Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe.

OBJECTIVES: Appropriate use of and access to antimicrobials are key priorities of global strategies to combat antimicrobial resistance (AMR). The WHO recently classified key antibiotics into three categories (AWaRe) to improve access (Access), monitor important antibiotics (Watch) and preserve effectiveness of 'last resort' antibiotics (Reserve). This classification was assessed for antibiotic stewardship and quality improvement in English hospitals. METHODS: Using an expert elicitation exercise, antibiotics used in England but not included in the WHO AWaRe index were added to an appropriate category following a workshop consensus exercise with national experts. The methodology was tested using national antibiotic prescribing data and presented by primary and secondary care. RESULTS: In 2016, 46/108 antibiotics included within the WHO AWaRe index were routinely used in England and an additional 25 antibiotics also commonly used in England were not included in the WHO AWaRe index. WHO AWaRe-excluded and -included antibiotics were reviewed and reclassified according to the England-adapted AWaRE index with the justification by experts for each addition or alteration. Applying the England-adapted AWaRe index, Access antibiotics accounted for the majority (60.9%) of prescribing, followed by Watch (37.9%) and Reserve (0.8%); 0.4% of antibiotics remained unclassified. There was unexplained 2-fold variation in prescribing between hospitals within each AWaRe category, highlighting the potential for quality improvement. CONCLUSIONS: We have adapted the WHO AWaRe index to create a specific index for England. The AWaRe index provides high-level understanding of antibiotic prescribing. Subsequent to this process the England AWaRe index is now embedded into national antibiotic stewardship policy and incentivized quality improvement schemes.

Antimicrobial Stewardship: Development and Pilot of an Organisational Peer-to-Peer Review Tool to Improve Service Provision in Line with National Guidance.

Antimicrobial resistance continues to be a considerable threat to global public health due to the persistent inappropriate use of antibiotics. Antimicrobial stewardship (AMS) programs are essential in reducing the growth and spread of antibiotic resistance, in an environment which lacks incentives for the development of new antibiotics. Over the years, a variety of resources have been developed to strengthen antimicrobial stewardship. However, the differences in resources available present a challenge for organisations/teams to establish the best resources to utilise for service provision. A peer review tool was formulated using four national documents on AMS and tested through three phases with feedback. A survey method was used to collect feedback on the validity, feasibility, and impact of the AMS peer review tool. Feedback received was positive from the earlier pilots. The tool was found to be useful at identifying areas of good practice and gaps in antimicrobial stewardship across various pilot sites. Feedback suggests the tool is useful for promoting improvements to AMS programs and highlights that the content and features of the tool are appropriate for evaluating stewardship.

Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus.

This study developed a patient-level audit tool to assess the appropriateness of antibiotic prescribing in acute National Health Service (NHS) hospitals in the UK. A modified Delphi process was used to evaluate variables identified from published literature that could be used to support an assessment of appropriateness of antibiotic use. At a national workshop, 22 infection experts reached a consensus to define appropriate prescribing and agree upon an initial draft audit tool. Following this, a national multidisciplinary panel of 19 infection experts, of whom only one was part of the workshop, was convened to evaluate and validate variables using questionnaires to confirm the relevance of each variable in assessing appropriate prescribing. The initial evidence synthesis of published literature identified 25 variables that could be used to support an assessment of appropriateness of antibiotic use. All the panel members reviewed the variables for the first round of the Delphi; the panel accepted 23 out of 25 variables. Following review by the project team, one of the two rejected variables was rephrased, and the second neutral variable was re-scored. The panel accepted both these variables in round two with a 68% response rate. Accepted variables were used to develop an audit tool to determine the extent of appropriateness of antibiotic prescribing at the individual patient level in acute NHS hospitals through infection expert consensus based on the results of a Delphi process.

Trends in Antibiotic Resistance in Urologic Practice.

CONTEXT: The significant global upsurge in antimicrobial resistance, particularly among Enterobacteriaceae, represents a serious threat to health care systems. The implications for urologic practice are of particular concern. OBJECTIVE: To review trends in antibiotic resistance in urologic practice. EVIDENCE ACQUISITION: We report current European trends of resistance in Gram-negative uropathogens. EVIDENCE SYNTHESIS: In addition to ß-lactam resistance, Gram-negative pathogens are often resistant to multiple drug classes, including aminoglycosides, fluoroquinolones, and carbapenems, commonly used to treat urologic infections. Interest is renewed in old antibiotics, and several new antibiotics are in the pipeline to meet the challenge of treating these infections. In this review, we summarise emerging trends in antimicrobial resistance and its impact on urologic practice. We also review current guidelines on the treatment and prevention of urologic infections with these organisms, and some key antibiotics in the era of resistance. CONCLUSIONS: Increasing antimicrobial resistance represents a challenge to urologic practice for both treatment and prophylaxis. Antibiotic choice should be determined according to risk factors for multidrug resistance. Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy. PATIENT SUMMARY: Antimicrobial resistance represents a challenge in urology. We summarise emerging trends in antimicrobial resistance and review current guidelines on the treatment and prevention of urologic infections, as well as some key antibiotics in the era of resistance.