In this article antimicrobial stewardship in the United Kingdom is discussed.
Interview with: Tariq Azamgarhi, MRPharmS, PGDip Clin Pharm, PG CEPIP
Interview by: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP
Article posted 1 August 2022
Antibiotic use and resistance varies geographically, but across the world antimicrobial stewardship (AS) and antimicrobial stewardship programs (ASPs) can serve as critical towards supporting safe and appropriate antimicrobial drug use. To learn about challenges from around the globe, we have been interviewing pharmacists at different countries about antimicrobial stewardship. So far we have has interviewed pharmacists from Nigeria, India, Bangladesh, Uganda, Thailand, Japan, Costa Rica, Australia, New Zealand, Canada, and Spain.
Recently a colleague connected me with Tariq and we set off on composing this interview. He is a pharmacist in the United Kingdom who supports antimicrobial stewardship within the area of bone and joint infection management.
For readers new to this series I recommend reviewing some of the other country interviews in addition to this one. We may be in different geographic regions of the world, but when it comes to antimicrobial resistance (AMR), a threat here or there is a threat everywhere.
Here is our interview on antimicrobial stewardship in the United Kingdom…
1. How did you get interested in antimicrobial stewardship as a pharmacist and what path did you take to reach where you are today?
Thank you for the invite, Tim. I was born and raised in Birmingham, England and studied Pharmacy on the South Coast. I moved to the southeast and spent my early career working in district general hospitals. I did not know what I wanted to do, but I experienced the usual medical and surgical rotations, enjoying new challenges whenever they arose. During my postgraduate Clinical Pharmacy Diploma, I gravitated towards antimicrobial stewardship whilst working in critical care. It is fascinating working with healthcare professionals, and their different views and attitudes appealed to me. Although, it is not without its challenges!
In 2017 I volunteered as a disaster relief pharmacist for a non-governmental organization. I worked in Sierra Leone for four months at an Ebola treatment centre, followed by a brief time in Nepal after the 2017 earthquake. I gained a greater insight into infectious diseases such as ebola, malaria and tuberculosis along with their impact on patients and their families in a lower-income setting. As with all disaster relief situations, it is not without its emotional and physical challenges, but the rewards far outweigh them. I saw very little of Sierra Leone and Nepal, but I hope to return one day!
When I returned to England, I applied for a 12-month position providing maternity coverage for the specialist antimicrobials pharmacist at the Royal National Orthopaedic Hospital (RNOH). I witnessed the devastating impact of orthopaedic infection on patients in the largest orthopaedic hospital in England. The pharmacist chose not to return after maternity leave, and I successfully applied to the substantive role and have remained there ever since.
My role includes antimicrobial stewardship (AMS), providing expertise to the bone infection unit, outpatient parenteral antimicrobial therapy (OPAT) team, and infection prevention and control (IPC). The pharmacy team is relatively small, with a total of 42 staff, so I have senior managerial responsibilities in my department. That side of my role can be challenging, and the skills I have developed certainly complement the AMS role.
I have been fortunate to work with amazing people within and outside the organisation while carving my niche. Areas I have enjoyed developing expertise in:
- Individualising systemic antimicrobial treatment for patients with bone and joint infections
- Implementing complex treatment plans for OPAT patients by working with healthcare workers across the complex national healthcare system
- The safe use of antimicrobials incorporated into medical devices such as bone cement coatings and other biomaterials
- Initiating and improving adherence to specialist guidelines for prevention and treatment of infection where there is little or no published evidence
I have found that patients come to RNOH from across the UK in search of help, often with a long history of bad experiences in the healthcare system. Working in a multidisciplinary team can be hugely rewarding when it works out because you can make a huge difference for patients, although, of course, that’s not always possible.
2. What is the status of antimicrobial stewardship in the United Kingdom, based on what you see in your practice?
During the first COVID-19 pandemic wave, the theatres and critical care areas at RNOH were reconfigured to care for COVID-19 patients in support of the surge in London. We saw significant increases in broad-spectrum antimicrobials, which differs significantly from our usual antimicrobial use patterns. Like all AMS teams, trying to be agile and respond to this change has been an enormous challenge. At the same time, there were multiple competing priorities, such as managing the bone infection caseloads, implementing changes to departmental IPC practice, vaccination programmes and new COVID-19 treatments.
In England, AMS targets are built into all National Health Services (NHS) hospital contracts. As we emerge from the pandemic, supporting the national strategy and getting back on track will be critical moving forwards. Our antimicrobial use is measured and freely accessible on public platforms. Maintaining reductions in antimicrobial use is a continuous challenge for AMS teams! Additionally, with competing priorities for AMS, drug shortages and squeezing of hospital budgets, it’s a challenging time to be an AMS pharmacist!!
I do not know enough about AMS in other countries to make comparisons. There have been notable achievements through the European Union, such as coordinated surveillance, antimicrobial development, and bans on antimicrobial use in animal husbandry. In general, the UK, alongside other countries, Netherlands, France, Germany, and Sweden, have led by example, trending towards lower AMR rates and antimicrobial consumption compared to other European countries.
3. What are pharmacists in the UK doing to improve antimicrobial stewardship?
The pharmacist’s role in antimicrobial stewardship has evolved tremendously since the early 2000s in the UK. Pharmacists have stepped up in the most remarkable way during the most challenging of times!
UK pharmacists play key leadership roles at a national and international level working within the multidisciplinary team to implement AMS. In England, pharmacists work at strategic levels within the NHS and various stakeholders, including professional bodies and in an advisory capacity at the government level.
They usually lead AMS programmes in hospitals within multidisciplinary teams (MDTs), initiating and reviewing empirical antimicrobial guidelines, governance, training, improvement, surveillance, innovation and research. AMS training for pharmacists, nurses and medics is a core part of what we do. More recently, I have developed a training programme for undergraduates and student pharmacists who visit RNOH on placement. It is a rewarding part of the job supporting early career development in AMS.
In the community, pharmacists are an accessible source of expertise, where they promote self-care and raise awareness of AMR. Pharmacists also undertake enhanced roles through nationally commissioned services, including managing minor ailments to avoid the need for medical intervention and clinical management of uncomplicated UTIs using patient group directions. There are also examples of community pharmacists working within the MDT with clinical infection management using decision aids/scoring tools to identify patients with sore throats who are more likely to benefit from antimicrobials, reducing the potentially avoidable use. In addition, I have seen encouraging pilot data of community pharmacists using C-reactive protein as a near-patient point of care test for respiratory infections and working with local general practitioners to reduce diagnostic uncertainty and target the use of antimicrobials.
4. What is the most important lesson you have learned about antimicrobial stewardship?
Build networks and collaborate.
We tend to work in silos in our complex healthcare system. The value of networking with peers and other healthcare professionals has been a big lesson. We face similar challenges, and all antimicrobial stewards have a common goal.
Luckily UK AMS pharmacists have multiple networks to access advice, learn from each other’s successes and failures and collaborate. I certainly feel more connected with my peers since the pandemic; more recently, our regional AMS group has set up a protocol for Penicillin de-labelling through our area’s medicines formulary committee. I am implementing this locally at RNOH to open antimicrobial options for bone and joint infection patients.
5. What is the most pressing antimicrobial stewardship issue in the United Kingdom today?
During the pandemic, we have seen significant pressure on using antimicrobials within hospitals. Multidrug-resistant organisms are always challenging but do not contribute to a substantial proportion of overall antimicrobial use in humans. The use of antimicrobials in the community for common infections caused by susceptible organisms is driving overall antimicrobial use.
In England, high-level targets for antimicrobial use are set out in the 2019 – 2024 National UK AMR action plan. The target for the overall usage of antimicrobials is a reduction of 15% by 2024. A steady decline was seen in the community pre-pandemic, followed by an accelerated decline during the pandemic due to fewer General Practitioner consultations. In hospitals, there is a target to reduce WHO watch and reserve antibiotics by 10% compared to 2017 levels. A steady decline pre-pandemic was accelerated during the pandemic, likely due to a decrease in overall hospital activity. Antimicrobial use is rising with increases in healthcare activity as we emerge from the pandemic, and managing this is the most pressing issue.
I must mention the enormous challenge of easing the backlog of elective orthopaedic surgery, which is a national priority. Reducing the burden of infection by optimising antimicrobial use to prevent infections through surgical prophylaxis and skin decolonisation are priorities to support this.
6. What do you predict for the future of antimicrobial stewardship in the United Kingdom?
As I reflect on the past 24 months, there is much to build on. Who would have thought the entire population would be routinely using rapid diagnostics such as lateral flow tests? Maybe we can use this to diagnose infections better so that antibiotics are only started where they are likely to be of benefit.
Also, how we interact with patients significantly changed during the pandemic. Using technology to be more in touch with our patients provides the potential for more robust feedback loops so that clinicians have more confidence in prescribing shorter antimicrobial course lengths where the evidence supports this.
At RNOH, we are implementing an open-source electronic prescribing system, so we are excited to see what opportunities an open-source system can bring for stewardship.
Using human genomics to support AMS is another exciting opportunity for further research.
Precision dosing is likely to become more common. I am currently working on a PhD project to see how we can adapt antimicrobial prophylaxis in patients with a highly vulnerable group of bone tumours. Hopefully, more to follow on this in the future!
Final thoughts
The best advice I can leave you with is to develop your team, make new links within and outside your organisation, be in it for the long haul, rest, and most of all, enjoy it!
Particularly Helpful Resources
English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report
- This report includes national data on antibiotic prescribing and resistance, antimicrobial stewardship implementation, and awareness activities
Antimicrobial stewardship: Start smart – then focus
- This toolkit provides an outline of evidence-based antimicrobial stewardship in the secondary healthcare setting
ABOUT THE INTERVIEWEE
Tariq Azamgarhi, has been specialist antimicrobial pharmacist at the Royal National Orthopaedic Hospitals NHS Trust since 2015. He was awarded a Masters in Pharmacy degree from University of Portsmouth in 2007, a diploma in clinical pharmacy practice from University of Medway in 2011 and became an independent prescriber in 2019.
He is currently the lead pharmacist for the bone infection unit at the RNOH delivering specialist care to patients being treated for complex bone and joint infections in an inpatient and outpatient setting. The RNOH is a centre of excellence for bone and joint infections, accepting referrals nationally and internationally.
Tariq has an interest in OPAT and antimicrobial stewardship. He also has an interest in research and is currently undertaking a PhD project on surgical prophylaxis in primary bone sarcomas. He has presented at various national and international orthopaedic conferences.
You can find him on Twitter @tariq_azamgarhi.
