Multidisciplinary antimicrobial management and the role of the infectious diseases pharmacist—a UK perspective

Journal of Hospital Infection (2003) 53: 85±90 doi:10.1053/jhin.2002.1350

REVIEW

Multidisciplinary antimicrobial management and the role of the infectious diseases pharmacistÐa UK perspective K. Knox*, W. Lawsony, B. Deanyz and A. Holmesx *Department of Microbiology, St George's Hospital, London; yDepartment of Pharmacy, Hammersmith Hospitals NHS Trust, London; zSchool of Pharmacy, University of London, London and xDepartment of Infectious Diseases and Microbiology, Imperial College, Hammersmith Hospital, London, UK Summary: Improved clinical outcome, patient safety, cost savings and a reduction in the burden of antimicrobial resistance are outcomes associated with optimizing antimicrobial use. Despite this, the misuse of antimicrobials in the hospital setting remains a huge problem. The development of antimicrobial management teams and the promotion of the role of the clinical pharmacist in antimicrobial prescribing are recommended strategies for improving prescribing practice. It is recognized that there is a lack of published evidence-based research looking at the effects of antimicrobial control programmes and there is a need for more data. In the UK, the role of the hospital pharmacist in promoting responsible antimicrobial prescribing has been largely undervalued and needs to be encouraged and formalized in line with current directives. Managerial structures within hospitals need to endorse multidisciplinary antimicrobial management schemes with appropriate authoritative, administrative and information technology support. & 2003 The Hospital Infection Society

Keywords: Antibiotic policies; antimicrobial management team; pharmacist.

Why manage antimicrobial use? Antimicrobial use contributes significantly to the drug budget of most hospitals, with 30±50% of patients receiving antibiotics at any one time. US studies estimate that in excess of 50% of prescriptions may be inappropriate either in terms of drug choice, route of administration, dose or length of treatment.1,2 The sub-optimal use of antimicrobials remains a huge problem despite the potential benefits of prudent, targeted prescribing. The reason for controlling antimicrobial use is to encourage

Author for correspondence: Dr Karen Knox, Department of Microbiology, 1st Floor D Block, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM1 5AA, UK. Tel.: 020 82962550; Fax: 020 86446317; E-mail: [email protected]

0195±6701/03/020085 ‡ 06 $35.00/0

responsible prescribing in order to (i) increase the quality of patient care, (ii) contain costs, and (iii) attempt to minimize the emergence of microbial resistance. More evidence-based research is needed as there is currently a paucity of robust data reporting the effects of antimicrobial prescribing control on such outcome measures. Cost containment is often considered to be the overriding priority, but with the rapid development and dissemination of multi-resistant organisms associated with human infection particularly in the hospital setting, global attention is now firmly focussed on controlling antibiotic use in order to halt the increase and spread of such organisms.3±5 Over the last 30 years or so, the impetus to control antimicrobial prescribing in both hospital (inpatient and outpatient) and community settings has gained & 2003 The Hospital Infection Society

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momentum, although its impact has yet to be quantified.6 Management methods The key components of successful management of antimicrobial use are the formulation, implementation, surveillance and update of antibiotic policies that are based on the local epidemiology of both prescribing and antimicrobial resistance patterns. National guidelines and data must also be taken into consideration where appropriate and available.4,5 The preparation of policies and implementation methods must involve the prescribers who have direct responsibility for individual patient care.7 Most commonly, antibiotic control policies comprise a restriction on range of available antimicrobials; protocols and guidelines for prophylaxis and treatment of specific conditions; automatic stop dates; requirement for prior authorization for use of restricted or reserve antimicrobials; and limited laboratory reporting of antibiotic susceptibilities.4 It is necessary to define the epidemiology of prescribing practices in individual settings before any attempts to alter it can be implemented. This will enable the identification of areas where interventions could have most impact. A good illustration is that of surgical antibiotic prophylaxis which accounts for a significant proportion of the drug budget for most hospitals and where misuse of antimicrobials is common. Successful outcomes, both clinical and financial, have been shown when antibiotic use for prophylaxis has been a target for optimization.8 It is essential to define other key process or outcome indicators by which the impact of any intervention may be assessed.9 This, in turn, requires that the appropriate epidemiological infrastructure and human resources required to collect, interpret and store such data are available. There are many factors that determine antimicrobial prescribing. It is likely that initiatives to control antimicrobial use are not wholly successful because the complexity of the issues that pertain to prescribing practices in individual settings are not fully appreciated. Changes in patient epidemiology over time (e.g., an increase in the number of immunocompromised patients) may have a significant impact on antimicrobial use particularly with regard to costs.10 Some of the factors that contribute to inappropriate prescribing include clinician inexperience, bed and staffing shortages, diagnostic uncertainty, patient expectation, the increased tendency to

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practice defensive medicine and consultation time constraints, together with lack of support from hospital management structure.11,12 A multifaceted approach is therefore required in any attempt to improve the situation. In order to alter prescribing habits, the use of passive education alone is not effective. In the UK, the rapid turnover of junior medical staff may contribute to this lack of success.11 It is only when some form of antimicrobial restriction has been combined with educational efforts (e.g., interactive educational meetings with or without computerassisted decision support systems at the point of prescribing) is used, that success in altering prescribing practices has been shown.13±15 An exception to this is one-on-one `educational outreach' that has been shown to be effective16 but is unlikely to be achievable or cost-effective in the National Health Service (NHS) setting. The introduction of any control strategy that attempts to alter clinical practice requires engaging senior clinicians from the outset. Consultant physicians and surgeons need to be convinced that interventions are active contributions to patient care rather than corrective measures. To this end, the appointment of a key healthcare practitioner to lead or oversee such a programme will validate it and increase the chances of its success.17 The backing of hospital administration is also essential. Published studies of antimicrobial control programmes in the hospital setting concentrate primarily on reporting economic outcomes (these being the most obvious and easiest to measure), with the effect on patient outcomes being crudely measured by length of inpatient stay and mortality. At worst, these show no detrimental effect on patient outcome18±20 and at best, reveal modest, positive outcomes with a trend towards reduced length of stay and mortality.21±23 Studies assessing effects of control strategies on antimicrobial resistance patterns are few, but a reduction in prevalence of resistance organisms has been shown.24,25 In the UK, a Working Party of the British Society of Antimicrobial Chemotherapy (BSAC) and the Hospital Infection Society (HIS) is currently carrying out a review of published literature on interventions to improve antibiotic prescribing in hospitals. This is under the supervision of the Effective Practice and Organization of Care group of the Cochrane Collaboration. Preliminary results confirm the paucity of and need for further well-designed and conducted studies to assess the impact of different models of antimicrobial control

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programmes on patient outcome and antimicrobial resistance (P. Davey, personal communication). Antimicrobial management teams It is therefore obvious, that the successful implementation of effective antibiotic control policies is a complex task that depends upon the co-operation of multidisciplinary teams. These teams include the departments of microbiology, infectious diseases, pharmacy, and infection control. In addition hospital epidemiology, which is poorly developed within UK NHS Trusts, needs to be expanded. Suitable supporting IT systems are essential. One of the clearest directives from the European Union Conference on `The Microbial Threat' in 1998 (`The Copenhagen Recommendations') was the recommendation that every hospital introduce an antibiotic team which includes clinical microbiologists, infectious diseases physicians and `other relevant clinical specialties'. This team should be given authority to modify antimicrobial prescribing practices, as well as being responsible for ensuring compliance with guidelines.26 Authority implies the support of hospital administration. The employment of a multidisciplinary team approach has long been advocated by the Infectious Diseases Society of America (IDSA).2 Such a team approach requires strong leadership, good management and organization with strict role definitions for each member in order to pre-empt potential conflict.2,27 The antimicrobial management team (AMT) can be viewed as the driving force behind the formulation and implementation of antibiotic policies, as well as having educational responsibilities. It is vital that members of the team be seen to have an active role in patient management, e.g., formal ward round reviews of selected patients who are on restricted antimicrobials. A clinical pharmacist with a strong background in infectious diseases and antimicrobial management, should play a lead role in the AMT and be viewed as a `co-therapist' with other members of the team.27,28 A pharmacist on the AMT can be called an infectious disease/antibiotic/microbiology pharmacist. The role of the pharmacist In the UK, as all inpatient drug charts and outpatient prescriptions are viewed by a pharmacist, the use of this resource is the most logical starting

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point for data collection on antimicrobial use. Pharmacy-based monitoring services with educational emphasis are a valuable tool for reviewing hospital prescribing practices and have been shown to have a positive impact.29,30 The infectious diseases pharmacist, depending on level of clinical training, can make specific contributions to optimizing antimicrobial prescribing in both inpatient and outpatient/community settings. Examples of the scope of this role have been published from both sides of the Atlantic (Europe26,30,31 and the USA27±29,32±34) as well as Australia35 (see Table I). The educational role is extremely valuable, with opportunities to inform prescribing clinicians at the point of care and more general.22,32 Two published studies from the USA illustrate how the infectious diseases pharmacist, as a part of a multidisciplinary AMT, may contribute to the promotion of responsible antimicrobial prescribing in the hospital setting.28,33 In both instances, clinical pharmacists with training in infection and antimicrobial management were employed to optimize antimicrobial prescribing in the hospital

Table I Role of the infectious diseases pharmacist 1. Educational role directed at  Clinicians at the point of care and generally; junior staff induction programmes; medicines information helpline  Nursing and technical staff  PatientsÐcompliance, patient medicines helpline (UK NHS)  Pharmacists 2. Monitoring of antimicrobial use (an overlooked fact is that in the UK all prescriptions are reviewed by pharmacists)  Collection and analysis of data on local prescribing  Compliance to policies  Prescribing errors 3. Audit and feedback  Includes evaluation of impact of clinical guidelines on process of care, patient outcomes and antimicrobial resistance patterns 4. Clinical role in the context of an antimicrobial management programme in conjunction with colleagues on antimicrobial management team (inpatient and outpatient management)  Prominent role in policy making, development and update of clinical practice guidelines (part of antibiotic steering group)  Identification of patients on antimicrobials that may benefit from therapeutic intervention by the antimicrobial management team  Initiation of sequential therapy (intravenous to oral switch)  Dose adjustments  Therapeutic drug monitoring (e.g., aminoglycosides, glycopeptides) 5. Member of the infection control committee  Integrating antibiotic control with infection control

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inpatient setting. The role was separate from, but complementary to, that of an infectious diseases physician (in the UK this could equally be a clinical microbiologist) who primarily gave advice on empirical treatment and consulted on difficult cases or non-responders. Prescribing clinicians were presented with advice in a non-confrontational manner and, in the majority of cases, the advice was willingly taken. The system was facilitated by a computerized software program that linked the microbiology laboratory with pharmacy. Cost savings and improvement in antibiotic use, probably via the sustained educational impact, were achieved with no detrimental patient outcomes reported. In both of the above illustrations, the pharmacist was also able to bring to the attention of the infectious diseases specialist those patients who may have required expert advice from this specialty. Importantly, programmes were endorsed and led by respected members of clinical staff with administrative backing. Despite the limitations of some of these studies with regard to adequacy of pre- and postinterventional data, they provide valuable insight into the potential benefits of an expanded role of the clinical pharmacist and a team approach to antimicrobial prescribing. Infectious diseases pharmacists in the UK In the UK, the role of the pharmacist in antimicrobial management was highlighted by a working party of the BSAC4 in 1994 and yet, a recent survey showed that only 25 out of 85 NHS Trusts employed an infectious diseases pharmacist.36 The majority of these posts had shared duties in other areas. As a result of this survey, a national network for pharmacists involved in antimicrobial prescribing has been established. The `Infection Management' practice interest group, under the auspices of the United Kingdom Clinical Pharmacy Association (UKCPA), aims to provide and exchange information regarding clinical experience, evidence and best practice. Its remit also includes encouraging and supporting practice research in addition to providing education events. This can be achieved partly through the E-mail newsgroup for members. The information can be further networked amongst existing UKCPA practice interest groups for pharmacists representing other hospital specialities such as critical care, surgery which also have a role in antimicrobial prescribing.

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The UK does not offer further post-graduate training for pharmacists. In the USA however, there are structured, full-time residency programmes in infectious diseases pharmacy practice available and fellowships in research or practice. However, there is now available a two year parttime MSc in Infection Management for pharmacists, which is a collaborative venture by Imperial College, the Academic Pharmacy Unit at the Hammersmith Hospitals NHS Trust and the Public Health Laboratory Service. The primary objective of this course is to promote the role of pharmacists in the prevention and treatment of infection in order to enhance prudent antimicrobial prescribing and to tackle problems of resistance. The future In the UK, as part of the Antimicrobial Resistance Strategy and Action Plan,37 the Department of Health is committed to exploring all options in the drive to promote prudent antimicrobial prescribing. Within the hospital setting, this includes the formation of multidisciplinary AMTs whose primary role is to co-ordinate the formulation, implementation and assessment of antimicrobial policies. Such teams must have authority to perform such a role and have backing of the hospital administration. It is apparent that in the UK the valuable contribution of the pharmacist in promoting responsible antimicrobial prescribing is under-recognized. The National Audit Commission's report on medicines management in hospitals highlights the point that `pharmacy services are an under-utilized resource, the status and profile of which need to be promoted'.38 The misguided view of the pharmacist as a `prescribing policeman' implementing restrictions and enforcing drug approval should be actively discouraged. A pharmacist with specialist training and experience in antimicrobial management should be a lead member of the AMT. There is a need to invest in such training for pharmacists, particularly in the postgraduate setting. This necessarily implies substantial, additional investment in terms of money and human resources, and the creation of new posts, not simply the stretching of current resources. Encouragingly, in the past two years, since the above-mentioned survey, at least 10 new NHS hospital-based posts for infectious diseases pharmacists have been established nationally. In addition, there is the need to develop a public health and epidemiology infrastructure within

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hospitals in order to facilitate and successfully implement the roles of the AMT and monitor compliance. Hospital infection control committee membership should include an antibiotic pharmacist and the antibiotic control programme should be integrated with infection control. Investment in suitable IT systems is required, with exploration of computerized links between pharmacy and microbiology.33 In this era of accountability and antibiotic resistant `superbugs', there is no room for complacency in the use of antimicrobials and we can no longer afford to shy away from the responsibility of ensuring responsible antimicrobial prescribing. References 1. Jarvis WR. Preventing the emergence of multidrugresistant microorganisms through antimicrobial use controls: the complexity of the problem. Infect Cont Hosp Epidem 1996; 17: 490±495. 2. Marr JJ, Moffet HL, Kunin CM. Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Diseases Society of America. J Infect Dis 1988; 157: 869±876. 3. House of Lords Select Committee on Science and Technology. Resistance to antibiotics and other antimicrobial agents. 7th Report. Session 1997±1998. London: HM Stationary Office. 4. The Working Party of the British Society for Antimicrobial Chemotherapy. Working Party Report: Hospital antibiotic control measures in the UK. J Antimicrob Chemother 1994; 34: 21±42. 5. Shales DM, Gerding DN, John JF et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Cont Hosp Epidemiol 1997; 18: 275±291. 6. Goldmann DA, Weinstein RA, Wenzel RP et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant micro-organisms in hospitals: a challenge to hospital leadership. J Am Med Assoc 1996; 275: 234±240. 7. Knox KL, Holmes AH. Regulation of antimicrobial prescribing practicesÐa strategy for controlling nosocomial antimicrobial resistance. Int J Infect Dis 2002; 6(Suppl. 1): S8±S13. 8. Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS Hospital, Salt Lake City. Clin Infect Dis 2001; 33 (Suppl. 2): S78±S83. 9. Nathwani D, Gray K, Borland H. Quality indicators for antibiotic control programmes. J Hosp Infect 2002; 50: 165±169. doi:10.1053/jhin.2001.1171. 10. Gould IM, Jappy B. Antimicrobial practice. Trends in antimicrobial prescribing after 9 years of stewardship. J Antimicrob Chemother 2000; 45: 913±917.

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