Shared Learning: Prescribing and Stewardship

Prescribing and Stewardship projects


The Nottinghamshire Antimicrobial Stewardship Committee (Winner – Antibiotic Guardian Awards 2017)

Name: Amelia Joseph, Nottingham University Hospitals NHS Trust and Health Education England in the East Midlands

Provide a brief overview of the project: Improving the Management of Urinary Tract Infections in the Community in South Nottinghamshire:

Working across healthcare boundaries and professional groups, the Nottinghamshire Antimicrobial Stewardship Committee has enacted measurable and substantial changes in the management of Urinary Tract Infections (UTIs) in the local community. As the second commonest cause for antibiotic prescriptions in the community, and in the face of rising antimicrobial resistance in urinary tract isolates in Nottinghamshire, an enhanced stewardship approach for UTIs was initiated in early 2015. Supported by the appointment of a local microbiology registrar to an Integrated Antimicrobial Stewardship Fellowship post (Health Education England East Midlands, Innovation & Improvement Programme), new local management guidelines were developed following research into the local resistance and prescribing trends. New laboratory testing methods, including new antibiotics and a rapid 24hr turnaround time to reporting of urine sensitivities, enabled the addition of the antibiotic pivmecillinam to the local formulary for routine use. These new guidelines were approved by the Area Prescribing Committee, recognising the potential for patient benefit in reducing treatment failures and further rises in resistance rates.

An education programme was implemented to support initial guideline introduction, to cover the four local CCGs, with presentations and Q&A sessions with GPs and Prescribing Advisers. These were designed to be local evidence based, with research indicating that local resistance data is highly valued by GPs. The initial education programme was subsequently extended to other prescribing groups, who at that time did not receive any training on appropriate use of antibiotics; GP registrars, Urgent Care Practitioners, Community Matrons, and Community Hospital Nurse Practitioners. Tailored sessions to each group were designed and feedback received with the aim of improving and embedding these sessions into regular training cycles. Non-prescribing professionals were also recognised to play a vital role in antimicrobial stewardship, so sessions were introduced to cover community nursing groups e.g. continence specialist nurses, district and practice nurses. A a resource pack for local Patient Participation Groups was developed by the Committee’s patient representative, with the aim of presentations and resources being disseminated into GP practices through active patient groups.
As a result of this stewardship initiative, there has been a dramatic reduction in inappropriate prescribing for UTIs in Nottinghamshire, and a subsequent drop in local resistance rates in UTI organisms; demonstrating the direct and impressive effects that promoting the safe and responsible use of antibiotics in the community can have on a local population.

List any supporting partners or organisations worked with: Nottinghamshire Antimicrobial Stewardship Committee
Nottinghamshire Area Prescribing Committee
Elaine Belshaw, former Infection Prevention and Control Quality Governance Manager, Nottingham City CCG and Chair of the Nottinghamshire Antimicrobial Stewardship Committee
Empath (Diagnostic Microbiology Laboratory for Nottingham University Hospitals and surrounding area)
Health Education England in the East Midlands
Nottingham University Hospitals NHS Trust

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Engagement from the start of the initiative with CCG Prescribing Advisers and GPs, in the development and launch of new guidelines

Education campaign to improve appropriate antimicrobial prescribing, focusing on UTIs:
Education sessions designed and delivered to both prescribing and non-prescribing groups as increased local awareness of antimicrobial resistance, and empowered local healthcare professionals to disseminate good practice and improve antibiotic use in their own areas of practice. Excellent feedback has led to these education sessions becoming a regular addition to current training provided to Urgent Care practitioners, Infection Prevention Control Link Nurses, GP registrars and community nurses.
The positive data that is now demonstrating the significant reductions in trimethoprim use and the subsequent fall in trimethoprim resistance rate will be shared within the local healthcare community, to foster pride and ownership of antibiotic stewardship in the local area. Regular communications through prescribing newsletters to GPs and pharmacists, as well as ongoing presence at educational meetings, are keeping antibiotic stewardship on the agenda locally. Individual GP practice-level feedback on antibiotic prescribing is being use in local CCGs, along with in depth prescribing reviews and feedback by the Integrated Stewardship Fellow in high-prescribing practices.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?

  1. The education campaign to numerous groups of prescribing and non-prescribing healthcare professionals has raised awareness of current and local antimicrobial resistance, and promoted their individual roles and responsibilities in protecting antibiotics.
    Quotes from feedback highlighting the promotion of the protection of antibiotics from the local education campaign:
    “Antimicrobial resistance is a very important topic as it will impact us all in the future. Very relevant to my work and I can disseminate this message to my team.” Community nurse, Nottinghamshire Healthcare Foundation Trust.
    “Thank you for coming to our community ward round last week to talk about antibiotics. The feedback from the team was really positive and they found it very informative and interesting.” Community Matron, Rushcliffe CCG
    “Great use of scenarios to make you think about your own practice with antibiotics” Urgent Care Practitioner, Nottingham City CCG
    “Whole session brilliant and very relevant to our practice” GP registrar, Nottingham University Hospitals NHS Trust2. Laboratory testing of community urine samples has been updated, with the introduction of an automated method that provides clinicians with a culture and sensitivity result within 24 hours, supporting clinicians in more responsive, sensitivity-based prescribing. The introduction of routine testing of pivmecillinam has encourage clinician’s to use narrow-spectrum agents when possible, and the selective reporting of results (for example, routinely withholding co-amoxiclav sensitivity results) supports the choice of agents in line with local guidelines.3. Resource pack for GP Patient Participation Groups promoting the protection of antibiotics, developed by the patient representative member of the Antimicrobial Stewardship Committee. Presentation to the Patient Participation Group chairs of a local CCG to enhance education and support the use of the pack. Extending the use of the resource pack and presentations to other local CCGs is planned for 2017.

Key outcomes of project?: We have achieved a dramatic reduction in inappropriate prescribing for urinary tract infections in South Nottinghamshire patients:

Following the introduction of the new Urinary Tract Infection guidelines and education campaign, the uptake in nitrofurantoin use as the first-line choice for urinary tract infections has been dramatic, with trimethoprim usage falling significantly. Prior to introduction of the guidelines and education campaign (started in Q2 2015/16), the four South Nottinghamshire CCGs had an average Trimethoprim : Nitrofurantoin prescribing proportion of 61% (Q1 2015/16). This was in line to the national average. This has since fallen to 23%, with the Nottinghamshire CCGs now having the lowest prescribing ratios in England. This has been achieved whilst continuing to reduce prescribing of broad-spectrum antibiotics (e.g. co-amoxiclav, cefalexin and ciprofloxacin).

What impact has this change in antibiotic prescribing had on local resistance rates?
With this dramatic reduction in trimethoprim use, the resistance rate for urinary tract E.coli isolates from community patients has fallen significantly. Prior to the guideline introduction and education campaign, the trimethoprim resistance rate for E.coli in community urine samples was 35%; this has now fallen to 23%. This means it is a suitable treatment option for more patients and is likely to be due to the reduction in selective pressure from prescribing in the local community. By reducing selective pressure through stewardship interventions, we are protecting this useful and effective antibiotic for use in certain groups now, and potentially more widespread use again in the future (using the rationale of cycling the antibiotic formulary). This effect has also been seen in local community-onset bloodstream infection E.coli isolates, with resistance rates falling from 43% to 31%. This means it can be used as a narrow-spectrum intravenous to oral step-down antibiotic option in more patients than previously due to high resistance rates.

Production of new local guidelines on the management of recurrent urinary tract infections:
Supporting local GPs in avoiding starting long-term antibiotic prophylaxis, identifying patients on long-term antibiotics for review, and supporting them in stopping long-term antibiotics where appropriate. This will support the achievement of the Quality Premium in reducing trimethoprim items prescribed to >70 year olds, and be added to local CCG QUIPPs for 2017/18.

How is the project to be developed in the future?: The introduction of fosfomycin into local community antibiotic guidelines is imminent, supported by a laboratory evaluation and introduction of routine testing of all urine samples sent to the laboratory at Nottingham University Hospitals. This will further improve treatment options for community patients, especially for those with resistant organisms, allergies, or renal impairment. The wider spread use of fosfomycin for UTIs within the local health economy is currently being planned.

Regular practice-based audit across Nottinghamshire GPs on use of prophylactic antibiotics over 6 months are commencing in April 2017, with practice pharmacists or prescribing advisers flagging patients for review by clinicians using the new local guidelines on management of recurrent urinary tract infections.

Proactive multi-disciplinary investigation of local areas where community E.coli bacteraemias rates are rising, to understand the interaction between prescribing for urinary tract infections & E.coli bacteraemias and to mitigate for any unintended consequences of increasing nitrofurantoin and pivmecillinam use.

Health Education East Midlands Innovation & Improvement Programme have agreed to support another Integrated Fellowship post in Community Antimicrobial Stewardship in the future, recognising the contribution that this role can have to the local health economy with regards to action to promotion of the protection of antibiotics.

Key Outcomes




University Hospital Southampton NHS Foundation Trust (Highly commended – Antibiotic Guardian Awards)


Name: Hayley Wickens, Consultant Pharmacist, Anti-infectives

Provide a brief overview of the project: At UHS, we implemented a programme of measures to achieve our CQUIN targets for reduction of total antibiotic, carbapenem, and piperacillin-tazobactam prescribing in 2016/17. Compared to the previous year, we needed to reduce these by 5%, 11% and 12% respectively in order to reach 99% of the levels used in 2013/14: at 10 months, we are on course to do so. We also implemented supportive tools to promote 72h review of antibiotic prescriptions.
This achievement required a multi-disciplinary effort from pharmacy, nursing and medical staff throughout the hospital, led by a newly-formed subgroup of the Antimicrobial Stewardship (AMS) Team dedicated to CQUIN delivery, which met regularly to assess progress.
Key activities included:
• Delivery of a major educational programme on AMS, highlighting 72h review, iv-oral switch, appropriate course lengths, and empiric antibiotic choices. Consultants in Microbiology/ID and Pharmacy ran sessions as follows:
All current FY1 and FY2 doctors across four sessions
o All new intake FY1 doctors (two sessions)
o A session for clinical trainees (medical registrars)
o Consultant meetings in Critical Care, General Surgery, Elderly Care, Hepato-biliary, Respiratory and Acute Medical Unit
o Grand round
o Infection prevention link nurses
o Pharmacy team

  • Change of empiric guidelines, replacing piperacillin-tazobactam with alternative agents (e.g. co-amoxiclav /gentamicin), supported by local epidemiological information. Trust documents (e.g. MicroGuide antibiotic app, sepsis screening tool, PGD for sepsis) were altered accordingly, and information included in the training programme.
  • Antibiotic e-prescribing reports, to support AMS ward rounds, were sent daily to an ‘AMSReports’ e-mail account, accessible by Microbiology/ID doctors and pharmacists. Reports included all patients on carbapenems, those on iv antibiotics > 3 days, oral antibiotics > 5 days, or started on antibiotics in the past 24hours.
  • Implemented default course lengths for oral antibiotics on e-prescribing (3/5/7 days).
  • Implemented a new ‘flag’ on our electronic Doctors Worklist software that highlighted all patients on antibiotics, and those who had been on for >72h and overdue a review, prompting documentation of the review on the system. Each ward is also audited monthly for compliance with 72h review, and data fed back to teams.
  • We generated new formats for feeding back data on CQUIN progress to the delivery team, AST and Trust Executive. Monthly data on proportions of overall, carbapenem and piperacillin-tazobactam contributed by each clinical area, cross-referenced to the volume of usage, were used to target AMS activity e.g. ward rounds.

List any supporting partners or organisations worked with: Sepsis and Antimicrobial Stewardship (AMS) Team at UHS
Trust Executive Committee, UHS
Microbiology and Infectious Diseases Consultants and Infection Prevention and Control Team, UHS
Public Health England

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category: Education: We delivered 14 targeted educational sessions to doctors of all grades from FY1 to consultant, highlighting good antimicrobial prescribing practice, including the importance of 72h review, iv-oral switch, appropriate course lengths, and choice of empiric antimicrobials. These sessions were well-attended and well-received; we feel that the increase in visibility of the AMS team, and awareness of practical aspects of AMS, has been highly important in driving the changes seen in our Trust.
Electronic systems: Previously, when prescribing an antibiotic on our e-prescribing system, no course length was automatically generated, apart from a small number of set treatment protocols, and therefore a majority of prescriptions were left open-ended. We assigned default course lengths of 3, 5 or 7 days to all oral antibiotics on the system, requiring prescribers to select one of these at the point of prescribing. It is still possible for the prescriber to amend course length if required, at any point; however, this then becomes a conscious decision to do so. We believe this encourages fewer unnecessarily long courses of antimicrobials.
On a daily basis, we provide information on ‘live’ prescriptions from our systems to Microbiology/ID doctors, to facilitate targeted AMS ward rounds.
We have also implemented a flag system on our Doctors Worklist software, which prompts prescribers to review patients who have been on an antibiotic for 47-72h. This is searchable, in order to generate AMS review lists, and supports online completion of review documentation.

New reporting methods: We generated innovative formats for feeding back data on CQUIN progress to the delivery team, AMS Team, Infection Prevention and Control Committee, and Trust Executive; these combined overall Trust trajectory data with data focusing on the contributions made to overall figures by individual clinical areas. These data were also used with clinical teams to help them understand the impact of their prescribing within the organisation.
Monthly data on proportions of total antibiotic, carbapenem and piperacillin-tazobactam prescribing contributed by each clinical area, cross-referenced to the volume of usage, were used to assess progress and impact across the Trust. For example, obstetrics increased use of piperacillin-tazobactam by a large percentage, but given that the drug is rarely used in this area, this had a lower impact than a small percentage increase in an area of much higher usage (e.g. medicine), allowing us to target our AMS resource appropriately, for instance by focusing AMS ward rounds in the latter area.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: We have reduced our overall usage of antibiotics per 1000 admissions, along with our piperacillin-tazobactam and carbapenem use, which will contribute to reducing selection pressure for resistant organisms, and protecting these antimicrobials for use in future patients.

We have put in place several electronic systems that permit targeting of AMS activity resource; a Microbiogist or ID doctor, or specialist pharmacist, can now review all patients in the hospital currently receiving meropenem, or all those on an intravenous agent for over 48h, or all those who are currently overdue a 72h review, all from their desk. They can then and access the electronic prescriptions and notes for those patients, discuss with the medical teams, and target resource for e.g. AMS ward rounds to review them in person.

We have increased the engagement of the medical staff in our Trust with AMS, and the CQUIN process has raised the profile of AMS at the highest levels of our organisation. Pharmacy and nursing staff have also been actively involved. We believe that such Trust-wide, multidisciplinary commitment is key for ensuring antibiotics are prescribed and reviewed appropriately. We would like to acknowledge the support of the Trust Executive in funding some staff time to deliver these initiatives, which have been so successful that we have secured funding for several pharmacy and nursing posts for ongoing delivery of AMS and sepsis initiatives over the coming year.

Key outcomes of project?: CQUIN reduction targets on target to be met for overall antibiotic use, piperacillin-tazobactam and carbapenems. Innovative usage reports developed for Trust level and clinical speciality have supported this.
All grades of medical staff educated on AMS, increased engagement between clinical teams and Microbiology/ID service.
Automated electronic systems now in place to identify, and allow prioritisation of, patients for AMS team clinical review.
Ongoing funding secured for AMS and Sepsis teams to continue delivering improvements in treatment of infection and AMS for patients over the coming year.

How is the project to be developed in the future?: We are developing further reporting from our e-prescribing system that will allow us to monitor antimicrobial usage more effectively, with the assistance of a recently-employed data analyst. For instance, we will soon be able to report ‘Days of therapy’ as a monthly metric, at Trust, Speciality or ward level, taken from the administration data within our e-prescribing system. This will be useful for assessing impact of implementing changes to course lengths within our systems and guidelines.

We are continuing our education programme, in conjunction with our recently-appointed AMS specialist nurse, and targeting other professions as well as medicine.

We will continue to increase our targeted AMS ward round activities, with two antimicrobial specialist pharmacists currently training as prescribers to support this.

We are grateful for the support of the Trust Executive in funding the continued delivery and development of our AMS and Sepsis programme over the coming year.



NHS Leeds North Clinical Commissioning Group

Name: Heather Edmonds, Head of Medicines Management


Provide a brief overview of the project: Audit to improve antibiotic prescribing in primary care.

For the last few years Leeds North CCGs have asked their GP practices to undertake an antibiotic review as part of the prescribing engagement scheme.
The specific aims of the audit are to:-
1. To maintain and/or improve evidence-based and appropriate prescribing of antibiotics across Leeds and compliance with local antibiotic guidance.
2. To reduce the risk of antibiotic resistance and maintain the usefulness of existing agents
3. To reduce the risk of Healthcare Associated Infection (HCAI).
4. To ensure all prescribers can demonstrate they have the necessary competencies to prescribe antibiotics.
5. To implement the NICE guidance NG15 “Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use”.
6. To ensure practices have a process to use and record the use of delayed/back-up prescriptions.
7. To support the patient awareness antibiotic campaign.

The GP practices are asked to review a sample of patients on a monthly basis, covering a different group of antibiotics each month so that all antibiotics are reviewed twice a year. For each patient being reviewed, the indication for antibiotic is reviewed against the guidelines to ensure that the correct antibiotics is being prescribed, at the correct dose, by the correct route for the correct length of course and including any reasons for deviation, this is recorded and submitted to the CCG medicines optimisation team on a quarterly basis.

We also asked all our prescribers to undertake the prescribing competence in, the antibiotic prescribing competencies tool produced by PHE and report the number of prescribers who had completed.

We also asked out GP practices to develop and implement a process within their practice for recording use of back-up /delayed antibiotic scripts.

The medicines optimisation feedback the progress to practices on a monthly basis via our reporting dashboard and the progress for the audits six monthly at our prescribing leads GP meeting.

Please see copy of the audit tool send in the separate email.

List any supporting partners or organisations worked with: Leeds North CCG
GP practices within the Leeds North CCG area
Local Care Direct (out of hour’s provider)
Walk-in centres

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Over the last 3 years there has been a gradual improvement in the compliance with the guidance in all areas, as demonstrated in the graphs (sent via a separate email). Reviewing the patients like this ensures that the guidelines are reviewed and practices are aware of any changes. We have encouraged the GPs to critically review prescribing and reflect on changes that they can make. The drop in trimethoprim prescribing reflects when we made changes to the UTI guidelines.
With regards to delayed/back-up prescriptions, the GPs were quite reluctant to use this approach. However so far this year we have identified 249 occasions where this approach has been used and on at least 29 occasions the patient didn’t get the prescription dispensed. More practices are using delayed/back-up scripts that the previous year.
We have also identified that out of 184 prescribers within our GP practices, that 70% of these prescribers have completed the antibiotic prescribing competencies tool produced by PHE.
This approach has also reduced the amount of antibiotic being prescribed within the Leeds North CCG area. Items/STARPU for 12 months up to Nov 16 was 1.037, which was a reduction compared to the previous 12 months. Please see graphs sent in separate email which demonstrates the continued reduction of both total antibiotics/STARPU and percentage broad spectrum antibiotics of the total antibiotics prescribed.
This seems to be also having an effect on resistance as the average proportion of ‘multi-drug resistant’ E. coli blood specimens from key antimicrobials (gentamicin, ciprofloxacin, piperacillin/tazobactam, 3rd-generation cephalosporins, carbapenems;) by CCG and by Quarter is gradually reducing as shown in the information send via email.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics

  • The overall improvement in compliance with the antibiotic guidance, including correct antibiotics, dose, route and duration.
    • The number of prescribers that have completed the antibiotic prescribing competencies
    • The continued reduction of antibiotics being prescribed and the positive effect this is having on resistance.

Key outcomes of project?: The continued improvement in the compliance with guidance, in respect to antibiotic choice, dose, route and duration. This is noticeable with the reduction of trimethoprim use, when we changed the guidance, which does demonstrate this is a good method of checking GPs are aware and implement the guidelines.
That about 70 % of our prescribers have completed the antibiotic prescribing competences and have the basic education to ensure that antibiotics are prescribed appropriately.
More GPs are using delayed /back-up prescriptions as a tool to aid appropriate use of antibiotics and we have demonstrated that not all these prescriptions are dispensed.
Antibiotic prescribing continues to reduce for all antibiotics and that this is having a positive effect on antibiotic resistance

How is the project to be developed in the future?: Each year we review the content of the audit to ensure we support achievement of national measures. This year we have taken some elements out such as the antibiotic prescribing competencies. We have added in some NICE quality standards around testing for UTIs and also added a section around accurate recording of penicillin allergy status and continue to provide education and feedback.
We ensure that all our providers such as out of hour’s providers and walk-in centres also complete this audit and we promote our audit to the other local CCGs.


NHS Leeds North CCG

Click here to find out more about the project


NHS Tayside

Name: Heather Kennedy


Provide a brief overview of the project: Antimicrobial resistance is a major global health problem and as such healthcare professionals should be aware of the basic principles of stewardship in order to retain the effectiveness of our finite resource of currently available antimicrobial agents. Historically the stewardship agenda has always been addressed by a pharmacist or physician and so this project aimed to promote the key concepts of stewardship using a pharmacist and nurse partnership. An antimicrobial /infection ward round was introduced in two surgical wards within an acute teaching hospital with the aim of promoting optimal antimicrobial management, promoting best practice in antimicrobial prescribing, promoting timely de-escalation and creating a multidisciplinary approach to infection management. Surgery was chosen as the clinical specialty due to the high burden of antimicrobial consumption and also the minimal resource available by the ward pharmacist.
The Advanced Nurse Practitioner (ANP) for stewardship along with the Advanced Antimicrobial Pharmacist (AP) attended one consultant led ward round on each ward per week and all interventions and outcomes collated. The primary focus of these ward rounds targeted and encouraged compliance with antimicrobial policy – more specifically indication, route, duration, suitability for IVOST and review of microbiology so as to streamline treatment.
Data was collected over a 6 month period on various parameters including prevalence, compliance, number of interventions and the number of interventions accepted by the clinical teams. Due to the education aspect of our project, it was important to decipher if a change in behaviour had occurred so these two wards were re-audited 4 months after the intervention to determine whether a sustainable change had taken place.

List any supporting partners or organisations worked with: NHS Tayside Antimicrobial Management Team

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? This project highlighted stewardship in a number of ways throughout its course. Compliance with policy is paramount when promoting antimicrobial stewardship within any clinical area. Policies within NHS Tayside are produced in line with national recommendations and highlight agents to be used which will minimise harm and provide the best patient outcome. This project audited compliance and the improvement in compliance over time demonstrating that prudent prescribing was more prevalent after the task. Duration of antimicrobial therapy is another factor which is vitally important when looking at overall consumption and burden of agents within a health board. The review of IV antimicrobials regularly should be engrained into daily practice. Oral antimicrobials should be prescribed for the shortest duration to ensure the patient receives the best outcome but also to address the national agenda of antimicrobial resistance. Again this venture addressed this as documentation of duration was one of the principles audited and education provided. Education and training of ward staff is important to instil sustainable change at ward level. All staff should be aware of the stewardship agenda and how they can impact by rolling out a few key messages within their daily role. Infection control can also be enforced and issues around line care, hand washing and contamination etc can be addressed. By carrying out this project, learning was provided to the clinical teams in real time while discussing the patient’s management. Collaborative working is hugely important to ensure the patient receives optimal care and management. Multi professional working is essential when implementing change to ensure sustainability. This project demonstrated the benefits of a collaborative approach and how the disciplines can work together and share learning to ensure optimal patient care and management. Safer and effective use of medicines is another concept addressed in this project. The AP and ANP provided advice and recommendations around the prescribing of all antimicrobials as it happened. Also advice about future prescribing decisions could be addressed to ensure the patient received the safest and most appropriate treatment plan.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics? The first example which highlights the promotion of the protection of antibiotics is compliance with antimicrobial policy. Within NHS Tayside our antimicrobial policies are regularly reviewed and scrutinised so that all of the high risk c.difficile agents have been removed as first line options. Broad spectrum agents have been replaced with a combination of narrower spectrum to preserve these key drugs for more resistant organisms.
The second example which highlights the promotion of the protection of antibiotics is by ensuring antimicrobials are reviewed and prescribed for an appropriate duration. A key aspect of this project was to ensure that IV antimicrobial agents were reviewed daily as an integral part of the ward round process. Also that oral antimicrobial agents had a documented duration on the medical chart and/or medical notes which was compliant with local and national guidance.
The third example which highlights the promotion of the protection of antibiotics is around the streamlining of treatment and assessing the suitability for IV to oral switch. As part of the project all patients who were on IV therapy were reviewed to see if they were suitable for an oral agent. A combination of empirical agents is appropriate on admission, but it is critical that microbiology is reviewed and treatment is de-escalated accordingly. Within NHS Tayside, guidance exists around eligibility criteria for switching to an oral agent and this was adhered to throughout the audit.

Key outcomes of project?:

Ward A – 124 patients on antimicrobials
Antimicrobial prevalence Compliance with policy No of interventions No of interventions accepted
Overall 31% (124/405) 95% (118/1124) 43 (35% 43/124) 34 (79% 34/43)
26/6-16/9 33% (75/228) 94% (71/75) 36 (53% 36/68) 27 (75% 27/36)
23/9-02/12 28% (49/177) 96% (47/49) 7 (14% 7/49) 7 (100% 7/7)

Ward B – 126 patients on antimicrobials
Antimicrobial prevalence Compliance with policy No of interventions No of interventions accepted
Overall 29% (126/427) 95% (120/126) 41 (32% 41/126) 33 (80% 33/41)
04/7-18/9 32% (72/225) 93% (67/72) 36 (50% 36/72) 28 (77% 28/36)
25/9-27/11 27% (54/202) 98% (53/54) 5 (9% 5/54) 5 (100% 5/5)

The number of interventions made by the AP and ANP between the first and the latter phases in both clinical areas reduced significantly (p <0.0001) demonstrating that a behaviour change had been adopted. Although not statistically significant, the number of interventions accepted by the surgical teams increased in both ward areas. This suggests that over time, the AP and ANP gained credibility and the confidence of the surgical teams.
In both wards it can be shown that over the audit time antimicrobial prevalence is decreasing along with number of interventions. Also compliance with policy is increasing and so these findings highlight the positive impact attending the ward round along with continual education and training had on patient outcomes.

How is the project to be developed in the future?: This project can be further developed in the future by introducing a pharmacist and nurse led ward round in other clinical areas to see if the positive results are repeated in other clinical specialties. Developing a work program for nursing staff to compliment ward round intervention would be hugely beneficial. Liaising with the clinical ward pharmacist so they can continue to educate and integrate themselves into the team while addressing the stewardship agenda.


Birmingham CrossCity CCG

Name: Rakhi Aggarwal


Provide a brief overview of the project? Birmingham CrossCity CCG Antimicrobial Stewardship project has run for the last two years; Key points of the project include:

  1. Antibiotic focus in General Practice as part of CCG ACE Foundation initiative: Every practice appointed an Antibiotic Lead and all prescribers undertook CPD module from the TARGET Toolkit. Audit of antibiotic prescribing was carried out by Prescribing Support Pharmacists in collaboration with prescribers. All GP practices were given printed copies of the ‘Antibiotic Guardian’ leaflet and the ‘Treat your infection’ leaflet to use with patients.2. Continued promotion of Pan Birmingham Primary Care Antimicrobial Guidelines and education about antimicrobial resistance and antimicrobial stewardship (see below for methods used – all of which were supported by Dr Das Pillay, Consultant Microbiologist PHE at Heart of England NHS Foundation Trust).• Education events held for:
    1. Medicines Management Team
    2. Practice nurses and nurse prescribers
    3. GPs
    4. Care Homes• A series of prescribing newsletters for primary care prescribers focussed AMR and AMS.• Quarterly ongoing feedback to practices of antimicrobial prescribing to individual practices (items/STARPU and % as ceph/quinolones/co-amoxiclav)• AMS awareness for CCG staff through Team Stand Up presentations.• Community Pharmacy awareness campaign (see below for more detail)• Meetings with out-of-hours providers.3. All GPs, nurses, practice staff, CCG staff and Care home staff were encouraged to become an Antibiotic Guardian.

    4. Antibiotic Guardian Social media campaign through November 2015 and November 2016, run jointly by the Medicines Management Team and the CCG Communications team – including Facebook, Twitter, local media, CCG website.

    5. Community pharmacy campaign (Feb 2017). Birmingham CrossCity CCG organised a Public Health community pharmacy campaign promoting AMS. Delivered in collaboration with PH (Birmingham), local NHS Hospital Trusts and Birmingham Local Pharmaceutical Committee. We invited Birmingham South Central CCG and Sandwell and West Birmingham CCG to take part and support the campaign, in order to ensure we covered the whole Birmingham geography. The campaign was one of the six mandatory PH campaigns within the contract and comprised of a launch educational event with resources provided to be used in the following month to promote antimicrobial stewardship in the community. Resources included: A poster; ‘Antibiotic Guardian’ leaflets; Antibiotic Guardian Checklist’ (a reminder of the counselling points when dispensing antibiotics); ‘self-care guide to help treat your infection’, leaflets.

List any supporting partners or organisations worked with: Heart of England NHS Foundation Trust- especially Dr Das Pillay
University Hospitals Birmingham NHS Foundation Trust
Public Health (Birmingham)
Birmingham Local Pharmaceutical Committee
Birmingham South Central CCG
Sandwell and West Birmingham CCG

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Max 400 words: shows a 12% decline in total antibiotic prescribing (twelve month rolling total number of prescribed antibiotic items per STAR-PU) from June 2014 to September 2016. This decline was greater than that shown at national level. shows a 48% decline in twelve month rolling percentage of prescribed antibiotic items from cephalosporin, quinolone and co-amoxiclav. This decline was greater than that shown at national level. shows Antibiotic Guardians per 100,000 population per calendar year by CCGs. The highest count in England, with one of the highest rates in our region.

Recognition from PHE for number of healthcare professionals undertaking AMR module from TARGET toolkit The CCG had 169 responses 6 were nurses, 3 were pharmacists and 160 were GPs. This was in the time frame of 22/12/2014 – 13/06/2016. ( personal communication).

Awaiting feedback from Community Pharmacy campaign, so far 158 out of 354 pharmacies have provided feedback, deadline to provide feedback is 31st March 2017.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics? Max 400 words: 1. Clinical audit carried out in 100% of practices ( appropriate use of PAN Birmingham Primary Care antimicrobial guidelines)
2. Community Pharmacy Campaign: education and promotion of the ‘self-care guide to help treat your infection’, leaflet.
3. Education sessions with variety of healthcare professionals, supported by Consultant Microbiologist.

Key outcomes of project?: – Reduction in total number of prescribed antibiotic items per STAR-PU
– Reduction in percentage of prescribed antibiotic items from cephalosporin, quinolone and co-amoxiclav
– Increase in Antibiotic Guardians
– Educational impact was not measured with any quantifiable tool

How is the project to be developed in the future?: Having provided and resources on general AMR and AMS, this financial year we are focusing on key infection syndromes as these areas were highlighted as those needing further education or resources from the clinical audits which were completed in 2016 in general practice:
UTIs – correct diagnosis (promotion of PHE UTI leaflet and quick ref guide once update published)
UTIs – prophylaxis. A guide for the prophylaxis of recurrent UTIs has been produced in collaboration with Birmingham Antibiotic Advisory Group.
Acne – A need for local guidelines was identified and is planned for 2017/18
Azithromycin for respiratory conditions – A local guideline is in development.
We are also continuing the social media campaign and education events in 2017/18. Education will focus on the pending update to the antimicrobial guidelines and on diagnosis, treatment and prophylaxis of UTIs.


Abertawe Bro Morgannwg University Health Board

Name: Debra Woolley


Provide a brief overview of the project: ABMU Health Board has, for a number of years had the highest antibiotic prescribing in Wales and one of the highest across England and Wales combined. Prescribing data also shows wide variation in the prescribing of antibacterials.
The Medicines Management team had implemented a variety of antimicrobial stewardship improvement interventions over several years with limited success which culminated in the successful case for a funded Big Fight Campaign with a dedicated team of staff which commenced in early 2016. The team includes an antimicrobial pharmacist, infection control nurse and data analyst.
The Big Fight Campaign aims to improve patient outcomes and minimise the potential risks for increasing antibiotic resistance and C. difficile infection (CDi) through the development and implementation of a multidisciplinary programme through which the principles of prudent healthcare can be applied to improve antimicrobial stewardship in primary care.
Key stakeholders include:

  • Patients, carers and the public
    • Local authorities
    • Healthcare professionals (including GP practices, community pharmacies and care homes)
    • The Big Fight team were able to access a variety of support through the Bevan Commission Exemplar programme. This support enabled the team to take a ‘fresh look’ at implementation of improved antimicrobial stewardship in the community and develop a programme of work.Goal and targets include:
  • A reduction in overall antimicrobial prescribing in primary care across ABMU Health Board.
    • A reduction in variation of overall antimicrobial prescribing in primary care across ABMU Health Board.
    • That more key stakeholders across ABMU Health Board (including care home staff, GP practice staff and community pharmacy staff as a minimum):
    o understand the importance of and feel well informed and supported regarding antimicrobial stewardship.
    o have a good working knowledge of prevention and optimal management of C. difficile infection, re-infection and relapse.
    • A reduction in inappropriate GP appointments for self limiting viral infections across ABMU Health Board.
    • A reduction in overall C. difficile infection cases in non-inpatients across ABMU Health Board.


List any supporting partners or organisations worked with: The Big Fight Campaign is a Bevan Academy Exemplar and the Big Fight Conference was supported by 1000 lives

How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? The Big fight team have progressed a number of priority actions to improve antimicrobial stewardship in the community. Two such examples are reported as separate posters (‘GP Practices’ and ‘Enhanced Antimicrobial Stewardship in Care Homes’).


Others include:
• Engagement with key stakeholders
• Utilisation of the ABMU Health Board ‘GP Practice Prescribing Management Scheme’ to:
o Introduce non-clinical local Big Fight Campaign Managers in GP practices
o Facilitate GP Practice based antimicrobial stewardship improvement plans, clinical audit and patient engagement activities
• Production of a toolkit to support cluster based pharmacists and technicians to support antimicrobial stewardship activities.
• Provision of resources to support patient education and co-production.
• Analysis and dissemination of GP level prescribing data linked to the Welsh National Prescribing Indicators
• Inclusion of Antimicrobial Stewardship in GP Cluster Plans across the ABMU Health Board area
The Big Fight team undertook a stakeholder engagement event in November 2016 – ‘The Big Event’ was multidisciplinary with over 100 attendees (including from GP practices, care homes and patient representatives), which generated a wealth of ideas around engagement with the population of ABMU Health Board.


Cite 3 examples within the project which highlight promotion of the protection of antibiotics?

  • Messages will be co-produced with members of the public to educate and raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance. This will help to manage patient expectation/demand for antibiotics during GP consultations.• Education/support for members of the public about self care of self limiting infections will better enable them to choose well when seeking support i.e. community pharmacist advice. It is anticipated that this will also help to reduce inappropriate GP consultations.• Improved cost effectiveness of antimicrobial prescribing.• A reduction in harm e.g.
    o Likelihood of receiving an unnecessary prescription for antibiotics and associated potential for side effects, drug resistance etc
    o It is anticipated that improved antimicrobial stewardship in the community will minimise the potential risks of increasing antibiotic resistance and C.difficile infection• Enhance antimicrobial stewardship knowledge of GPs and other key stakeholders in the community e.g. practice nurses, Care Home staff etc which will:
    o Reduce variation of antimicrobial prescribing practice.
    o Improve communication, knowledge sharing and links between key stakeholders in the community regarding antimicrobial stewardship.
    o Improve quality of antimicrobial prescribing by Primary Care prescribers, through increased monitoring, audit and education.


Key outcomes of project?:

Primary Care:
Recent prescribing data shows that ABMU Health Board is reducing overall prescribing of antibacterials at a greater rate than the rest of Wales.

The rates of C difficile infection in the community has reduced more than other Welsh health Boards.

All GP Practices have a nominated (Antimicrobial Steward)

All GP practices have a local Big Fight Campaign Manager (Antimicrobial Champion), a non clinical member of the primary care team.

80% of practices participated in EAAD 2016
Infection prevention and Control
established and strengthened Big Fight and IPCN relationships with care home staff.
• Improved knowledge as evidenced by post session questionnaires
• Positive feedback evidenced through post-training evaluations.
• Self assessments completed by staff also demonstrate that they perceive they have increased knowledge after the training.
• Identified baseline knowledge amongst staff is variable requiring a flexible training approach


How is the project to be developed in the future?: This year the project will increase the engagement with other healthcare professionals such as community pharmacy, through a number of initiatives linked to the pharmacy contract. The public health campaign will focus on World Antimicrobial Awareness Week and EAAD. A multidisciplinary audit will look at delayed prescribing