Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use

This guideline covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.

# What is this guideline about and who is it for?

# Purpose of this guideline
The purpose of this guideline is to provide good practice recommendations on systems and processes for the effective use of antimicrobials.

# Audience for this guideline
Health and social care practitioners (a term used to define the wider care team of hospital staff , community matrons and case managers, GPs, dentists, podiatrists, pharmacists and community nurses , domiciliary care workers and care home staff , social workers and case managers).
Organisations commissioning (for example, clinical commissioning groups or local authorities), providing or supporting the provision of care (for example, national or professional bodies, directors of public health, health and wellbeing boards, healthcare trusts and locum agencies).
Adults, young people and children (including neonates) using antimicrobials or those caring for these groups. This includes people and organisations involved with the prescribing and management of antimicrobials in health and social care settings.
The guideline may also be relevant to individual people and organisations delivering nonNHS healthcare services, and to other devolved administrations.
It is anticipated that health and social care providers and commissioners of services will need to work together to ensure that patients benefit from the good practice recommendations in this guideline.

# Scope of this guideline
The guideline covers the effective use of antimicrobials as part of all publicly funded health and social care commissioned or provided by NHS organisations, local authorities (in England), independent organisations or independent contractors.
The guideline may also be relevant to care delivered by nonNHS healthcare services, and to other devolved administrations.
The guideline does not cover:
specific clinical conditions (although some evidence identified included patients with a specific infection such as community acquired pneumonia)
named medicines
public health awareness of antimicrobial resistance
research into new antimicrobials
immunisation and vaccination
antimicrobial household cleaning products
antimicrobial use in animals
hand hygiene, decolonisation and infection prevention and control measures
medicines adherence, except where there are specific issues for health and social care practitioners to address relating to antimicrobials
access to medicines, including local decisionmaking for medicines not included on local formularies
medicines shortages, including supply issues and discontinued medicines
prescription charges
waste medicines.
All NICE guidelines are developed in accordance with the NICE equality scheme.# Person-centred care
This guideline offers best practice advice on the effective use of antimicrobial medicines.
Patients and health professionals have rights and responsibilities as set out in the NHS Constitution for England  all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their health professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. If it is clear that the child or young person fully understands the treatment and does not want their family or carers to be involved, they can give their own consent. Health professionals should follow the Department of Health's advice on consent. If a person does not have capacity to make decisions, health and social care practitioners should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
NICE has produced guidance on the components of good patient experience in adult NHS services. All health professionals should follow the recommendations in NICE's guideline on patient experience in adult NHS services. In addition, all health and social care practitioners working with people using adult NHS mental health services should follow the recommendations in NICE's guideline on service user experience in adult mental health. If a young person is moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people. Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people and diagnosis and management should be reviewed throughout the transition process. There should be clarity about who is the lead clinician to ensure continuity of care.# Recommendations
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See how we develop NICE guidelines for more details.
This guideline should be read in conjunction with NICE's guideline on antimicrobial stewardship: changing risk-related behaviours in the general population and the NICE guidance on managing common infections.

# Terms used in this guideline

## Antimicrobial stewardship
The term 'antimicrobial stewardship' is defined as 'an organisational or healthcaresystemwide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness'.

## Antimicrobial resistance
The term 'antimicrobial resistance' is defined as the 'loss of effectiveness of any antiinfective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines'.

## Antimicrobials and antimicrobial medicines
The term 'antimicrobials' and 'antimicrobial medicines' includes all antiinfective therapies, (antiviral, antifungal, antibacterial and antiparasitic medicines) and all formulations (oral, parenteral and topical agents).

## Organisations
The term 'organisations' (also known as the 'service') is used to include all commissioners (clinical commissioning groups and local authorities) and providers (hospitals, GPs, outofhours services, dentists and social enterprises) of health or social care services, unless specified otherwise. Occasionally, in order to make a recommendation more specific to the intended care setting, the setting is specified; for example, the recommendation will state 'hospital'.

## Health and social care practitioners
The term 'health and social care practitioners' is used to define the wider care team, including but not limited to, case managers, care coordinators, GPs, hospital doctors, microbiologists, pharmacists, nurses and social workers.

# All antimicrobials

## Recommendations for organisations (commissioners and providers)
Commissioners should ensure that antimicrobial stewardship operates across all care settings as part of an antimicrobial stewardship programme.
Establish an antimicrobial stewardship programme, taking account of the resources needed to support antimicrobial stewardship across all care settings.
Consider including the following in an antimicrobial stewardship programme:
monitoring and evaluating antimicrobial prescribing and how this relates to local resistance patterns
providing regular feedback to individual prescribers in all care settings about:
their antimicrobial prescribing, for example, by using professional regulatory numbers for prescribing as well as prescriber (cost centre) codes
patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable lifethreatening infections, infections with Clostridium difficile or adverse drug reactions such as anaphylaxis
providing education and training to health and social care practitioners about antimicrobial stewardship and antimicrobial resistance
integrating audit into existing quality improvement programmes.
Ensure that roles, responsibilities and accountabilities are clearly defined within an antimicrobial stewardship programme.
Involve lead health and social care practitioners in establishing processes for developing, reviewing, updating and implementing local antimicrobial guidelines in line with national guidance and informed by local prescribing data and resistance patterns.
Consider developing systems and processes for providing regular updates (at least every year) to individual prescribers and prescribing leads on:
individual prescribing benchmarked against local and national antimicrobial prescribing rates and trends
local and national antimicrobial resistance rates and trends
patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable lifethreatening infections, infections with C. difficile or adverse drug reactions such as anaphylaxis.
Consider developing systems and processes for identifying and reviewing whether hospital admissions are linked to previous prescribing decisions in patients with potentially avoidable infections (for example, Escherichia coli bacteraemias, mastoiditis, pyelonephritis, empyema, quinsy or brain abscess).
Organisations establishing antimicrobial stewardship teams should ensure that the team has core members (including an antimicrobial pharmacist and a medical microbiologist) and can co-opt additional members depending on the care setting and the antimicrobial issue being considered.
Support antimicrobial stewardship teams, by developing processes that promote antimicrobial stewardship or by allocating resources, to:
review prescribing and resistance data and identify ways of feeding this information back to prescribers in all care settings
promote education for prescribers in all care settings
assist the local formulary decisionmaking group with recommendations about new antimicrobials
update local formulary and prescribing guidance
work with prescribers to explore the reasons for very high, increasing or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in local (where available) or national guidelines
provide feedback and advice to prescribers who prescribe antimicrobials outside of local guidelines when it is not justified.

## Antimicrobial stewardship interventions
Consider using the following antimicrobial stewardship interventions:
review of prescribing by antimicrobial stewardship teams to explore the reasons for increasing, very high or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in local (where available) or national guidelines
promotion of antimicrobials recommended in local (where available) or national guidelines
IT or decision support systems
educationbased programmes for health and social care practitioners, (for example, academic detailing, clinical education or educational outreach).
Consider providing IT or decision support systems that prescribers can use to decide:
whether to prescribe an antimicrobial or not, particularly when antimicrobials are frequently prescribed for a condition but may not be the best option
whether alternatives to immediate antimicrobial prescribing may be appropriate (for example, backup  prescribing or early review if concerns arise).
Consider developing systems and processes to ensure that the following information is provided when a patient's care is transferred to another care setting:
information about current or recent antimicrobial use
information about when a current antimicrobial course should be reviewed
information about who a patient should contact, and when, if they have concerns about infection.
Consider prioritising the monitoring of antimicrobial resistance, to support antimicrobial stewardship across all care settings, taking into account the resources and programmes needed.
Consider supplying antimicrobials in pack sizes that correspond to local (where available) and national guidelines on course lengths.
Consider evaluating the effectiveness of antimicrobial stewardship interventions by reviewing rates and trends of antimicrobial prescribing and resistance.

## Communication
Encourage and support prescribers only to prescribe antimicrobials when this is clinically appropriate.
Encourage health and social care practitioners across all care settings to work together to support antimicrobial stewardship by:
communicating and sharing consistent messages about antimicrobial use
sharing learning and experiences about antimicrobial resistance and stewardship
referring appropriately between services without raising expectations that antimicrobials will subsequently be prescribed.
Consider developing local networks across all care settings to communicate information and share learning on:
antimicrobial prescribing
antimicrobial resistance
patient safety incidents.
Consider developing local systems and processes for peer review of prescribing. Encourage an open and transparent culture that allows health professionals to question antimicrobial prescribing practices of colleagues when these are not in line with local (where available) or national guidelines and no reason is documented.
Encourage senior health professionals to promote antimicrobial stewardship within their teams, recognising the influence that senior prescribers can have on prescribing practices of colleagues.
Raise awareness of current local guidelines on antimicrobial prescribing among all prescribers, providing updates if the guidelines change.

## Laboratory testing
Ensure that laboratory testing and the order in which the susceptibility of organisms to antimicrobials is reported is in line with:
national and local treatment guidelines
the choice of antimicrobial in the local formulary
the priorities of medicines management and antimicrobial stewardship teams.

## Recommendations for prescribers and other health and social care practitioners
Health and social care practitioners should support the implementation of local antimicrobial guidelines and recognise their importance for antimicrobial stewardship.

## Recommendations for prescribers
When prescribing antimicrobials, prescribers should follow local (where available) or national guidelines on:
prescribing the shortest effective course
the most appropriate dose
route of administration.
When deciding whether or not to prescribe an antimicrobial, take into account the risk of antimicrobial resistance for individual patients and the population as a whole.
When prescribing any antimicrobial, undertake a clinical assessment and document the clinical diagnosis (including symptoms) in the patient's record and clinical management plan.
For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available.
For patients in primary care who have recurrent or persistent infections, consider taking microbiological samples when prescribing an antimicrobial and review the prescription when the results are available.
For patients who have nonsevere infections, consider taking microbiological samples before making a decision about prescribing an antimicrobial, providing it is safe to withhold treatment until the results are available.
Consider pointofcare testing in primary care for patients with suspected lower respiratory tract infections as described in the NICE guideline on pneumonia in adults.
Prescribers should take time to discuss with the patient and/or their family members or carers (as appropriate):
the likely nature of the condition
why prescribing an antimicrobial may not be the best option
alternative options to prescribing an antimicrobial
their views on antimicrobials, taking into account their priorities or concerns for their current illness and whether they want or expect an antimicrobial
the benefits and harms of immediate antimicrobial prescribing
what they should do if their condition deteriorates (safety netting advice) or they have problems as a result of treatment
whether they need any written information about their medicines and any possible outcomes.
When an antimicrobial is a treatment option, document in the patient's records (electronically wherever possible):
the reason for prescribing, or not prescribing, an antimicrobial
the plan of care as discussed with the patient, their family member or carer (as appropriate), including the planned duration of any treatment.
Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a selflimiting condition.
If immediate antimicrobial prescribing is not the most appropriate option, discuss with the patient and/or their family members or carers (as appropriate) other options such as:
selfcare with overthecounter preparations
backup (delayed) prescribing
-ther nonpharmacological interventions, for example, draining the site of infection.
When a decision to prescribe an antimicrobial has been made, take into account the benefits and harms for an individual patient associated with the particular antimicrobial, including:
possible interactions with other medicines or any food and drink
the patient's other illnesses, for example, the need for dose adjustment in a patient with renal impairment
any drug allergies (see the NICE guideline on drug allergy; these should be documented in the patient's record)
the risk of selection for organisms causing healthcareassociated infections, for example, C. difficile.
When prescribing is outside local (where available) or national guidelines, document in the patient's records the reasons for the decision.
Do not issue repeat prescriptions for antimicrobials unless needed for a particular clinical condition or indication. Avoid issuing repeat prescriptions for longer than 6 months without review and ensure adequate monitoring for individual patients to reduce adverse drug reactions and to check whether continuing an antimicrobial is really needed.
Use an intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines for a patient who needs an empirical intravenous antimicrobial for a suspected infection but has no confirmed diagnosis.
Consider reviewing intravenous antimicrobial prescriptions at 4872 hours in all health and care settings (including community and outpatient services). Include response to treatment and microbiological results in any review, to determine if the antimicrobial needs to be continued and, if so, whether it can be switched to an oral antimicrobial.

# New antimicrobials

## Recommendations for organisations (commissioners and providers)
Consider establishing processes for reviewing national horizon scanning to plan for the release of new antimicrobials.
Consider using an existing local decisionmaking group (for example, a drug and therapeutics committee, area prescribing committee or local formulary decisionmaking group) to consider the introduction of new antimicrobials locally. The group should include representatives from different care settings and other local organisations to minimise the time to approval.
Consider using multiple approaches to support the introduction of a new antimicrobial, including:
electronic alerts to notify prescribers about the antimicrobial
prescribing guidance about when and where to use the antimicrobial in practice
issuing new or updated formulary guidelines and antimicrobial prescribing guidelines
peer advocacy and advice from other prescribers
providing education or informal teaching on ward rounds
shared risk management strategies for antimicrobials that are potentially useful but may be associated with patient safety incidents.
Once a new antimicrobial has been approved for local use, organisations should consider ongoing monitoring by:
conducting an antimicrobial use review (reviewing whether prescribing is appropriate and in line with the diagnosis and local  and national guidelines)
costing the use of the new antimicrobial
reviewing the use of nonformulary antimicrobial prescribing
evaluating local prescribing and resistance patterns
reviewing clinical outcomes such as response to treatment, treatment rates, emerging safety issues, tolerability and length of hospital stay.

## Recommendations for local decision-making groups
Consider coopting members with appropriate expertise in antimicrobial stewardship when considering whether to approve the introduction of a new antimicrobial locally; this may include those involved in the antimicrobial stewardship team (see also recommendation 1.1.8).
Ensure that local formularies, prescribing guidelines and care pathways are updated when new antimicrobials are approved for use.
When evaluating a new antimicrobial for local use and for inclusion in the local formulary, take into account:
the need for the new antimicrobial
its clinical effectiveness
the population in which it will be used
the specific organisms or conditions for which it will be used
dose, dose frequency, formulation and route of administration
likely tolerability and adherence
any drug interactions, contraindications or cautions
local rates and trends of resistance
whether use should be restricted and, if so, how use will be monitored
any additional monitoring needed
any urgent clinical need for the new antimicrobial
any plans for introducing the new antimicrobial.
Local decisionmaking groups should assess the benefits and risks of restricting access to a new antimicrobial.
If access to a new antimicrobial is restricted:
document the rationale for and the nature of the restriction, and ensure that this information is publicly available
review the restriction regularly to determine that it is still appropriate.
Ensure that there is a plan for the timely introduction, adoption and diffusion of a new antimicrobial when this has been recommended for use.
Discuss with commissioners early in the approval process if funding concerns for a new antimicrobial are likely to cause delay in its introduction, adoption and diffusion.
Indicate where prescribers can find accurate, evidencebased and uptodate information about the new antimicrobial, such as the:
British National Formulary (BNF)
British National Formulary for Children (BNFC)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMA)
Medicines and Healthcare products Regulatory Agency (MHRA).# Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

# Reducing antimicrobial resistance
What interventions, systems and processes are effective and cost effective in reducing antimicrobial resistance without causing harm to patients?
Recommendation
One or more randomised controlled trials should be undertaken to determine whether short versus longer courses of antimicrobials, directly administered (or observed) therapy, continuous versus intermittent therapy and inhaled antimicrobials reduce the emergence of antimicrobial resistance and maintain patient outcomes compared with usual care in the UK setting.

# Decision-making
What interventions, systems and processes are effective and cost effective in changing health and social care practitioners' decisionmaking and ensuring appropriate antimicrobial stewardship?
Recommendation
Randomised controlled trials should be undertaken to determine whether using pointofcare tests in decisionmaking is clinically and cost effective when prescribing antimicrobials in children, young people and adults presenting with respiratory tract infections.