University of Birmingham

Provide a brief overview of your project?

Infections account for over 20% of global deaths and are particularly problematic in low and middle-income countries (LMICs).  Bacterial infections contribute significantly to this burden, killing approximately five million people annually.  The crisis of AMR means our options for controlling bacterial infections are narrowing, and it is important that we address this urgent problem.

Vaccines save millions of lives yearly and are a cost-effective approach to prevent infectious disease and their devastating sequelae.  By preventing disease, vaccination reduces the need to use antimicrobials and thus the opportunity for AMR to develop.  Whilst vaccines save lives, there are many infections against which there are no, or only sub-optimal, vaccines.  Historically, there has not been an umbrella organisation for specialists in bacterial vaccinology to come together to drive bacterial vaccine development forward.

To address this we have established BactiVac, a global network to help deliver new or better vaccines against bacterial infections in animals and humans, particularly LMIC-relevant diseases.  Since our inception in August 2017 we have grown to nearly 700 members across 63 countries, from academia, industry and other partners.  We have also attracted over £3.8 million of funding from the Global Challenges Research Fund, Medical Research Council, Biotechnology and Biological Sciences Research Council, Innovate UK and Department of Health & Social Care (DHSC).  Our aim is to provide support and advocacy for bacterial vaccine development, promote expertise-sharing to help deliver new vaccines and thus stop AMR from developing and/or prevent infections where AMR is already a problem.  To achieve this, BactiVac provides funding for catalyst pump-priming projects and training to foster new partnerships and encourage cross-collaboration between academic and industrial partners.  Through working with other stakeholders, such as local communities and Parliament, we promote the use and value of vaccines as solutions to the problems of infectious diseases and AMR.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. Developing the only network to accelerate the development of bacterial vaccines
   BactiVac has an inclusive ethos and welcomes membership applications from individuals with an interest in advancing bacterial vaccinology. The Network has recruited nearly 700 members across 63 countries since its launch in August 2017, with 39% based in LMIC countries and 11% in industry. BactiVac brings the bacterial vaccinology community together to work collaboratively, accelerating the development of bacterial vaccines.2. Awarding funding to generate new partnerships and support projects to make new and better vaccines against bacterial infections
   To date, BactiVac has funded 20 projects, awarding more than £1 million (see https://www.birmingham.ac.uk/research/activity/immunology-immunotherapy/research/bactivac/funded-work.aspx).  These include a WHO-led global consultation on gonococcal vaccine development and a research project on the generation of new vaccines against typhoid, two major pathogens where there is a high prevalence of AMR.BactiVac has successfully secured additional funding, including:
   •  £1 million from DHSC’s Global AMR Innovation Fund (GAMRIF), in January 2019 after Secretary of State for Health and Social Care Matt Hancock announced the UK’s 20-year vision and five-year (2019-2024) AMR national action plan.  This funding will support catalyst projects to develop new and better vaccines that directly address the issue of AMR (see https://www.birmingham.ac.uk/university/colleges/mds/news/2019/01/bactivac-dhsc-funding.aspx)
   •  £600k from the Industry Strategy Challenge Fund (ISCF) to support catalyst projects involving industry partners (see https://www.birmingham.ac.uk/research/activity/immunology-immunotherapy/research/bactivac/news/bactivac-receives-additional-funding-from-UK-Government’s-Industrial-Strategy-Challenge-Fund.aspx).

   3. Bringing people together through Annual Network Meetings
   BactiVac has held two highly successful Annual Network Meetings, which have both been oversubscribed (180 international delegates will be attending the March 2019 meeting).  Our meeting programmes include a line-up of world-leading international experts in bacterial vaccinology, offering their perspectives on the bacterial vaccine development pipeline (see https://www.birmingham.ac.uk/Documents/college-mds/immunology-immunotherapy/bactivac/Programme-2nd-Annual-Network-Meeting-20-21-March-2019.pdf for 2019 programme).  The Annual Network Meetings also offer fantastic opportunities for our members to network, knowledge share and to identify potential collaborators.

How is the project to be developed in the future?

BactiVac’s ambition is to continue building critical mass and influence.  We will achieve this by continuing to grow our membership, awarding further catalyst pump-priming project and training funds, hosting Annual Network Meetings, continuing to engage effectively with key stakeholders and advocating the importance of accelerating the development of bacterial vaccines and an alternative and important way of addressing the global AMR challenge.

London School of Hygiene and Tropical Medicine

Provide a brief overview of your project?

Antimicrobial resistance (AMR) is a public health threat and high rates of inappropriate antibiotic use contributes significantly to the problem, suggesting the need for enhanced antimicrobial stewardship programmes. Clinical diagnostics are laboratory tests that can guide antibiotic prescribing decisions and also play an important role in combating AMR. However, its application remains low and medical schools still have gaps in their diagnostics and AMR teaching content.  Innovative ways are needed to expand AMR and diagnostics training.
In response to this need, we organised a challenge contest using crowdsourcing methods to solicit clinical cases on diagnostics /AMR from the medical students and infectious disease fellows, physicians and other health professionals Crowdsourcing is a bottom-up approach that allows many individuals to attempt to solve a problem and then shares solutions with the public. The aim of the call was to encourage medical students, trainees, physicians, and others to write clinical cases to support AMR educational materials.
The call for participation was translated into the six official languages and disseminated through social media channels, partner organization’s mailing lists, and some in-person events. Banners and posters were also printed and distributed to create awareness about the contest. All cases received were screened for eligibility and sent to judges for review. Judging criteria include focus on diagnostics and AMR, relevance to medical teaching and capacity to enhance appropriate antibiotic use.
After judging three cases emerged as finalists, now published on Partners ID Images, an open access online library focused on infectious diseases. The finalist cases have been developed into an online learning module for physicians focused on AMR and the use of clinical diagnostics. They were also presented at an open symposium on AMR organized by the LSTHM International Diagnostics Centre.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Increase Public awareness on AMR:
The call for entries outlined the problem of AMR and the need for solutions. It was translated into six official WHO languages and disseminated globally using social media channels (including Facebook, Twitter and YouTube), partner organizations, professional association mailing lists, and in-person events. Links to a one-minute video and a website developed for the contest were shared as part of the call. The website received an average of 117 page views. Banners and posters were also printed and displayed in some hospitals and medical schools. The dissemination of this call for entries contributed to increased public awareness on AMR.

Emphasise use of clinical diagnostics to decrease unnecessary antibiotics use:
Our project focused on the use of clinical diagnostics in the management of resistant bacteria infections, which was one key criterion set for entries. Doing this was able to get people to think about the use diagnostics as a guide to choose of antibiotics in managing infections, which ultimately supports a more rational prescribing decision and appropriate use of antibiotics.  Also, the learning module developed as an output of our project is a form of educational antimicrobial stewardship aimed at increasing clinical diagnostics skills to decrease unnecessary and inappropriate antibiotic use.

Create open access AMR educational materials:
Our crowdsourcing project created educational materials on AMR freely available to the public. The three finalist cases have been published online at Partners ID images, which supports education and training on resistant infections. The cases have been integrated into an interactive open access learning module.

How is the project to be developed in the future?

This project demonstrates substantive and technical innovation. To the best of our knowledge, this is the first-time crowdsourcing methods was used to create educational materials to improve medical education focused on AMR and clinical diagnostics. The learning module has already been piloted at four townships and three villages and will be formally evaluated in a randomized controlled trial. In addition, we will organize a second challenge to continue collecting cases.

Boots UK Ltd

Provide a brief overview of your project?

The majority of people in long-term care facilities (LTCFs) frequently develop infections and are at increased risk from healthcare associated infection. Use of antibiotic prescribing data is essential to support improvement; currently this is not reported at a LTCF level. Additionally, this workforce needs to understand the risk from antimicrobial resistance and the importance of appropriate use of antibiotics in this vulnerable population.

Purpose: Identify antibiotic prescribing in residents in LTCFs across the UK, and potential gaps in knowledge and support for carers and residents when using antibiotics; and ultimately how pharmacy teams in the community can support residents and carers in LTCF settings.

Analysis of routine dispensing data captured by community pharmacy systems showed that almost 1 in 2 of 341,536 residents had ≥1 antibiotic prescription dispensed in the 12 month period.

A point prevalence survey conducted by 57 pharmacists during visits to LTCFs collected data for 17,909 residents in 644 LTCFs across the UK (November-December 2017). Mean proportion of residents on antibiotics on day of visit was: 6.3% England (536 LTCFs), 7.6% Northern Ireland (35 LTCFs), 8.6% Wales (10 LTCFs), 9.6% Scotland (63 LTCFs). The percentage of antibiotics prescribed for prophylactic use were 25.3%. Antibiotic related training was reported as being available for staff in 6.8% LTCFs, and 7.1% of LTCFs reported use of a catheter passport scheme. Pharmacists conducting the PPS intervened during the survey activity for 9.5% of antibiotic prescription events; 53.4% of interventions were clinical and 32.2% for administration.

There are opportunities for community pharmacy teams to improve antimicrobial stewardship, including through the delivery of workforce education. This innovative project was as a result of a collaborative approach, working with LTCFs to identify the extent of antibiotic use and opportunities to improve antimicrobial stewardship within these care settings.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

• Use of routine dispensing data combined with a point prevalence survey (PPS) has described antibiotic use in a large sample of LTCFs across the UK for the first time. Almost 40% of antibiotics are used to treat UTI, which are known to have a high risk drug-bug resistance in this vulnerable population, and are a known risk associated with blood stream infection
  • The workforce reported low levels of antimicrobial stewardship awareness and training, and this has identified the opportunity for community pharmacy teams to support workforce development
  • The use of PPS identified medication omissions for multiple reasons, such as the resident refusing to take the antibiotic, asleep at time of administration or because of problems with dosing schedules. There is an opportunity for pharmacy teams to optimise appropriate antibiotic use in this care setting, improving appropriate use of antibiotics and patient outcomes

How is the project to be developed in the future?

There is a clear opportunity for pharmacy teams to improve antimicrobial stewardship in LTCF settings, working collaboratively with care staff and other healthcare professionals. This supports delivery of the UK AMR National Action Plan ambitions to reduce drug resistant infections by 10% and reduce antibiotic use by 25% in the community by 2024, and the improvements identified within this project could inform the planning to deliver medicines optimisation within the NHS Long Term Plan.

University of Bristol

Provide a brief overview of your project?

The Farmer Action Group project was established in 2016 as a participatory, bottom-up project to reduce the use of and need for antimicrobials on UK dairy farms. Coordinated as a research project through the AMR Force at the University of Bristol and funded by AHDB Dairy and the Langford Trust, the Farmer Action Groups consisted of 30 diverse dairy farms united in their effort to reduce reliance on antimicrobials. Participant farms formed 5 groups spread across South West England who met together every few weeks to learn, improve and support one another to change practices around antimicrobial use (AMU). The outcome was a facilitated, farmer-led Action Plan for each hosting farm that committed to an array of practical solutions to reduce AMU. These Action Plans were revisited within a year and farmers evaluated how well their colleagues had done in completing them. As a result of this participatory project, farmers were empowered with new knowledge, so much so that they began pushing their veterinarians for more assistance in becoming antibiotic stewards! Seven farmers also participated in a knowledge exchange trip to the Netherlands which inspired them to implement further antibiotic reduction strategies on their farms. Farmers have since shared their learning with European counterparts at a series of international workshops as part of a wider European project called Eurodairy. Farmer Action Groups demonstrate that with the support of a facilitator and working within a participatory framework, farmers can co-create practical solutions to reduce reliance on antimicrobials and play a fundamental role in reducing AMR.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1. Twenty-seven of the 30 farms reduced or eliminated use of highest priority critically important antibiotics, despite veterinary prescription of these medicines during the time of the study (2016-2018). On average, each farm implemented more than half of the actions on their Action Plan in the first year, equating to an average of five different changes to practice per farm. Specific examples they gave were increasing use of anti-inflammatory drugs before reaching for antibiotics, discussing changes to treatment protocols with their veterinarians, improving the detection of mastitis and lameness, improving management of bedding areas and changes to calf housing and calf feeding protocols with the overall aim of reducing the need for antibiotics in the first place.
   2. Through participation in a bottom-up project, farmers were empowered to use their local knowledge in combination with newly acquired knowledge of the causes of AMR, which encouraged them to change practices to improve herd health and prevent disease. This had a knock-on effect on AMU and allowed them to farm without relying on antimicrobials – 50% of farms reduced their total AMU from year one to two. Farmers cited the group meetings, seeing and hearing from other farmers and the facilitated discussions on improving practices on farm as critical components in helping them change and become Antibiotic Guardians. They came to trust and rely on one another for ideas, and even termed the meetings ‘Antibiotics Anonymous’!
   3. The idea of Farmer Action Groups has taken flight in Australia and New Zealand and the model has been expanded to beef and sheep farmers focusing on grazing and profitability. Farmers from the project have spoken at numerous UK events such as industry shows, policy workshops, webinars and interviews with the BBC to share their experiences with the wider industry (see supporting material).

How is the project to be developed in the future?

The farms in the Farmer Action Groups are continuing to adapt and make changes to on-farm practices as a result of their interaction and development in the project. Many have gone on to discuss with their veterinarians about ways they can further reduce AMU and have disseminated the work they have done more widely throughout farming communities. Although the research funding has ended, there is a general desire from participants to continue the groups or to roll out the farmer-led model across the country. The research team has proposed further facilitation of similar groups to the project funders (the Agriculture and Horticulture Development Board) and other interested parties who have an interest in knowledge exchange in agriculture. The researchers are also working on establishing funding and support for facilitation across the UK so that more farmers and industry bodies may benefit. With new UK agricultural legislation being drafted, the role and value in facilitated, farmer-led approaches has attracted much attention from government, and both the researchers and farmers are active in influencing this new legislation. The main researcher is actively supporting international developments of these types of projects and plans to travel later this year to contribute to ongoing work in Australia and New Zealand, plus has collaborated with other organisations (the Food and Agricultural Organisation) to expand the reach of a farmer-led approach.

Gloucestershire LPC

Provide a brief overview of your project?

What do we aimed to do?
To increase community pharmacy staff’s capability, opportunity and motivation to provide self-care and adherence advice to patients / carers collecting antibiotics.

Why community pharmacy staff?
Community pharmacy staff have the opportunity to influence patients’ knowledge and behaviour around antibiotic use. All pharmacy staff are involved in an antibiotic prescription’s journey, from hand-in of an antibiotic prescription, through dispensing and finishing with hand-out of an antibiotic.

Why capability, opportunity and motivation?
The COM-B model postulates that in order for a behaviour to occur, a person needs to:
• be capable
• have the opportunity
• be motivated
…to perform the behaviour

Why provide adherence advice to patients / carers collecting antibiotics?
Patient non-adherence to antibiotic use may lead to treatment failure, re-infection, and bacterial resistance.

Why provide self-care advice to patients / carers collecting antibiotics?
Self-care can help patients get better more quickly and links to preventing future infections and therefore, reduces antibiotic use.

What has been developed?
Working with local community pharmacists, pharmacy users, behavioural researchers, information designers, experts in antimicrobial resistance, a community pharmacy campaign to Keep Antibiotics Working has been developed and piloted in Gloucestershire.
1. Educational webinar to give pharmacy staff the capability and motivation to provide self-care and adherence advice to patients / carers collecting antibiotics.
2. Antibiotic checklist and other reinforcing materials to give pharmacy staff the opportunity to provide self-care and adherence advice tailored to the individual patient and antibiotic.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Outcome one: increased capability and motivation of community pharmacy teams to provide adherence and self-care advice to patients/carers collecting antibiotics.
Gloucestershire community pharmacy staff reported that the educational webinar increased their understanding, specifically:
• Increased their understanding of the global impact of antibiotic resistance
• Given them a greater appreciation for their personal role in antibiotic use in the general population who visit their pharmacy
• Given them a greater understanding of the impact they can have on antibiotic use, and therefore antibiotic resistance, by improving the advice they give around antibiotic adherence and how to prevent infections in the future
• Increased their understanding of what advice they should be giving patients / customers about antibiotics
Community pharmacy staff reported that the educational webinar increased their confidence, commitment and intention to give antibiotic adherence and self-care advice.

Outcome two: increased opportunity of community pharmacy teams to provide adherence and self-care advice to patients/carers collecting antibiotics.
Over four weeks, twelve pharmacies in Gloucestershire completed over 900 Antibiotic Checklists, providing tailored advice to patients/carers around the antibiotics that had been prescribed. Pharmacy staff reported that the Antibiotic Checklist enabled them to have more conversations with the patients and facilitated antibiotic counselling.

Outcome three: educated patients on appropriate antibiotic use.
Patients/carers were followed up to see what they had understood, and then what they did with this information.
On follow-up, 80% (47/59) reported that they definitely would not keep antibiotics for future illnesses. As a result of the advice pharmacy staff had given them, as well as the reinforcing messages around the pharmacy, over 50% (30/59) now intended to return unused antibiotics to the pharmacy; 28/59 already did this.
The results of the follow-up after their course of antibiotics are pending.

How is the project to be developed in the future?

The research group are meeting at the end of March to decide how the project should be modified, shared and taken forward in the future. We will focus on how follow-up of patients/carers can be automated and feedback to pharmacies streamlined.

Scottish Universities Life Sciences Alliance (SULSA)

Provide a brief overview of your project:

SULSA is holding a two day conference on AMR (26/27 April; http://www.sulsa.ac.uk/amr/). The first day will showcase research that is tackling the challenges of AMR, and the second day is a policy day, and includes speakers such as the Chief Medical Officer in Scotland, representatives from funders of AMR research (the Wellcome Trust and MRC), clinicians and public health officials. One of SULSA’s main aims is to bring the Scottish life sciences research community together, and this conference will inform and coordinate fundamental and applied research activity on AMR within SULSA universities and other relevant organisations in Scotland. This conference is timely considering the UK AMR strategy is being refreshed this year.

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

1. We have a sold-out AMR conference of 150 researchers, clinicians, funders, government workers attending
2. We have 50 poster presentations showing research across all areas of AMR and antimicrobial stewardship
3. We are having breakout sessions to discuss topics such as: Speeding the Antibiotic Discovery Pipeline, clinical Considerations in AMR, A One Health Approach to Tackling AMR, Maximising Funding Opportunities for AMR Research, Diagnostics, and Public Health Considerations in Dealing with AMR.

How is the project to be developed in the future?:

We are funding a seed-funding grant call to promote collaboration of AMR researchers across Scotland, and to drive further innovations in AMR research. http://www.sulsa.ac.uk/seed-funding/

University of Leeds (Highly Commended – Antibiotic Guardian Awards 2018)

Provide a brief overview of your project:

Research project title: Student attitudes to rapid point-of-care diagnostics and the avoidance of antibiotic resistance.

My survey research (n=206) was three pronged and looked to:

1. Assess current knowledge of antibiotic utility and AMR in a student population
2. Determine existing attitudes towards antibiotic prescribing amongst students
3. To determine if point-of-care diagnostics will improve attitudes to antibiotic prescribing in a primary-care setting.

The most pertinent aim was to investigate whether the use of point-of-care diagnostics would improve attitudes to prescribing amongst ‘pester patients’ who idealise antibiotics as a ‘magic pill’ to help them get better. The outputs were to assess receptivity amongst this cohort and therefore develop recommendations for future public engagement techniques, and specific barriers to address for their successful roll-out and on-boarding.

I found that introduction of a diagnostic test would improve attitudes to prescribing and patient satisfaction: 56% of students agreed they would be happier leaving a consultation with no antibiotics (a 13% superiority achieved compared to feelings towards the existing diagnostic protocol), only 1% would remain unhappy.

My research uncovered that without understanding the wider advantage a diagnostic test confers in the fight against AMR, patients may express resistance or develop specific concerns such as the test deterring them from getting better, questioning why a doctor needs a test (do they not know what they are doing?), and ultimately deeming them unnecessary.

A set of recommendations which identified that the UK population are not homogeneous in their understanding of AMR and that specific sub-populations with very specific misconceptions exist, and tailored public engagement is therefore mandatory when rolling them out were developed.

https://longitudeprize.org/blog-post/have-we-truly-considered-barriers-point-care-testing.

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

The survey questions asked respondents key questions about AMR and antibiotic utility in order to generate a ‘total knowledge score of antibiotics’. We fed this back to respondents and many were alarmed that they couldn’t identify simple indications e.g. ‘antibiotics cannot treat viruses or a common cold’. We received feedback that this initiated a behaviour change on interaction with their HCP.

I conducted a pilot focus group and through this, healthy discussion around what AMR is and how it is already affecting us was sparked. In addition, whilst handing out the surveys, my colleague and i engaged with students discussing the implications of AMR. I then delivered a research presentation to peers, discussing findings and promoting the importance of AMR as a public health matter. Students commented that they don’t feel AMR is prioritised compared to other public health matters such as cancer or flu jabs, my research identified ways to make AMR more relevant to the average student e.g.  consistently pairing it with sexual health such as super gonorrhoea and AMR.

Recommendations developed cite the importance and potential for point-of-care diagnostics to be introduced and suggest they could reduce the number of patients who place pressure on their GP to describe. This will be used as an evidence base for submission of a point-of-care diagnostic being developed at The University of Leeds to The Medical Research Council and should it be accepted, will ultimately lead to preservation of antibiotics.

How is the project to be developed in the future?:

Another survey iteration/ focus groups with HCPs and another group such as children. All of these will produce recommendations for submission to the Medical Research Council to support the research question of how receptive the general public are to point of care diagnostics.

University College London Hospitals (Winner - Antibiotic Guardian Awards 2018)

Provide a brief overview of your project:

Antibiotic prescribing behaviour in acute care is linked to social norms and beliefs.  The views of clinicians have been described in the literature, however despite their key role in organisational leadership, change management and finance, there is a paucity of research on the views of hospital managers on antibiotic stewardship.

This year-long Healthcare Infection Society (HIS) funded qualitative research project, led by a microbiology registrar at University College Hospital London (UCLH)  during her Ayliffe infection control fellowship, is the first multi-disciplinary British stewardship study to have included hospital managers amongst its participants.

The objective of the study was to analyse what staff at UCLH understand by the term stewardship, what their barriers and facilitators are to doing it in order to design sustainable behaviour change interventions from board to ward.

The research was designed and enhanced iteratively in collaboration with interdisciplinary team including a psychologist/qualitative researcher at the UCL Centre for Behaviour Change, UCL School of Pharmacy with public and patient involvement.

39 interviews were conducted across 5 in-patient sites across UCLH including managers, senior doctors, junior doctors, pharmacists and nurses.

Thematic analysis was applied to the data to extract key themes using an abductive approach.  Themes were mapped to behaviour change domains using the Theoretical Domains Framework.

Facilitators included stewardship metrics, strong clinical leadership, an expected new IT system with point of care e-prescribing and multi-disciplinary pharmacist led education.

Understanding of the rationale for antibiotic use was high, however staff were less familiar with the term stewardship and inter-disciplinary contributions.  Understanding was highest amongst pharmacists and areas visited frequently by infection staff.  Managers reported spending little time discussing stewardship as, perceiving it as an ‘operational’ not ‘strategic’ issue and not enough of a burning platform.

Barriers included antibiotic knowledge, fear of under treating sepsis, diagnostics and inaccessibility of electronic prescribing systems.

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

1) Staff engagement – taking the time to recruit and conduct one to one face to face depth interviews with a range of doctors, nurses, pharmacist and managers at each site and at all levels including executive board members has provided detailed insight into how staff genuinely perceive the threat of antibiotic resistance and the need for stewardship and where it sits in amongst other priorities.  Researchers would travel to participants place of work to conduct interviews and this willingness to go to busy clinical staff has resulted in a high degree of staff engagement on stewardship.  Involvement of the executive board may be particularly helpful ensuring support for future work.

2) Local behavioural analysis – by undertaking a local analysis using behavioural science it will be possible to map evidence based stewardship interventions to our trust in order to enhance their success.

3) Dissemination of data for action – Data has been presented to the research team, to our local stewardship strategy group and as an oral presentation at the national BSAC Spring Conference and will be presented at infection departmental clinical governance meetings in order to inform local and national stewardship strategies.  The recent establishment of the multi-disciplinary UCLH antimicrobial stewardship strategy group and the appointment of 2 new consultants with dedicated stewardship PA time provide an opportunity for this data to become embedded in our clinical workflow.

How is the project to be developed in the future?:

Our data suggests that sepsis criteria, 1 hour CQUIN sepsis targets and fear of missing sepsis are key barriers to antimicrobial stewardship at UCLH, particularly in acute care settings.  National data also suggests a need for more research and intervention design in acute care settings.

According to the ESPAUR report, only 9.2% of 72 hour ‘review and revise’ decisions were to stop antibiotics, most were to continue.  This has prompted the design of multimodal behaviour change interventions such as the ARK study, a 5 year NIHR funded research study which aims to improve ‘review and revise’ decision making at 72 hours.

Consequently, research has already begun on phase 2 of the project which will involve interviewing doctors, nurses and pharmacists in ED and AMU on their views on interventions that will help them improve their stewardship.  This will enable the local design of evidence based stewardship interventions to pilot based on behaviour change science.

This is believed to be one of few qualitative research studies on stewardship in a British ED setting and has potential to inform behaviour change strategies targeting the 12-24 hour antibiotic review point, an area of increased national attention.

University of the Punjab

Provide a brief overview of your project:

In the unending battle of microbes against antimicrobials, the microbes appear to be winning, and the pipeline of drugs is near to the end. Antimicrobial resistance (AMR) is a rising threat for community health which has appealed the attention of international and national organizations like WHO, SHEA, IDSA etc. For only the fourth time in history, on 21st September 2016, AMR topic took central juncture at a United Nations General Assembly (UNGA) high level convention to progress towards the 2030 SDGs. I am working on a mixed methodological study desig in which quantitative together with qualitative

studies are wielded to evaluate the factors of AMR in Pakistan. For qualitative study, semi-structured interviews are conducted of the physicians, pharmacist and patients to highlight determinants of AMR. In the quantitative studies, first a survey was conducted to evaluate the number of antimicrobial stewardship practices. Another quantitative point prevalence survey of antimicrobial use (AMU) and health care associated infections was conducted among the representative sample of all in-patient wards of private, public and charity hospitals by using the standard methodology employed by ECDC and ESAC.

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

In Pakistan, there are no local guidelines for antibiotic use. These studies are sort of situational analysis to give a baseline. By doing PPS, we came to know that prophylactic use of ceftrioxone, metronidazole and ciprofloxacin is very high. Second, knowledge of pharmacists and physicians is very poor about ASP. Lastly, there are very few antimicrobial stewardship activities taking place in hospitals.

How is the project to be developed in the future?:

Findings from this situation analysis (PPS) will provide an opportunity to identify interventions to be implemented through antimicrobial stewardship programs in hospital. This will yield important information to convince the policy-makers and budget holders to invest in AMR prevention and containment measures and serves as a baseline against which improvements may be monitored.Based on the situation analysis, the key gaps in infrastructure and HR skills will also be identified. I’ll work to establish technical working groups and sub-groups in order to push this forward. Political support from the government leadership is critical and is critical to ensure allocation of the budget, so I’ll not forget to involve the financial advisors in the process. Partnerships with behaviour change leaders and thought-influencers are important through the involvement of faith based organizationa (FBO)  as well as civil society organizations (CSO). The stake holder meetings with different partners will be conducted to brainstorm.