Patient safety

The right culture is key to antimicrobial stewardship

Prof. Dilip Nathwani is a speaker at the Infection Prevention Society’s Infection Prevention Conference 2018, consultant in infectious diseases and honorary professor of infection at the University of Dundee, and past president of the British Society of Antimicrobial Chemotherapy (BSAC). Here, he argues that the right culture is the key to antimicrobial stewardship.

Human studies suggest that more than one fifth of prescribed antibiotics are unnecessary or inappropriate. This is a major issue that threatens the effective prevention and treatment of an ever-increasing range of infections. A key factor in ensuring the correct prescribing of antibiotics is creating the right culture within whatever setting the antibiotics are used in. Antimicrobial stewardship aims to improve antibiotic prescribing and relies on a series of informed decisions made in a supportive, trusting and engaged environment.

Part of building a supportive culture means engaging fully with all the key stakeholders involved in the prevention, diagnosis and treatment of infection. For example, an integrated approach that sees the laboratory working closely with prescribing clinicians, stewardship and infection prevention teams will achieve better patient outcomes, increase patient safety and reduce antimicrobial resistance and C.difficile.

Trusting your multi-disciplinary team can also play a key role in antimicrobial stewardship. As the person present throughout the majority of patient activities, the role of the nurse in supporting stewardship activity is deemed important. For instance, if the patient is eating breakfast and is improving, they might be able to take oral antibiotics allowing the team to remove the intravenous line, a potential source of infection. To support this approach, we in Dundee have been at the forefront of supporting the development of the nurse’s role in stewardship. As a sign of the organisations commitment to this, we appointed the first antimicrobial stewardship nurse practitioner in 2015.

Providing education and the right environment and culture also means ensuring that healthcare workers feel confident in being able to tell patients that antibiotics is not the best course of action. Patients may put pressure on their doctor to prescribe an antibiotic when in fact they are unlikely to benefit from it. Whilst it might be tempting to prescribe a course of antibiotics to a demanding patient, or in time of great diagnostic uncertainty when working in extremely pressurised environments, we must be sure as healthcare professionals that the prescription is the right decision. Even if this leads to an antibiotic prescription, good stewardship is about getting that decision and prescription reviewed promptly so adjustments, including stopping the treatment, can be made. Once again an open, multi-professional, supportive team approach to prescribing that encourages review, reflection and feedback, and is a sign of a mature and high functioning system. Involving patients in this process is also key to success

The importance of ‘culture’ also applies more literally to the taking of microbiological cultures to identify the organism that is causing the infection. Of patients given antibiotics in US hospitals, around 40% have not had a microbiological culture. This leads to unnecessary use of antibiotics and often use of rather broad-spectrum agents, often for protracted periods, all of which drives antibiotic resistance. In addition to not taking cultures, the current available tests often do not grow the bug or take a long time to get the result to the prescribing doctors. This perpetuates the need to use antibiotics inappropriately. To optimise this, prescribers need to maximise the use of laboratories and, on the other hand, laboratories have to invest in emerging innovative diagnostics that will support the rapid identification of the organism and the best treatment. Reducing diagnostic uncertainty is fundamental to good stewardship. Finally, even if we achieve this, making sure that results from the laboratory are correctly actioned in clinical practice is critical to ensure optimal patient care and outcomes .

There is now strong evidence that a range of stewardship interventions, in a variety of settings, delivered by skilled teams working in a cohesive way that are supported by the organisation and its leadership, will have a positive impact of a range of clinical, resource, economic and microbiological outcomes. While we still need to understand many things about how best we tackle AMR, about why some things work in certain setting and not in others, the question is no longer if stewardship works, but rather how can we most effectively implement it. We all have a responsibility to ensure good antimicrobial stewardship.

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