CURRENT PLEDGES: 216890
Shared Learning 2025 – Research
Organisation
Oxford University Hospital NHS Foundation Trust
Project title: The impact of antimicrobial stewardship ward rounds on antimicrobial use and predictors of advice, uptake, and outcomes
Project Overview
Antimicrobial resistance (AMR) is a major cause of mortality and morbidity globally. It is a growing and urgent problem driven by use and overuse of antimicrobials. In response, antimicrobial stewardship (AMS) programmes have been developed to reduce inappropriate antimicrobial use.
Since September 2021, weekly multidisciplinary team (MDT) AMS rounds consisting of an infectious diseases doctor, AMS pharmacist and AMS nurse was implemented at one of the Oxford University Hospitals Trust hospital sites which was expanded to other hospital sites over the next few years.
Patients on piperacillin-tazobactam, carbapenems, ciprofloxacin, cephalosporin, co-amoxiclav and antifungals were reviewed on the MDT AMS round and the intervention data were documented prospectively. The clinical data were again reviewed to determine whether the advice was acted upon 24 hours post MDT AMS round.
To investigate the impact of the AMS ward rounds in hospital 1 an interrupted time-series approach was used, also comparing to Hospital-2 where AMS ward rounds were not yet implemented. The research illustrated that introducing AMS MDT ward rounds was followed by new or accelerated declines in ceftriaxone, ciprofloxacin, amoxicillin-clavulanate, meropenem and piperacillin-tazobactam use at Hospital-1. Except for ceftriaxone, similar declines were not seen at Hospital-2.
In a second analysis, 6878 AMS reviews were documented across Hospitals 1-3 while a detailed database of advice given, and uptake of the advice was kept by the AMS team. Half of reviews (3471/6878;50%) resulted in an intervention and 2003/2726(73%) of the recommendation were subsequently implemented by clinical team. The greater the number of AMS reviews completed by a consultant prior to each review the more likely advice was to be followed. Following advice to deescalate/stop antimicrobials was associated with a 0.58 day [95%CI 0.22-0.94] reduction in hospital stay.
In conclusion, MDT AMS ward rounds reduced antibiotic use and could reduce length of hospital stay.
Impact on tackling AMR
Reducing patient exposure to broad-spectrum antibiotic in the WHO AWaRE “Watch” and “Reserve” category is instrumental to tackle AMR in line with UK AMR national action plan. Following introduction of senior doctor-led AMS ward rounds at Hospital-1, there was an acceleration in declines in use of broad- spectrum antibiotic. This includes ceftriaxone and ciprofloxacin, and new declines in amoxicillin-clavulanate, meropenem and piperacillin-tazobactam use. In contrast, at Hospital-2 where stewardship ward rounds were not introduced at the time, rates of ciprofloxacin and meropenem use increased compared to the underlying trend. Overall antibiotic use fell at Hospital-1 compared to the underlying trend and at Hospital-2.
816 instances of advice to de-escalate antibiotics had a documented review of advice uptake. Fifteen patients where identifiers in the AMS database could not be matched to the remainder of the electronic data were excluded. AMS advice was followed in 70% (563/801). There were 1535 AMS reviews with advice to de-escalate or stop antibiotics, an available review of advice uptake, and where patients were current inpatients. Of these, 12 were excluded that could not be matched to other hospital data. Advice was actioned in 1138/1523 (75%) reviews. Median (IQR) length of stay was 1.85 (0.68-4.72) days where advice was followed and 2.64 (1.10-5.85) where it was not. After adjusting for patient factors, following advice to deescalate/stop antimicrobials were associated with a 0.58 day [95%CI 0.22-0.94] reduction in hospital stay.
Overall, 73% of recommendations to make a change were implemented, including 80% of all suggestions to stop antibiotics and 71% of suggestions to deescalate antibiotics. The relatively high uptake of advice likely reflects the design of the AMS intervention, using face-to-face contact with a MDT, underpinned by existing trust and good relationships between the infectious diseases consult service and teams throughout the hospital.
Future Development
There are several possible areas for further work. Considering more precise details of the clinical syndrome, clinical/vital sign/laboratory parameters, and microbiology results could allow differences in decision making to be better understood. It may also be possible to use these data to predict what an average AMS reviewer would have suggested, both as an educational tool and potential clinical decision aid. This study, like many others, assessed measures of process including consult numbers and rates of advice to change antibiotics. We also measured immediate outcomes, including AMS advice uptake rates, length of stay and antibiotic consumption. Despite having data on several thousand AMS reviews, our study had insufficient power to rule out important differences in mortality depending on uptake of advice; a much larger dataset would be needed to do this. Further studies are needed to ensure AMS advice is optimal, not only considering reductions in antibiotic use, but also impacts on a wide range of patient outcomes including readmission, reoperation, subsequent antibiotics, functional recovery, and patient experience.
Organisation
Nottingham Trent University, Makerere University and Buckinghamshire NHS Trust
Managing penicillin allergy in primary care: an important but neglected aspect of antibiotic stewardship
Project Overview
The Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) 2 project between Nottingham Trent University (UK), Makerere University (Uganda) and Buckinghamshire Healthcare NHS Trust (UK) aims to improve awareness of Antimicrobial Resistance (AMR) and its drivers using a One-Health approach. Substandard and falsified medicines (SFMs) pose a significant threat to public health globally and can contribute to the emergence of AMR. We conducted a cross-sectional survey in Wakiso District, Uganda that employed a structured questionnaire among 432 community members, 12 focus group discussions and 11 key informant interviews to assess knowledge, attitudes, and practices of SFMs among humans and animals. Key informant interviews were also undertaken to obtain qualitative data under several themes including drivers of use of SFMs.
Most respondents (83%) stated that they had ever heard about SFMs, however 31% could correctly define them. Almost two-thirds of the respondents disagreed that human (62%) and animal (60%) SFMs were as good as genuine medicines. Half (51-55%) of the respondents strongly agreed / agreed that SFMs could be very dangerous to humans and animals. Respondents reported having bought SFMs for use in humans (14%) and animals (24%). Only 25% of the respondents mentioned informing a health worker and 3.5% reported suspicions of SFMs to the National Drug Authority. From the qualitative findings, the key drivers of use of SFMs were inadequate knowledge, poverty, lack of access to authentic pharmacies, poor law regulation and enforcement, and the business orientation of pharmacies.
There was generally a lack of knowledge, mixed attitudes and associated poor practices regarding SFMs among both humans and animals. There is a clear need for key stakeholder engagement involving health and regulatory authorities in both human and animal medicine to increase awareness on SFMs to minimise the potential risks to health among the community.
Impact on tackling AMR
- AMR awareness and Antimicrobial Stewardship (AMS) training workshops that our project conducted included training on SFMs that gathered insights of this quantitative and qualitative data. Education and training were delivered to explain how SFMs are defined, how to identify them, drivers of use and implications of this, and how to report them. Training was conducted amongst 292 health practitioners in Nakaseke, Butambala and Wakiso districts, and 531 Community Health Workers (CHWs) in Wakiso district, Uganda. Evaluation of trained health workers and CHWs has indicated improved knowledge on antimicrobial use and supporting members of the community to access safe and quality medicines when possible.
- Current efforts to address SFMs globally focus on the supply-side of medicinal products and health facilities without consumer engagement. Consumers need to be educated and empowered to demand for quality and genuine medicines. Research on SFMs that focuses on consumers’ experiences in human and animal health is limited. It is paramount to understand how a multisectoral approach that involves various stakeholders including consumers (from both the human and animal sectors) might be useful for low- and middle-income country economies to tackle SFMs. In Uganda, evidence is sparce on SFMs from a consumer perspective. Our study therefore addressed this research gap by assessing the knowledge, attitudes, and practices on SFMs among humans and animals in Wakiso district, Uganda. Our intention is to publish the data from this study in an international open access peer-reviewed journal.
- Qualitative methods allow for more in-depth exploration of participants’ experiences, perceptions, and motivations, providing context and nuanced insights, but few such studies have so far been applied to the problem of SFMs in sub-Saharan Africa. The health partnership plans to further disseminate the qualitative data from this study through local and international conferences, blogs, workshops, seminars, and webinars.
Future Development
We intend to use this data to inform AMS interventions in both healthcare facilities and in the community setting to reduce the use of SFMs in humans and animals in Uganda and beyond which can be a driver of AMR. AMS interventions will be considered as part of quality improvement projects with a subsequent check on knowledge, perceptions and attitudes in the future.
