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Practical approaches to AMS in human medical practice

Neil Powell discusses some ways to implement AMS in a human setting in this interview style video.
The diagnostic uncertainty at the front door of the hospital remains. And we haven’t been able to tackle that. There’s a real need for good, rapid diagnostic tests to help us differentiate between infective and noninfective causes of symptoms, and then viral and bacterial causes of symptoms. So that’s a sort of evolving field, and we are very closely watching that to see what diagnostics we can incorporate into alternative pathways for patients to try and help us with that diagnostic uncertainty. But that remains a challenge. And as such, patients are exposed to broad-spectrum antibiotics when they come into the hospital. Where we have seen more success is around switching patients from IV antibiotics to oral antibiotics once they have improved.
And we’ve been successful here with that, because the data to support that, the research that’s being done to show that’s an effective and a safe intervention to make, is now what is widely acknowledged. And we’re able to use that data to sort of motivate and empower clinicians to do that. And then there are many, many benefits to doing that, and it’s well received. So we’ve been successful and prompt by these oral antibiotic switching because of the evidence. The other challenge around stopping antibiotics when you’ve ruled infections out– so about 10% of antibiotics that are started in our hospital, and it’s the same across the land, about 10% are stopped within 72 hours, because infection is ruled out.
But we know there’s much more opportunity to stop antibiotics than that. And there’s been a multi-centre study come out of Brighton called the Antimicrobial Review Case study, the ARC study, which is a decision tool for clinicians to try and facilitate early antibiotic stopping once you’ve ruled infections out. And so we’ve increased our antibiotic stop rate from 10% to 17%. And other hospitals that enrolled in that study have increased their antibiotic stop rates from 10% up to 30%. So there have been some sort of movement there. As far as using shorter antibiotic courses, we know that you can use shorter antibiotic courses than we do for many of the common infections we see.
And there is evidence from randomised controlled studies that back that up, and demonstrate that shorter courses are as effective and actually better in terms of reducing future resistance and side effects. But the barriers to bringing the evidence into shorter course lengths really are around historical practise and changing historical practise. So we’ve always used 7 days or 10 days for antibiotic course lengths. And to try and now change our ideas to convince clinicians that actually five days is enough for many infections requires a bit of behaviour change, and a bit of understanding of what motivates clinicians around the longer course length. So it’s a piece of work we’re doing here to try and embed shorter antibiotic courses.
That’s been more of a challenge.
So when we talked about that diagnostic uncertainty at the front door of the hospital, if you get admitted to hospital with symptoms such as shortness of breath that could be caused by many different pathologies, there’s a wide differential. We say it could be a pulmonary embolus. It could be heart failure. It could be pneumonia. And sometimes, although the differential is wide, it could be many different things, kind of– you might– infection might be low on your suspicions. But we would cover that empirically, currently. But procalcitonin is a very good biomarker specific for bacterial infection.
So patients, where you are not really that convinced the patient has an infection, but you need to cover infection because a patient is so unwell, you can use procalcitonin just sort of to help with your decision-making. So if the procalcitonin is negative or low in a patient like that, you can then confidently stop the antibiotic. And there’s been a few small studies that have done that. In patients with diagnostic uncertainty and low procalcitonins, they withheld antibiotics. And those patients have done OK, and not suffered as a consequence.
So in primary care, there’s a target toolkit hosted by the Royal College of General Practitioners that was developed by PHE. And that is a one side piece of A4 paper with the common upper respiratory tracts infections on it, with information about expected duration of illness, how to self-manage without antibiotics. So a lot of these infections, upper respiratory tract infections are viral. So as we get that point across that they’re viral, self-care is the best option, and antibiotics have a limited role. And there’s also safety netting parts. So a bit on that leaflet that says, if you have these symptoms, which may be indicative of sepsis or more severe infections, then to seek help.
And that’s a very quick leaflet that the GP can go through with the patient, and just reassure the patient that antibiotics are not the best option, and to get– to work with the patient, really, to work to sort of– to decide how best to self-manage. And that’s a pretty powerful tool, I think, in helping GPs reduce antibiotic prescribing. But we know in Cornwall, for example, and we hear around the rest of the country that there aren’t many GPs using this toolkit. So there’s a real behaviour change element to this to try and embed that toolkit into sort of routine general practice and consultations.
And there’s a lot of work going on trying to reinforce the message of self-care for patients who are suffering with flus and cold symptoms, or severe infections, to sort of self-manage those. So to not then go and see a GP, and try and get it managed by the community pharmacies– take pressure off the GP. Because there’s a real a perceived– a perception from GPs that the patients are coming to see them for antibiotics. So we need to also undo that. And although, there’s a perception from GPs that the patient’s expecting antibiotics, actually the research that’s been done with patients would indicate that the patients aren’t after antibiotics, often. They’re after reassurance.
And again, that’s where the target toolkit can really help. So we’ve got some work to do there with some pretty powerful interventions, potentially. There are some decision support tools out there. And one that comes to my mind immediately is a fever pain scoring for patients who present with sore throat. And you can, based on certain criteria, decide whether they’ve got a high score or low score, so more severe and more likely go on to develop complications, or a low score, less severe, and unlikely to develop complications. And the advisement is if they score lowly, and they have a low fever pain score with the sore throat, to not give antibiotics. Often, these sore throats are minor anyway.
And if they have a high score to give antibiotics. And then the NICE guidance on sore throat really supports that and promotes that toolkit, or decision support aid, should I say. And there are many other NICE guidances out there now for upper respiratory tract infections that promote an antibiotic sparing approach, and to only give antibiotics to people with upper respiratory tract infections, severe infections, and sinusitis, for example, if they meet certain criteria to certain comorbidities or other more concerning symptoms. Otherwise, to withhold antibiotics and offer self-care. So decision support aids is really the best thing we have in lieu of point of care rapid diagnostics for GPs.

In this video, Neil Powell describes how antimicrobial stewardship has been implemented in his local context as a human medical practitioner in the Royal Cornwall NHS Trust.

He is asked the following questions:

  1. What measures have you introduced to improve antimicrobial stewardship in the hospital setting?
  2. What role can diagnostics play in improving antimicrobial stewardship?
  3. Do you have any tips for primary care practitioners on responsible prescribing?
  4. Are there any decision support tools for primary care practitioners?

In the video, Neil reflects on the challenges he previously mentioned in step 1.17, and provides some potential solutions that have been used in human medicine. Use the comments section to discuss what is different between what Neil has said, and what you know about veterinary medicine.

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Antimicrobial Stewardship in Veterinary Practice

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