Five Rights of Antibiotic Safety: Antimicrobial Stewardship at One NHS Foundation Trust in England Before and During the COVID-19 Pandemic
Authors: Abdelsalam Elshenawy R , Umaru N , Aslanpour Z 
Published: November 2023

Abstract

Introduction
The study highlights the urgency of combating rising multi-drug-resistant infections, projecting 10 million deaths annually by 2050. With over 1.2 million deaths in 2019, Antimicrobial Resistance (AMR) has become a significant public health issue. Antimicrobial Stewardship (AMS) promotes judicious antibiotic use1. 'The Five Rights of Antibiotic Safety' ensure appropriate usage. It encompasses the right patient, drug, dose, time, and duration2. The COVID-19 pandemic, causing around 6 million deaths by 2023, has intensified AMR challenges. The Royal Pharmaceutical Society's AMS policy advocates for maximising the use of pharmacists' expertise to promote prudent antibiotic use, strengthen stewardship, and reduce AMR3.

Aim
This study aimed to evaluate AMS and adherence to the 'Five Rights of Antibiotic Safety' in antibiotic prescribing at an NHS Foundation Trust during 2019 and 2020 amidst the COVID-19 pandemic.

Methods
This research study was conducted using a cross-sectional retrospective design and undertook an in-depth analysis of 640 patient records in 2019 and 2020. The study included adult patients aged 25 and above, immunocompromised and pregnant individuals, and those prescribed antibiotics for respiratory tract infections or pneumonia during 2019 and 2020. A validated data extraction tool facilitated data collection. This study was registered under ISRCTN number 14825813, receiving ethical approval from the University of Hertfordshire Ethics and Health Research Authority (HRA) (REC Reference number 22/EM/0161). The Citizens Senate reviewed the study protocol, ensuring public and patient involvement.

Results
The study evaluated inappropriate antibiotic prescribing, identifying a rise in inappropriate antibiotic prescribing with no indication from 16% in 2019 to 20% in 2020. Inappropriate routes of administration also increased from 33% to 36%. While inappropriate drug choice remained steady around 63-64%, inappropriate dosing rose from 13% to 18%. Interestingly, inappropriate duration reduced slightly from 70% to 66%. The study assessed AMS champions, pharmacists' participation increased from 19% to 21%, and doctors decreased from 19% to 12%. However, combined collaboration jumped from 58% to 71%.

Discussion/Conclusion
This study highlights the surge in incorrect antibiotic prescribing during the 2020 COVID-19 pandemic, stressing the necessity of the 'Five Rights of Antibiotic Safety.' Strict guideline adherence and increased professional education are pivotal. Progress in reducing improper duration was seen, indicating the significance of refining prescribing practices. This research highlights the critical role of pharmacists and doctors as AMS champions. It demonstrates that their collaborative efforts during the pandemic positively impacted patient outcomes, thus reaffirming the Royal Pharmaceutical Society's AMS policy on the importance of a multidisciplinary team in ensuring appropriate antibiotic use.
This study reveals a worrying increase in incorrect antibiotic use during 2020, calling for stricter compliance with the five safety rules and enhancing professional education. Reduced inappropriate duration of use suggests improvements in prescribing practices. The critical role of pharmacists and doctors in AMS, with heightened collaboration yielding prudent antibiotic use and better patient outcomes. Despite these insights, limitations like potential reporting bias, not exploring the causes of inappropriate prescribing in-depth, and a limited focus on doctors and pharmacists in AMS need future research.

References
1. Murray CJ. Global Burden of Bacterial Antimicrobial Resistance in 2019: a Systematic Analysis. The Lancet. 2022 Jan 19;399(10325):629–55.
2. Federico F. The Five Rights of Medication Administration | IHI - Institute for Healthcare Improvement [Internet]. www.ihi.org. 2007. Available from: https://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx
3. The pharmacy contribution to antimicrobial stewardship [Internet]. Available from: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/AMS%20policy.pdf.