology services are crucial to identify, monitor, and control infectious diseases.
The Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme aims to enhance capabilities of health-institutions and workforce in 8 African countries to address the challenges of AMR.
The CwPAMS programme has worked to understand the issues and challenges faced in accessing diagnostics, and to propose solutions and recommendations to improve the integration and clinical engagement with microbiology services where possible. Lack of resources, reagents and consumables along with staff capacity and capability and communication barriers between laboratory and other hospital staff are reported as the main reasons for poor uptake of microbiology services in some of the CwPAMS sites.
In response to these findings, a multi-disciplinary team (academic and clinical microbiologists from the UK, Tanzania and Zambia, a pharmacist and a biomedical scientist) was established to create a toolkit of resources to support pre-analytical, quality sampling with a focus on clinical engagement. Upon advice from partnership countries, the toolkit covers blood cultures, urines, wound swabs and faeces. It has been launched via a webinar, disseminated across the partnership countries and is available on Commonwealth Pharmacists Association antibiotic prescribing companion website and app.
Impact on tackling AMR
The toolkit itself highlights the importance of communication between clinical and laboratory teams in the support of antimicrobial stewardship. The ‘It’s all about Culture’ infographic demonstrates the path of a microbiology sample and poses key questions to encourage an understanding of the importance of utilising microbiology samples and developing links between teams for bi-direction communication. The Best Practice Recommendations are educational documents to increase awareness of factors that affect quality results to aid clinical decisions around when and how to sample e.g. colonisation Vs infection. This is backed up with specimen checklists to guide clinical teams to take quality samples to improve pre-analytical parameters that may adversely affect diagnostic results and lead to inappropriate and unnecessary treatment. The checklists have been designed for use within patients’ notes if desired.
The toolkits also contain laboratory Standard Operating Procedures to optimise and improve laboratory diagnostic processes including reporting in a timely manner and developing quality control measures to ensure accuracy of results. A sample acceptance record and sample acceptance/rejection procedure has been created to track samples received with laboratories to improve communication between teams, encourage the use of quality samples and to facilitate data collection and sample audits. Finally documents for clinical guidance on initiating antibiotics, antibiotic review, decision making, microbiology result interpretation, IV to oral switch advice and duration are included to complete the loop. All documents have been developed with the use of relevant clinical and laboratory guidelines/standards and in discussion with partnership personnel to ensure they fit resources and practices across the partnership countries. The toolkit was launched via a multi-country webinar on zoom and attended by 165 professionals across the partnership countries. The resource pack along with the pre-implementation questionnaire has been sent to all health partnerships on Pulse and via the Commonwealth Pharmacists Association antibiotic prescribing companion website and app.
Future Development
Four additional ‘Best Practice Guidelines’ and ‘Specimen Checklists’ are currently in development for cerebral spinal fluid, sputum, throat swabs and genital samples chosen as areas of need either from webinar feedback or discussion with representatives from the health partnership countries. Pre and post toolkit resource implementation will be collected in the form of questionnaires to assess the impact (16 pre-implementation questionnaires received back to date). Data from sample acceptance record will be analysed to evaluate quantity and quality of samples received in the laboratory as a measure of service improvement.
Organisation
Cardiff University/Digital Health and Care Wales/Public Health Wales
Project title: Building the evidence: what happens when diagnostics support a community pharmacy-led sore throat test and treat consultation?
Project Overview
In Wales, community pharmacies have been delivering a national Sore Throat Test and Treat (STTT) service since 2018. The structured pathway includes screening of patients using FeverPAIN/CENTOR clinical scores, a point-of-care test (POCT) for Group A Streptococcus (GAS) if threshold scores are met, and antibiotic supply in the pharmacy, in line with NICE guidance.
A multi-factorial evaluation of the pilot (2018-2019) and post-pilot (2020-2022) data indicated that STTT promoted appropriate use of POCT and antibiotics, and it could be delivered at scale to align with a pre-specified pathway. However, concerns have been raised anecdotally that allowing antibiotic supply from pharmacies could lead to increased inappropriate use and antimicrobial resistance (AMR). To date, no data support these concerns, but longer-term outcomes (beyond the index consultation) have not been described or compared with outcomes following sore throat consultations with healthcare professionals at general practice.
In addition, other than a small-scale study looking at the STTT COVID delivery model, whereby the compulsory requirement for POCT was removed, not much evidence exists on the role of an additional GAS POCT in addition to clinical scoring.
To address this lack of evidence, we adopted a two-fold strategy:
a) we utilised unique data-linkage capability in Wales to, for the first time, link data from Choose Pharmacy (the national pharmacy IT platform in Wales), to other routinely collected national healthcare and administrative data via the SAIL databank, including GP consultations and hospital admissions; our aim was to estimate the effect of STTT on antibiotic prescribing, patient outcomes and health service utilisation, over 16 months.
b) we conducted a cross-sectional study with anonymised individual-level data from Choose Pharmacy to evaluate what having a POCT meant for STTT’s response to a substantial rise in sore throat presentations during the period of increased invasive GAS (iGAS) incidents in winter 2022-23.
Impact on tackling AMR
- Using data linkage, we found a 24% same day antibiotic supply for STTT consultations, and 39% for GP consultations. This remained lower within 28-days of the index date (28% for STTT compared to 40% for GP index consultations). Our results show that for every 100 patients presenting with sore throat at an STTT pharmacy, between 15-18 antibiotics are prevented. Even accounting for all possible re-consultations within 28 days, 12 antibiotic prescriptions are prevented.
- We looked at quinsy hospital admission rates within 14-days of pharmacy and GP consultations. In both groups, the rates were similar, low, and comparable to those reported in literature for GP consultations. This means that no unintended harm is caused, and STTT is as safe as a GP consultation. We conducted an economic analysis, and in all modelled scenarios, STTT was found to be cost-effective compared to GP sore throat consultations. This is the first economic analysis based on accurate rates of GP re-consultation and hospital visits, rather than surrogate measures and assumptions.
- Following the increased iGAS incidents announcements during December 2022, we observed a statistically significant increase of 1,700 consultations and a statistically significant decrease in supply rate of 13.9 antibiotics per 100 POCT. Despite a dramatic increase in sore throat consultation rates in response to media reports, the pre-specified pathway followed by pharmacists, with POCT to support diagnosis of GAS, ensured appropriate use of antibiotics, and absorbed a substantial workload that would otherwise end up in other healthcare settings.
Given the global importance of tackling AMR and the commitments made to wider use of POCT in the UK’s recently published National Action Plan for AMR, impact statements 1-3 provide further evidence that including rapid diagnostics to support clinical assessment in pharmacy sore throat management is crucial – as well as safe, and cost-effective.
Future Development
STTT is rolling out to all areas in Wales currently. As the service grows, we plan to regularly measure the long-term outcomes, and compare them to the ones we measured in this project. In addition, a more targeted analysis needs to be undertaken, as even though STTT and GP sore throat consultations included people with broadly similar characteristics in terms of age and sex, there is no available data on FeverPAIN/Centor scores for patients who present to their GP for management of sore throat symptoms, and this means that we cannot estimate differences in severity of their symptoms between them and the STTT group. We also had may challenges with coding, as despite GPs using mostly Read Code terminology, no standard data recording rules exist. A focused project will help explore whether these two factors have any impact on longer-term outcomes.
