Journal of Hospital Infection (2007) 65(S2) 82–84

Available online at www.sciencedirect.com

www.elsevierhealth.com/journals/jhin

Achieving prudence in the prescribing ofantimicrobials using clinical pharmacists inEnglish acute hospitals

Jonathan Cooke1*

R&D, and Pharmacy and Medicines Management, University Hospital of South Manchester NHSFoundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK

KEYWORDS Antibacterials; Antimicrobials; Antibiotics; Antibiotic pharmacist; Antibiotic policy; Antibiotic manage-ment; Pharmacist; Prescribing; Hospitals; Interventions; Monitoring

Background

The relationship between the use of antimicrobialsand the development of resistance is complex.Considerable variation in the intensity of usageof antimicrobials in outpatient practice has beenobserved across Europe1 and higher rates ofantimicrobial resistance have been noted in highconsuming countries, probably related to thehigher consumption in southern and eastern Europethan in northern Europe.

There is considerable evidence of increasing useof antimicrobials in hospitals worldwide2,3 andconcern is constantly highlighted to the extentof sub-optimal and inappropriate prescribing anduse.4,5 Macrolide resistance of Streptococcus pneu-moniae is becoming a problem, as is Escherichiacoli resistance to fluroquinolones.6

In order to address problems of antimicrobialuse in general and resistance in particular the De-partment of Health (DH) established the SpecialistAdvisory Committee on Antimicrobial Resistance(SACAR) in 2001 as an independent, UK-wideadvisory committee to provide expert scientific

* J. Cooke. Tel: +44 161 291 4195; fax: +44 161 291 2285.E-mail: jonathan.cooke@smtr.nhs.uk orjonathan.cooke@manchester.ac.uk (J. Cooke).

advice on resistance issues arising from medical,veterinary and agricultural use of antimicrobials.7

A number of studies had shown the value ofclinical pharmacists in optimising the rationaluse of medicines within hospitals.8 Others havedemonstrated the value of optimising the use ofantimicrobials through promotion of a formulary,early switching to oral agents and close liaisonwith microbiology.9 A systematic review of studiesthat aimed to evaluate interventions aimed toimprove the use of antimicrobials in hospitalsshowed that the majority of evaluations usedfundamentally flawed methodology. Furthermorethere was limited evidence of improvement overtime and it was felt that these problems could beresolved if researchers and referees of protocols ormanuscripts implemented the Cochrane EffectivePractice and Organisation of Care Group (EPOC)methodology.10

In order to promote the prudent antimicrobialprescribing in hospitals and to develop a databaseof antimicrobial usage in hospitals the Departmentof Health funded an initiative to develop, overa three-year period, enhanced hospital clinicalpharmacy activities. This was intended to addressthe rational, safe and cost-effective use of antimi-crobials in hospitals and develop a collaborative

1 The author is Chair of the Human Prescribing sub-group of the Specialist Advisory Committee on Antimicrobial Resistance(SACAR).

0195-6701/$ - see front matter © 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Towards prudence in prescribing antimicrobials using clinical pharmacists in English acute hospitals 83

approach to share information on antimicrobialusage.11

The aim of the initiative was to improvethe quality of prescribing, which would benefitboth patients and clinicians in the NHS, andbe an incentive to change practice. It wasrecognised that any associated cost savings wouldbe important and would be of particular interestto ministers and managers investing in this work.

Funding was allocated through primary caretrusts (PCTs) for trust chief pharmacists in Englishacute hospitals to secure and develop plansto support this programme. The funding wasdesigned to facilitate the development of clinicalpharmacy services and to provide a focus onantimicrobial management. It was expected thathospital pharmacies would use this opportunity toextend clinical pharmacy services to areas of highantimicrobial use and seeking to meet identifiedlocal issues.12

This would also facilitate a focus on key areassuch as antimicrobial use in surgical prophylaxis,antimicrobial use in children, and infectioncontrol. Action was expected to be taken toensure hospital antibiotic policies were in line withcurrent best practice and were evidence-based.This was expected to take place through existinggroups such as Drugs and Therapeutic committees.

The programme encouraged data collection ofantimicrobial usage in hospitals to supplementexisting data on primary care antimicrobial use.A complete database set would be very useful tomonitor use, identify areas of different use and tolink to resistance surveillance.

What has been achieved?

The Prescribing sub-group of SACAR has supportedthe programme in a number of ways.

A UK template for hospital antimicrobial guide-lines has been developed and promulgated. Thisproposes that hospitals should develop an antimi-crobial strategy with a list of available agents,regimens for treatment of common infections,guidelines for prophylaxis and methods for auditingthe appropriate use of antimicrobials. Methods forhospitals to calculate antimicrobial use have alsobeen recommended.13

There have been two National SACAR confer-ences in 2004 and 2005 and another in 2006.In a number of health regions there have beengroups of antimicrobial pharmacy staff establishedthat have shared data and techniques. Many ofthese have been multidisciplinary involving micro-biologists and clinicians as well as pharmacists.14

The regional offices of the Health Protection

Agency (HPA) have also been encouraging suchcollaboration.

The United Kingdom Clinical Pharmacy Associa-tion (UKCPA) has a specialist interest group thathas an electronic message board for subscriberswhere daily questions and answers are exchangedby pharmacy practitioners.15

UKCPA has also run a number of national coursesand regional courses in association with the BritishSociety for Antimicrobial Chemotherapy (BSAC).16

How has the programme beenmonitored?

It was initially left to Strategic Health Authorities(SHA) to manage the performance of this initiative.However the variable levels of pharmaceuticalsupport at SHA level and a number of changes inthe DH meant that this was not widely undertakenor reported.

The Healthcare Commission recently looked atthe programme as part of an annual audit of stan-dards of medicines management in NHS hospitalsand had sought information on, amongst otherthings, resources received and allocated to anti-microbial prescribing and processes introduced inorder to support the prudent prescribing of anti-microbials.17

A national report has shown heterogeneity in thelevel of antimicrobial management in 173 acutehospitals in England.18 It was observed thathospitals have generally used the funding partiallyto support a pharmacy post. The allocationwas distributed over a period of three yearswhich began in June 2003. In Autumn 2005hospitals reported having received £7.1 million,but 12 hospitals (6.9%) reported receiving nofunding [Sonander J, Personal communication].

The hospitals reported that they had an averageof 0.54 staff members working on antimicrobialusage. These staff have worked across thehospital to develop prescribing guidelines forclinical indications (in 94%) and surgical prophylaxis(in 95%). Close liaison with microbiologists toundertake audits looking at emergence of problemorganisms occurred in 76% of hospitals, and 63%linked this to prescribing practices.

Point prevalence audits of the use of antimi-crobials in individual patients in a hospital wereundertaken in 63% of cases. Hospitals reportedusing defined daily dose (DDD) methodology in 42%of cases whilst 85% reported auditing by cost.

These criteria were used to assess the level ofantimicrobial management in each hospital. Thushospitals were assessed according to their progress

84 J. Cooke

0

20

40

60

80

1 2 3 4 5Score

Ac

ute

tru

sts

Figure 1. Progress on managing antimicrobial prescribingacute trusts in England, 2005 (Healthcare Commission, Acutehospital portfolio Medicines management).

with strategy, guidelines and audits by scoring ona scale of 1 (little activity) to 5 (considerableactivity).

The distribution of these scores across all 173acute hospitals is shown in Figure 1.

An independent survey showed that the majorityof hospitals have used the funding to employ staff,although most of the new posts are part-timeor combined with other responsibilities.19 Mostof the of the antimicrobial specialist staff arepharmacists and many have specialist postgraduatequalifications. Pharmacy activities have facilitatedthe development and review of evidence-basedantimicrobial prescribing guidelines, provision ofantimicrobial education programmes to all clinicalstaff, provision of an advisory service to clinicians,and reporting of antimicrobial use. A number ofhospitals have also noticed considerable cost sav-ings in their use of antimicrobials.

With the DH three-year funding stream havingcome to an end, there has been concern thatthis initiative might not continue. There is muchevidence that these posts have become widelyestablished within the country, however up toa third of posts that have been created using thefunding are liable to disappear at the end of thethree-year period; the impact of this loss has yetto be evaluated.

Conclusion

This programme has enabled a consistent approachto the management of antimicrobials to bepromoted across acute hospitals in England. Thefunding has had a demonstrable impact on theactivities of hospital pharmacy departments inmonitoring and controlling the use of antimicro-bials. The Healthcare Commission AHP audits haveidentified prudent antimicrobial management asone of a number of key indicators for optimalmedicines management in acute hospitals.

References

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16. British Society for Antimicrobial Chemotherapy. PastEvents.

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18. Healthcare Commission, Acute hospital portfolioMedicines management 2005/2006. Annual health checkMedicines management indicators and scoring.

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