Guidelines vs Policy

When building your AMS action plan, it is essential to be clear about the difference between guidelines and policies. The terms policy and guidelines are used interchangeably, though they mean different things. In this section we will outline the difference between the two, and provide some key examples of each.

To read more about AMS guideline and policy, this WHO resource provides a very clear and pragmatic approach to guideline, policy and antibiogram development and use. When your AMS programme is ready to consider guidelines, this is a very useful document for working through the process.

Definitions

When describing AMS programmes, it is essential to be clear about the difference between guidelines and policies.

Policy: a set of overarching principles providing a broad approach to stewardship within the local area, region or country.

Example: Surgical Prophylaxis Policy

In 2013, a team of clinicians at Thika Hospital, Kenya, shared their experience of developing and implementing a Surgical Antibiotic Prophylaxis (AP) policy as an intervention to change healthcare practitioners’ prescribing behaviour.

Their policy was based on national evidence with good buy-in from local clinicians and was developed as a core AMS intervention. The policy describes a clear pathway for patients undergoing surgery including what needs to be done, and covers the who, how, where and when of the intervention. The pathway highlights core areas where practice or process can be measured and results of compliance delivered back to the prescribers.

To read more about the study you can find the paper here.

Guidelines: an outline of best practice providing specific antimicrobial treatment or prophylaxis recommendations for individual diseases, syndromes etc.

Pre-requisites for guidelines

In order to develop a treatment or prophylaxis guideline, there are a number of pre-requisites you need to meet. Your guidelines should:

• Be based on local antibiograms.
• Be syndrome/disease based.
• Specify type of clinical setting.
• Specify the rationale of the guidelines.
• Provide evidence-based strength of recommendation.
• Involve treating physicians to bring ownership to the guidelines.
• Create pathways to support implementation, improve access and education.

Consider your local resources and what elements of this can be applied to your setting.

National versus local guidelines

Local guidelines for empiric treatment of common infections are a critical part of any hospital AMS programme. These often draw on national guidelines (if available) as well as published guidance from national or international organisations, e.g. IDSA, NICE, SIGN.

In some countries, national guidelines may be used but then adapted for local use to take account of local antibiograms or based on the availability or cost of specific antibiotics.

Unfortunately, some countries have not yet developed national guidelines, which makes developing a local guideline seem like a difficult task. However, to support those without national guidance the WHO has developed an Essential Medicines List Antibiotic Book which provides recommendations for the treatment of common infections presenting both in primary healthcare and hospital settings. This evidence-based handbook is an invaluable starting point for those looking to develop guidelines and also for those with guidelines to cross-check antibiotic choices against WHO recommendations.

The handbook includes helpful information about whether antibiotics are required for some conditions, and alternatives to antibiotics and promotes the use of Access group antibiotics. Colour coding of Access, Watch and Reserve antibiotics is included to support users with appropriate antibiotic choices. It also provides epidemiology information and advice on whether microbiology testing would be helpful for each infection type, as well as detailed dosing information for adults and children.

Guidelines and Compliance

Implementing guidelines or policies for antibiotic prescribing is a core AMS intervention. This 2017 real world study from Japan looked at compliance with national guidance for intravenous (IV) to oral antibiotic switch in patients with community-acquired pneumonia (CAP).

The Japanese Respiratory Society 2017 guidelines strongly recommend switching from IV to oral antibiotics in patients with CAP following improvement in clinical symptoms and laboratory findings.

However, this observational study demonstrated that the overall switch rates did not change over the study period of 2010-2018, suggesting that the recommendation to switch from IV to oral antibiotics was not widely implemented.

Solutions to poor compliance

Poor compliance with guidelines is judged often by incorrect choice, dose, route or duration of antibiotic and sometimes by a composite measure of all these.

The figure below illustrates other disease areas where guideline compliance is often poor, particularly in low and middle-income countries.

But what can we do about poor compliance? The table below shows a list of potential barriers to following guidelines and proposed interventions to tackle these issues.

Click here to see a larger version of this image.

This infographic is also available as a screen-reader compatible PDF.

This shows that engagement, communication, and education of all healthcare staff are key to guidelines being accepted, accessed and used to inform patient care.

Please share your experience of using guidelines in the comments below. Have you been involved in developing a guideline? Have you used guidelines in your practice and what is your view of them?