Standing Advisory Committee on Antimicrobial Resistance (SACAR)
Antimicrobial posts may disappear
Hayley Wickens: need evidence base |
One-third of specialist antimicrobial pharmacy posts may disappear
when funding from the Department of Health for the clinical pharmacy
initiative
ends next year, according to Hayley Wickens, senior microbiology pharmacist,
St Mary’s Hospital, London. The DoH announced in June 2003 that £12m
was to be provided over three years to promote the prudent use of antibiotics
in acute trusts in England. Dr Wickens sent questionnaires to 183 acute
hospitals in April 2005 to find out what procedures were being implemented
to promote rational antimicrobial use. She presented results of a preliminary
analysis from the first 64 forms to be returned.
Over 90 per cent of trusts now have a specialist member of staff dealing
with antibiotic prescribing. Almost half of these are D grade pharmacists,
with E and C grade pharmacists, respectively, being the next largest
groups. The majority of posts are being funded under hospital pharmacy
initiative money. However, many posts are permanent despite being funded
by DoH money, and Dr Wickens suggested that trusts have put together
business cases to use the money while it is available, and then continue
the funding afterwards.
The responsibilities of antimicrobial pharmacists include monitoring
antibiotic use, writing evidence-based guidelines, education and clinical
work. Production of expenditure reports has almost doubled as a result
of the initiative. Reporting of defined daily doses (the preferred method
for reporting antibiotic use) has increased from less than 5 per cent
to over 30 per cent and prevalence studies are now performed in over
60 per cent of trusts. More than 80 per cent of trusts now have a formulary
and guidelines and twice as many trusts now have an intravenous-to-oral
switching policy.
“We need to build an evidence base for our activities,” said Dr
Wickens, explaining that it will otherwise be difficult to justify any
pharmacist role. She also highlighted the challenge of finding funding
to ensure that the one-third of posts that are not permanent are able
to continue next year. Guidelines are variable
Variation in clinical practice is a sign that guidelines are required,
said Richard Mayon-White, department of primary health care, University
of Oxford. Antimicrobial prescribing guidelines provide a better chance
that an effective treatment will be chosen and reduce inequality in
the provision of health care. They also force prescribers to gather
and use better information, which leads to clarity of decisions and
facilitates audit. There are, however, risks with guidelines because
evidence can be wrong or inadequate and the advice can be inflexible,
he suggested.
A literature review in 1999 found 11 papers that demonstrated a reduction
in antibiotic resistance could be achieved with guidelines. The National
Audit Office has cited three case studies where Clostridium difficile was controlled by antibiotic policies. The NAO also found that 90 per
cent of English hospitals had antimicrobial guidelines in 1999. More
recent surveys suggest that this figure may have increased to around
95 per cent.
A survey of 23 antimicrobial guidelines in the south east of England
found that policies range in size from two to 61 pages of A4, although
four had pocket-size summaries. Three hospitals published their policy
on their intranet and one used a laminated notice. “Thought is
given to how to disseminate the policies,” said Dr Mayon-White,
adding, “[so] they do not just sit on the shelf.” They are
typically one year old and are revised in a two-year cycle. Other strengths
of these guidelines included ingenuity in design, increasing use of electronic
versions, collaborations with community and neighbouring hospitals and
a good coverage of respiratory and urinary infections. Weaknesses included
that a few were out of date, thin on evidence, too large to carry around
and had variable content.
Dr Mayon-White commended a template for hospital antimicrobial guidelines
written by the Specialist Advisory Committee on Antimicrobial Resistance
(SACAR). This template was published in the July/August issue of Hospital
Pharmacist (2005;12:280).
With regard to national antimicrobial guidelines, Dr Mayon-White said
that some people opposed them, suggesting that “their organisms
are different so policies should be determined by local experience”.
He said that this does not seem to reflect reality.. He asked participants
if they would welcome a national co-ordinated evidence base for antimicrobial
prescribing. If this were to happen, there would be a literature search
and first draft produced. This would be sent to SACAR members and other
interested parties for consultation, leading to a consensus of the evidence
base. A team game
Prescribing is a team game, according to Peter Davey, professor in
pharmacoeconomics, University of Dundee. He said that there had been
a big shift in medical
education to recognise that prescribing is not just about pharmacology
and pharmaceuticals, but also attitudes, behaviour and team working. “In
the past we thought about prescribing as someone writing a prescription,
[but today] it is all about identifying who needs the drug, correctly
prescribing, dispensing and administering it, and monitoring the outcome,” he
said. He commented that whether the prescribing is independent or supplementary,
there needs to be a team looking at medicines and the patient journey. “We
need to establish the competencies and decide who will do what,” he
said.
Professor Davey said that health care had much to learn from the airline
industry. Research had shown that most crashes occurred as a result of
a failure of human interaction and communication, rather than a technical
problem. Another problem was that teams are often brought together for
just one shift, which also occurs in health care. Training in aviation
had also focused just on flight simulators, but now also covers interactions
with other members of the crew. One of the important skills, which is
now being taught to surgeons, is situation awareness. This is the ability
to gather and understand information and then anticipate future problems
and communicate these to colleagues. Other skills being taught include
decision-making, task management, leadership and communication.
Pharmacists focus more on drug issues than microbiological or clinical
outcomes, suggested Professor Davey, citing a systematic review of published
literature on interventions for patients receiving antibiotics. Interventions
by antimicrobial teams were more balanced, affecting microbiological
and clinical outcome to a greater degree. “In prescribing antimicrobials,
we need a team that has microbiology, clinical and pharmacy input,” said
Professor Davey. |
The
Pharmaceutical Journal