Some ideas on how and where to start

In Step 2.3 and Step 2.4 some antibiotic stewardship issues from the scenario video were identified and discussed.

In this article we have revisited some of these issues and linked them to potential ‘start points’ if you were trying to improve antimicrobial stewardship on the scenario ward.

These are not listed in any order of priority and are not exhaustive. You may have additional ideas, perhaps more relevant to your own working environment, and want to post these for other learners to read and comment on.

As it is usually best to start small and then evolve, you may also want to consider and comment on which would be your preferred ‘start point’ and why?

• Lack of staff knowledge and concern about antibiotic resistance “it wasn’t anything to be too concerned about”. This suggests that staff do not understand the implications of antibiotic resistance and/or do not consider it a priority. Improving staff education/training on antibiotic resistance, including the potential roles for nurses in antibiotic stewardship and perhaps integrating this with infection prevention and control education/training (hygiene was also an issue in the scenario), may be worth considering.

• Poor adherence with antibiotic advice from the microbiologist and local antibiotic treatment guidelines “blockbuster antibiotics he normally uses for such cases”. This suggests a poor working relationship between at least one senior ward doctor and the microbiologist and sub-optimal adherence with local guidelines. Consideration could be given to how to improve this, perhaps through improved communication and collaboration between the ward team and microbiology and/or the antimicrobial management team and accounting for the concerns of all involved, leading to consensus on how similar patients are managed in the future and perhaps new and better implemented local antibiotic treatment guidelines. Adherence with the latter could then be measured, longitudinally monitored and fed-back to healthcare staff, something that will be considered more in Week 3.

• Length of antibiotic therapy “he normally says 14 to 28 days”. Consideration could be given to what length of antibiotic therapy guidance and controls are currently in place. One advantage of this as a ‘start point’ is that it is relatively easy to measure and monitor improvement of and then feed-back to healthcare staff, something that will be considered more in Week 3.

• A suggestion of inappropriate antibiotic use for prophylaxis (rather than therapy) “frequently he likes to use them [blockbuster antibiotics] to prevent such infections” although “not on our policy”. Consideration could be given to what antibiotic prophylaxis guidance is currently in place and to what extent this is adhered to. As with length of therapy, this is relatively easy to measure and monitor improvement of and then feed-back to healthcare staff, something that will be considered more in Week 3.

• No evidence in the video of doctors and pharmacists (or an antimicrobial stewardship team) working together to optimise prescribing. Consideration could be given to how prescribers, pharmacists and/or the antimicrobial management team currently work together and liaise.