The National Institute for Health and Care Excellence (NICE) has published guidance to help doctors, nurses and pharmacists promote and monitor the sensible use of antimicrobials - a group of medicines that kill or stop the growth of microorganisms and include antibiotics, antivirals, antiparasitics and antifungals.
Antibiotics have been the mainstay of treating infections for over 60 years. Although a new infectious disease has been discovered nearly every year over the past 30 years, very few new antibiotics have been developed. This means existing antibiotics are used to treat an ever greater variety of infections and infectious diseases.
Overall antibiotic prescribing in England has been steadily increasing over several years. Nationally, 41.6 million antibiotic prescriptions were issued in 2013 -14 at a cost to the NHS of £192 million1. Despite considerable guidance that prescribing rates of antibiotics should be reduced, 9 out of 10 GPs say they feel pressured to prescribe antibiotics2, and 97 percent of patients who ask for antibiotics are prescribed them.3
"The more we use antibiotics, the less effective they become. Infections can evolve and become resistant to existing medicines," said Dr Tessa Lewis, GP and Medical Advisor to All Wales Therapeutics and Toxicology Centre and Vice Chair of the Guideline Development Group. "Resistance to antibiotics is increasing and there have been very few new antibiotics developed in recent years, so we need to make sure that, as well as searching for new antimicrobial medicines we use the ones we currently have in the most effective way.
"This NICE guideline considers the whole area of antimicrobial prescribing. It looks at the evidence and makes recommendations for health and social care practitioners and organisations on the best ways to minimise antimicrobial resistance."
As well as highlighting the need for local antimicrobial stewardship programmes, the guideline also recommends setting up multidisciplinary antimicrobial stewardship teams working across all care settings. These teams should be able to review prescribing and resistance data frequently and feed this information back to prescribers. They should also be able to work with prescribers to understand the reasons for very high, increasing or very low volumes of antimicrobial prescribing as well as provide feedback and assistance to those who prescribe antimicrobials outside of local guidelines where this is not justified.
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "We need to 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 and national guidelines and no reason is documented."
"It's not just prescribers who should be questioned about their attitudes and beliefs about antibiotics," continued Professor Baker. "It's often patients themselves who, because they don't understand that their condition will clear up by itself, or that perhaps antimicrobials aren't effective in treating it, may put pressure on their doctor to prescribe an antibiotic when it is not indicated and they are unlikely to benefit from it.
"Research has shown that misconceptions about antimicrobial resistance are widespread. Many people think that it is their body which becomes resistant, rather than the bacteria that cause antimicrobial-resistant infections. This often makes it feel that the issue of resistance is someone else's problem.
"The guideline therefore recommends that prescribers take time to discuss with patients the likely nature of their condition, the benefits and harms of immediate antimicrobial prescribing, alternative options such as watchful waiting and/or delayed prescribing and why prescribing an antimicrobial may not be the best option for them - for example, if they have a self-limiting respiratory tract infection. The guideline also recommends that patients are given advice about who they should contact if they have concerns about infection after discharge from hospital."
Dr Diane Ashiru-Oredope, Pharmacist Lead, Antimicrobial Resistance Programme at Public Health England, said: "Public Health England (PHE) welcomes this new guidance from NICE on antimicrobial stewardship for commissioners and providers.
"Antimicrobial stewardship programmes which aim to reduce inappropriate prescribing and optimise antibiotic use are a crucial part of work to combat antimicrobial resistance (AMR), and antimicrobial stewardship is an important element of the UK Five Year Antimicrobial Resistance Strategy.
"Tackling AMR is one of PHE's national priorities and today, in partnership with NHS England and Health Education England, we have issued a patient safety alert on antimicrobial stewardship, which highlights the key tools that can help organisations fulfil many aspects of this new guidance from NICE."
RCGP response to new NICE guidelines on antibiotics prescribing
Dr Tim Ballard, Vice Chair of the Royal College of GPs, said: "Antibiotics are fantastic drugs that can treat a huge range of diseases - but the growing resistance to them is a global threat and our challenge remains getting this message through to our patients.
"When diseases become resistant to antibiotics, it means that antibiotics will cease to work and as it stands, we don't have an alternative. The guidance today to prescribe the right antibiotic at the right dose at the right time is a sensible mantra and one that GPs try to abide to wherever possible.
"But we can come under enormous pressure from patients to prescribe antibiotics, even when we know they are not the best course of action. People must realise that this is dangerous for each and every one of us, not just 'other people'.
"These can be very difficult and stressful conversations for GPs to have and we know that NICE acknowledges this. We need a societal change in attitudes towards the use of antibiotics and any suggestion that hard pressed GPs - who are already trying to do their jobs in increasingly difficult circumstances - will be reported to the regulator is counter productive and unhelpful.
"If this were to happen, we would be looking to the General Medical Council to support any GP or other health professional who finds themselves on the receiving end of complaints or criticism about decisions made over the prescribing of antibiotics.
"The College welcomes the team approach to ensuring that antibiotics prescribing is done appropriately and responsible, and the opportunity for reflection that is advocated in this guidance, as long as it is implemented in an open and supportive way.
"It is also concerning that there hasn't been a new class of antibiotics produced in over 25 years, so we seriously need investment into research to develop new drugs that are effective at tackling existing and emerging diseases.
"But this won't happen overnight and in the meantime, we all have a responsibility to curb this trend, and we need to work together to make the public realise that prescribing antibiotics is not always the answer to treating minor, self-limiting illness.
"The RCGP has highlighted the challenge that we face through resistance to antibiotics and we have developed the TARGET antibiotics toolkit, with Public Health England, to support GPs in the appropriate prescribing of antibiotics."