Improving practice—working together to improve the use of antimicrobials Free

Abstract

The Hospital Pharmacy Initiative (HPI) was launched in 2003 with a letter from the Chief Medical and Pharmaceutical Officers that 3 years of funding was to be invested in this programme.¹ Hospital chief pharmacists were asked to plan developments to improve the prudent use and monitoring of antibiotics in their hospital, and hospital finance officers were asked to liaise with the appropriate primary care trust to ensure that funds were allocated to the trust and that these funds were applied for their intended use. It was expected that hospital pharmacies would use this opportunity to extend clinical pharmacy services to areas of high antibiotic use and seek to meet identified local issues. This would also facilitate a focus on key areas such as antibiotic use in surgical prophylaxis, in children, and infection control. Action was expected to ensure that hospital antibiotic policies were in line with current best practice and evidence based, and managed through existing groups, such as drugs and therapeutic committees.

The programme was not performance managed by Strategic Health Authorities as planned because of NHS reorganization but the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) had a watching brief on the project and organized two conferences for hospital clinical pharmacists. These events were well attended and provided valuable opportunities for networking and sharing good practice.

A considerable amount of benefit has been associated with the HPI. A recent comprehensive review describes evidence for the benefits of the impact of it on clinical, microbiological and financial outcomes, along with examples of innovative practice and culminating with a vision for the future of the antibiotic pharmacist.²

The Healthcare Commission has reviewed the HPI as part of the annual health check for acute hospitals and has found that most trusts have used the funding to employ additional clinical pharmacy staff.³ A number of positive initiatives have been commended and the Commission expects trusts to continue with this work after the special funding ends. A review of best practice sharing for antimicrobial prescribing for the 2005/06 Healthcare Commission ‘Audits for Medicines Management’ described additional information provided on antimicrobial prescribing from 135 English, 11 Northern Irish and 6 Welsh acute hospitals.⁴ A further commendation of good practice for addressing antimicrobial prescribing is highlighted in the latest Health Commission report on healthcare-associated infection.⁵

Many of the pharmacists employed in English trusts under the HPI have facilitated the improvement in interaction between themselves and microbiology departments. Without this funding, it is unlikely that trusts would have deployed additional staff in this area, and certainly not to the degree seen. Over 100 specialist antimicrobial pharmacists were funded in English trusts at least partially as a result of the HPI, and 141 such specialist staff were in post at April 2005.⁶ Thus, 88% of Trusts in England had at least one member of pharmacy staff specializing in microbiology/infectious diseases following the HPI initiative, compared with 6% in 2000.⁷

Antimicrobial pharmacists in England should be congratulated for their achievements and the employment of these staff has produced benefits for both the NHS and patients.⁸ A number of benefits have been identified for clinical and organizational developments directly attributable to the HPI funding.^9–11 Local networks of antimicrobial pharmacists have been set up to share practice, conduct benchmarking activity around antimicrobial use, and organize collaborative research such as multisite antimicrobial prevalence studies involving up to 2000 patients at a time. Contributions from specialist antimicrobial pharmacists have allowed the UK Clinical Pharmacy Association Infection Management Group (UKCPA-IMG) to flourish and develop strong links with other professional organizations such as the British Society for Antimicrobial Chemotherapy and the Infection Control Nurses Association, paving the way for multidisciplinary training events and collaborative research projects.

Evidence for the cost-effectiveness of the HPI is compelling. A number of hospitals have reported considerable reductions in their expenditure on antimicrobials over this period and the overall expenditure on antimicrobials in English acute hospitals over a 5 year period indicate that the total spending fell for the first time in 2005 after annual 10% rises over at least the previous 4 years. This represents a projected decrease of around £30 million in 1 year; almost three times the outlay for the Hospital Pharmacy Initiative provided from central funds.¹²

In recent years, an increasing focus has been placed on hospital pharmacists as guardians of prudent antimicrobial prescribing both in England and elsewhere. The antimicrobial stewardship team model, to include a clinical pharmacist and microbiology/infectious diseases staff, is well accepted and forms the basis of the Department of Health's latest recommendations on best prescribing of antimicrobials,¹³ as well as lying at the core of the Scottish Antimicrobial Prescribing Practice and Policy document.¹⁴ Thus, we would suggest that both approaches have much in common and the way forward lies in the sharing of good practice.

Transparency declarations

J. C. has received funds for research studies, advisory boards or speaking at symposia organized by the Abbott, Altana, Ashley Communications, AstraZeneca, Bayer, Chiron, GSK, Hayward Medical Communications, Janssen-Cilag, Menarini, MSD, Munro and Forster Healthcare, Pfizer, Roche, Sanofi-Aventis, Ted Butler and Associates, and Wyeth. P. D. has served on Advisory Boards for Johnson and Johnson (Global Anti-infectives) and Wyeth (UK tigecycline), received honoraria for speaking from Johnson & Johnson, Optimer, Pfizer, Wyeth and received research funding from Boehringer Ingelheim, GlaxoSmithKline and Pfizer. C. J. has served on an advisory board for Westaway Gillis and received honoraria for speaking from Conventus, Wyeth and Pfizer. Y. G. has shares in GlaxoSmithKline, has served on an advisory board for Pfizer and received funds to attend/speak at meetings from Roche, GlaxoSmithKline, Gilead, Boeringer and BMS. The remaining authors have none to declare.

Editor-in-Chief's comment on the editorial process

This issue of the Journal of Antimicrobial Chemotherapy contains two Leading articles that comment on the Hospital Pharmacy Initiative from differing perspectives. Readers may have noted that the article by Masterton and Caldwell was published in the Advance Access section of the Journal website well in advance of this article by Cooke et al. As the circumstances leading to the publication of the article by Cooke et al. were unusual, and for the editorial process to be transparent, this comment provides the relevant background.

Masterton and Caldwell submitted a Leading article for consideration that was subjected to peer review and subsequently accepted for publication. When the article was published in JAC Advance Access, the Editor-in-Chief was made aware that a number of people wished to respond to it. Following a number of discussions, the Editor-in-Chief decided to offer the opportunity for a single collaborative response of equal prominence rather than receive several items of correspondence that were likely to have significant overlap. Professor J. Cooke and others were therefore offered the option of preparing a second Leading article that would appear in print alongside the first. This chain of events accounts for the differences between the online publication dates for the two articles. The offer to Cooke et al. was made with the knowledge and support of Dr Masterton.

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