Organisation

Swansea Bay University Health Board

Project title: Implementing antimicrobial stewardship through the National Cellulitis Improvement Programme (NCIP) in Wales.

Project Overview

Cellulitis, a bacterial skin infection, can lead to emergency admissions and sepsis if not promptly treated. In Wales, hospital admissions and GP events for cellulitis are rising, with 1.7% of emergency admissions in 2021-2022 attributed to cellulitis. In Wales, cellulitis causes over 32,000 bed-days and 200,000 GP events annually, costing over £28 million. Equally, evidence shows a misdiagnosis rate of approximately 30%, where patients are receiving antibiotics unnecessarily. The majority of people admitted with Cellulitis across the Health Boards in Wales are not receiving composite advice on risk reduction. Strategies such as oedema management, skin care, exercise, healthy weight advice, fungal treatments and the use of prophylactic antibiotics are not explored. These simple strategies could decrease the incidence of repeated Cellulitis episodes as many of the people who experience Cellulitis have a recurrence (research indicates 10-50% recurrence rate within a year). Enhancing quality of care through evidence-based, patient-centred approaches and reducing waste and harm is crucial to the NHS.

The aims of the National Cellulitis Improvement Programme (NCIP) are:

• To reduce cellulitis recurrence with the associated antibiotic usage and admissions, by 10% annually.
  All patients in Wales diagnosed with cellulitis in secondary care are contacted by the team. We provide education, effective treatment and support to manage the risk factors thus reducing the risk of recurrence.
• Raise the awareness of healthcare professionals (HCPs) in identifying and managing cellulitis effectively including appropriate antibiotic treatment.
  Education session are offered to all GP surgeries in Wales and HCP’s in secondary care highlighting how the risk factors which attribute to a Cellulitis episode can be reduced.

Impact on tackling AMR

• Since 2020, 6,967 patients have completed their treatment with the NCIP. Cellulitis episodes have reduced from 6,770 in the previous 12 months to 225 in the subsequent 12 months. For some patients their episodes were more historic, occurring over 12 months ago. Over the same period, admission have reduced from 3,620 to 46, and length of stay from 27,302 days to 254, a projected saving of over £15 million. The initial goal to reduce recurrence rates by 10% has been greatly exceeded. This reduction in admissions has obviously significantly reduced the usage of antibiotics in this cohort.
• The NCIP collaborated with the All Wales Antimicrobial Guidance Group to develop cellulitis guidelines for people with lymphoedema. These guidelines are also acknowledged by the All Wales Medicines Strategy Group. As a result of this collaboration, the recommended prophylactic course was reduced from 12 months to 6 months treatment and the antibiotic choices were reduced to only 2, either phenoxymethylpenicillin or clarithromycin. Decreasing the length of treatment is a significant factor in reducing the risk of resistance. Since 2020 316 patients have been prescribed a 6 month course of prophylaxis by the NCIP. These patients are closely monitored for recurrence and all are reviewed after 6 months and their courses ceased. Equally 97 patients have been identified as taking prophylaxis when not indicated and their prescription has been ceased.
• The NCIP has conducted 243 educational sessions, training 1,481 HCPs in Wales about cellulitis. In the evaluation forms submitted post training 91% of respondents reported that the education will change their practice with 40% reporting that they would decrease their prescribing as a result of the session.

Future Development

• Plans are to role the programme out into primary care working with GP Practices and the Welsh Antimicrobial Pharmacy Group (WAPG) to identify patients who have been prescribed flucloxacillin more than 3 times in the last 12 months offering them the same risk reducing programme. The benefits of those admitted to secondary care can be replicated in primary care reducing antibiotic prescriptions and decreasing GP and ED attendance. Evidence suggests a high misdiagnosis rate, continuing to roll out the education programme to all ED’s and minor injuries departments as well as primary care will aim to allow better diagnostics and a lower misdiagnosis rate associated with the subsequent inappropriate use of antibiotics.
• Collaboration with GPs and WAPG to include the review of patients receiving long-term prophylactic antibiotics for cellulitis. We know anecdotally that there is poor review of prophylaxis and that patients often remain on antibiotics indefinitely or were historically informed that they were to be lifelong. By offering the same review and assessment to these patients we should be able to cease the prophylaxis for most. Misdiagnosis and inappropriate use of antibiotics can be addressed by the review with the specialist Cellulitis team.
• Wales sets a global precedent in cellulitis care with a replicable NCIP model. This model could be rolled out to counties outside of Wales to decrease antibiotic usage and to improve outcomes for patients in their cellulitis management.

Organisation

NHS England (South East Region)

Project title: Promoting shortest effective antibiotic course lengths for uncomplicated infections (South East region)

Project Overview

Background
Shorter antibiotic courses are as effective as longer ones for uncomplicated infections, reducing adverse events, resistance, and environmental impact while supporting the UK 5-year action plan for antimicrobial resistance (AMR). In July 2022, the South East (SE) region identified shortest effective courses as a priority for antimicrobial stewardship (AMS), driven by PrescQIPP data. The SE was the second-lowest performing region, with only 33% of amoxicillin 500mg capsule courses prescribed for five days.

Aims
The project aimed to optimise antibiotic prescribing practices by safely reducing course lengths, leveraging a data-driven, evidence-based approach and digital tools to minimise antimicrobial consumption and reduce unwarranted variation.

Method
In 2023, a working group comprising a GP and AMS pharmacists from across the SE region, led by the Regional AMS Lead and Project Manager and supported by the East of England AMS team, developed NICE-aligned resources, including key messages, an evidence review bundle, infographics, and electronic prescribing guides. These resources were peer-reviewed, ratified, and published on FutureNHS in August 2023 for system-level implementation.

Results
Between August 2023 and December 2024, the resources were accessed 1,058 times, with 85% of views from outside the SE region. All ICBs in the SE promoted the resources to their GP practices and have reported sustained improvement, with five-day amoxicillin capsule prescribing increasing from 33% (July 2022) to 60% (September 2024), and variation between the highest and lowest ICBs reduced by 12%. Flucloxacillin 500mg capsule prescribing also increased from 11% to 24%, making SE the best-performing region. Nationally, 5-day courses rose 22% for amoxicillin, 14% for doxycycline, and 9% for flucloxacillin.

Conclusion
The initiative improved antibiotic prescribing by increasing five-day courses for amoxicillin and flucloxacillin. Resources were accessed 1,058 times nationally, demonstrating the success of a collaborative, data-driven and digitally optimised approach in enhancing stewardship, reducing variation, and combating resistance.

Impact on tackling AMR

Enhancing antimicrobial stewardship through evidence-based and digitally optimised prescribing practices. The SE region increased five-day courses of amoxicillin 500mg capsules, doxycycline 100mg capsules and flucloxacillin 500mg capsules over longer courses, reducing unnecessary antibiotic use and resistance risk. Kent and Medway ICB reported the lowest percentage of five-day courses in the SE (24% in July 2022) but increased to 62% (September 2024) by using the resources and implementing point-of-prescribing alerts. This progress supports the national action plan’s goal to optimise antimicrobial use through evidence-based practice, achieved by implementing an evidence bundle, digitally optimising primary care electronic prescribing systems and point of prescribing messages, and use of prescribing incentive schemes. These measures ensured prescribers have access to concise guidelines, evidence summaries, and prescribing alerts to promote adherence to recommended course lengths and safer prescribing practices.

Reducing regional variations in prescribing practices.
Variation in five-day amoxicillin courses between the SE ICBs decreased from 18% (July 2022) to 6% (September 2024). This aligns with the national action plan’s aim to reduce antimicrobial exposure through improved infection management. Reducing regional variation ensures consistent adherence to evidence-based prescribing practices, minimising overprescription and supporting efforts to prevent the development and spread of AMR while maintaining antibiotic effectiveness.

Empowering healthcare professionals.
The project empowered healthcare professionals through the resources, which were accessed 1,058 times nationally between August 2023 and December 2024, with 85% of views from outside the SE region. The resources included prescriber messages (41% of total views), infographics (30%), evidence bundles (21%), and prescribing guides (8%). Nationally, five-day antibiotic courses increased by 22% for amoxicillin, 14% for doxycycline, 9% for flucloxacillin, and 11% for phenoxymethylpenicillin. Evidence-based tools, such as shared decision-making guides and point-of-prescribing messages, supported adherence to course recommendations. Aligned with the National Medicines Optimisation Opportunities 2023/24, the project improved stewardship and addressed AMR effectively.

Future Development

Expansion of project scope
The project will continue to be promoted across the SE ICBs. Collaboration with the national APMO team and PrescQIPP will extend to developing resources for additional clinical indications and their subsequent data dashboards, aligning with evolving prescribing priorities.

Building on the success of the project in primary care, we are working collaboratively with the East of England region to increase adoption of the SE resources and further expand the project to include tailored resources for secondary care prescribers, addressing AMS in acute and specialised care settings.

Additionally, the project will focus on aligning antibiotic pack sizes with recommended course lengths to sustain progress in combating AMR. This will involve collaboration with the Department of Health and Social Care’s Medicines Supply Team and NHS England’s Medicines Value and Access Team to ensure alignment with national supply and optimisation strategies.

The success of this project and collaborating across the systems has stimulated other projects focused on AMS, including a paediatric focused project.

Optimisation of electronic prescribing systems.
The project will continue leveraging electronic prescribing systems to further optimise shorter effective course lengths. Features such as real-time prescribing messages and integrated decision support tools will be explored further, ensuring prescribers adhere to evidence-based course lengths.

Driving quality improvement through collaboration and knowledge sharing
To enhance quality improvement practices, case studies highlighting successful implementations and key lessons learned will be collected and disseminated, providing valuable insights for replicating success across regions. The initiative’s outcomes and best practices will be showcased at regional and national conferences, encouraging broader adoption and integration into AMS strategies. Additionally, the project team will work closely with the National Medicines Value Programme to align with the National Medicines Optimisation Opportunity initiative, leveraging data monitoring and sharing best regional practices to inform and guide the project’s trajectory.

Organisation

Sheffield Children’s NHS Foundation Trust

Project title: Improving AMS programmes for paediatric services across five hospital trusts in South Yorkshire via a new regional collaborative network.

Project Overview

This project, launched in August 2023, is dedicated to embedding AMS principles and practices into the routine care of children accessing Barnsley, Chesterfield, Doncaster, Rotherham and Sheffield Children’s hospital trusts. A service evaluation of the in-hospital AMS programmes for both adult and paediatric services revealed inconsistencies in AMS programmes between all five hospital trusts, with only 53% of quality indicators met in paediatrics versus 73% in adults. Staff shortages within AMS teams were identified as a significant barrier to meeting NICE quality indicators for children.

In response, a new regional paediatric AMS network was formed, comprised of 32 paediatricians, microbiologists and pharmacists, through which opportunities to improve antimicrobial use whilst reducing workload on individual trusts were discussed, including regionally coordinated quality improvement.

A standardised paediatric AMS education programme was designed and delivered face-to-face to prescribers and nursing staff in each of the five hospital trusts. The curriculum was designed in alignment to the UKHSA published antimicrobial prescribing and competency framework and agreed amongst members of the regional network, with local variations relevant to each trust. Topics included AMS principles, signposting to local and national guidance and resources, attitudes such as sense of responsibility, and human factors in prescribing. Nursing-specific AMS interventions were included in the session delivered to nursing staff.

A pharmacy-led antibiotic prescribing quality audit and feedback system was launched, which provided bi-monthly central analysis of individual trust PPS-style prescribing data benchmarked against regional averages. Reports were incorporated into regional AMS education sessions, delivering regular feedback to prescribers and nursing staff.

Connections strengthened across trusts has allowed Sheffield Children’s hospital to provide AMS programme support to surrounding district hospitals. The success of this project provides proof of concept for the hub and spoke model of delivering and supporting AMS programmes in district hospitals via tertiary centres.

Impact on tackling AMR

1) AMS programme structure and quality
AMS programme quality indicator compliance across the South Yorkshire region improved from 53% to 65%, closing the gap in AMS support between paediatric and adult services. These improved most significantly in quality indicators within the education and monitoring domains. Important organisational change as a result of this project includes a paediatrician sitting on the trust AMS committee for one district trust, and nursing champions for paediatric AMS identified in another. In addition, UK-PAS antibiotic recommendations were introduced to local guidelines committees, resulting in incorporation of such recommendations into local empirical guidance.

2) Education
Following education, confidence scores across prescribers (including principles of AMS, AMR risk awareness, accessing appropriate support and challenging prescriptions) rose from 71 to 90%. Nursing attitudes also improved from 57% to 88%, which included concern about AMR, sense of responsibility for AMS, knowledge of nursing interventions and confidence in challenging prescriptions.

3) Antibiotic prescribing quality
Prescribing quality data continues to be collected and analysed bi-monthly across the region (12 months of data collection rounds). Trusts report the survey has encouraged pharmacists to question prescriptions during data collection. Adherence to guidelines has increased from 87.1% to 91.9%, appropriate cultures taken prior to antibiotics increased from 43.5% to 75.7% and documentation of duration or review date risen from 35.5% to 41.9% regionally. The proportion of patients still receiving IV antibiotics past the point at which they meet switching criteria (IVOS CQUIN, target <15%) across the region reduced from 14.5% (Feb 2024) down to 6.8% (Oct 2024). The use of temporal run charts for benchmarking against other trusts and regional averages has played a significant role in motivation.

Future Development

Regular meetings within the South Yorkshire Paediatric AMS Group continue quarterly with administrative support from the ICB.

Connections have been made with the neonatal infection lead and neonatal microbiology lead at the tertiary neonatal unit for South Yorkshire to plan co-ordinated AMS interventions within the neonatal population.

UK-PAS national antibiotic recommendations have been adapted for local empirical paediatric guidelines in two trusts, with provisional agreement amongst stakeholders for use regionally.

Early plans are in progress for a regional penicillin allergy de-labelling project across paediatric inpatient services.

The success of this project provides proof of concept for the hub and spoke model, where tertiary centres can support AMS programmes in surrounding district hospitals to improve antibiotic use for children. We hope to encourage other regions to develop a similar model, to level up the provision of AMS support to paediatric services within district general hospitals.

Organisation

Cwm Taf Morgannwg University Health-Board

Project title: Quinolone checklist: how to reduce 4C prescribing without even mentioning the word stewardship!

Project Overview

As a health board, Cwm Taf Morgannwg (CTM) had the highest 4C prescribing rate of any of the other Welsh health-boards for primary and secondary care. In order to challenge this and to provide assurance that the MHRA advice regarding fluoroquinolone prescribing was being followed we put together a quinolone checklist and piloted it in one of the 3 district general hospitals within our area, Princess of Wales hospital. We approached the quinolone checklist from a medico-legal angle in order to reduce risk for prescribers who choose to prescribe a fluoroquinolone.

The MDT (Antimicrobial Pharmacists, Pharmacy Technician and Consultant Microbiologists) were all involved in the development of the checklist, which has been designed as a means to ensure the MHRA guidance is followed and that the shared decision making/patient consent had been documented. We ask prescribers to complete a checklist every time there is a decision to prescribe a fluoroquinolone.
After a successful pilot, the checklist was introduced across the health-board as a prescribing tool to ensure the safe prescribing of quinolones and to promote risk-benefit assessment.

Since the introduction of the quinolone checklist, significant progress has been made in reducing 4C prescribing in CTM health-board. As a result of this we were asked to feature in the All Wales Therapeutics and Toxicology Centre “Good Practice Spotlight.” This was not only acknowledgement of the progress made but also an opportunity to share best practice across Wales. CTM have introduced restrictive antimicrobial guidelines that recommend narrow spectrum antimicrobials, where possible. Narrow spectrum antimicrobials are, on occasion, advised in combination with other narrow spectrum antimicrobials in preference to the use of a single broad-spectrum agent. This strategy increases the total antimicrobial items prescribed but is believed to reduce antimicrobial resistance to the broad-spectrum antimicrobial and preserves more of the gut microbiome.

Impact on tackling AMR

1. Reduction of 4C prescribing across secondary care. The quinolone checklist was introduced to CTM in May 2021. Since then, we have seen an almost 30% reduction in 4C prescribing in secondary care.
In primary care we have had an 18.5% reduction.

2. Assurance that MHRA requirements and shared decision-making recommendations are being applied 100% of the time by providing medico-legal framework to reduce risk for prescribers who choose to prescribe a fluoroquinolone. MHRA requirements state that “systemic quinolone antibiotics must now only be prescribed when other commonly recommended antibiotics are inappropriate.” The quinolone checklist is mandatory every time a quinolone is prescribed. This is being promoted on ward rounds and when a supply request for a quinolone is made to pharmacy. It is not just pharmacy who are promoting the quinolone checklist use, we now have a multidisciplinary team of enthusiasts and Microbiology Consultants all championing and encouraging use of the checklist.

3. As an outcome of the introduction on the checklist, advanced education has been delivered on the use of the checklist and also improved awareness of the unintended consequences on quinolone use and opportunities for stewardship interventions to narrow the spectrum of the antimicrobial. Using alternatives to quinolones may have more side effects but they will be less severe than those with quinolones.

Future Development

Using the prescriber feedback in terms of usability and usefulness of the tool we have since adapted our quinolone checklist and made a version 2 which has recently been launched. The main changes we have incorporated into version 2 is the simplification of the questions, removal of any non-essential text and a space for a patient addressograph so that it can be kept in the patient notes. This is consistent with the EAST behaviour change framework in which the form is Easier to use, Attractive in format, Social in that whole departments are engaging with the form and Timely from the perspective that we have acted on the feedback we have received.

We will be sharing our work on the Cwm Taf Morgannwg Quinolone Checklist via the All Wales Therapeutics and Toxicology Centre “Good Practice Spotlight.” Through this we can demonstrate how we have used the tool to reduce our 4C prescribing across the health board. We plan to work with our Welsh colleagues to develop an All Wales Quinolone Checklist.

Introduction of quinolone checklist to Primary Care through embedding it in GP practice systems and through use of Scriptswitch, every time a fluoroquinolone is prescribed.