Antimicrobial Resistance (AMR) and Antibiotic Stewardship Principles at End of Life

Background

The World Health Organisation defines antimicrobial resistance (AMR) as occurring when microorganisms no longer respond to antimicrobial medicines. This means that antibiotics are less effective and that other medical procedures and treatments, such as surgeries and cancer chemotherapy, become much riskier.

In 2019 the UK government committed to a 20-year vision for AMR which is to be delivered in a series of 5-year National Action Plans (NAPs). The second of these ‘Confronting antimicrobial resistance 2024 to 2029’ was published in May 24 and is based around four themes and associated outcomes, with themes 1 and 2 being the most relevant to Ashtons.

Theme 1 – Reducing the need for, and unintentional exposure to, antimicrobials

Outcome 1 – Infection prevention and control and infection management.

Outcome 2 – Public engagement and education.

Theme 2 – Optimising the use of antimicrobials

Outcome 4 – Antimicrobial stewardship and disposal. This aims to improve the use of antimicrobials to preserve future effectiveness.

Outcome 5 – AMR workforce. This aims to raise awareness with the workforce in human health, animal health and agriculture to improve the optimal use of antimicrobials

There are two human health targets associated with Theme 2:

Target 4a: by 2029, to reduce total antibiotic use in human populations by 5% from the 2019 baseline

Target 4b: by 2029, to achieve 70% of total use of antibiotics from the Access category across the human healthcare system (UK-AWaRe antibiotic classification).

Antimicrobial Stewardship (AMS)

AMR occurs naturally as the result of rapid evolution of microbials in response to the presence of antimicrobials and cannot be prevented completely but misuse of antibiotics in humans and animals is accelerating the process. Antimicrobial Stewardship (AMS) has a key role to play in controlling and mitigating AMR. It is defined by NICE as ‘an organisational or health-care-system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness’.

Translating this to a patient level the main tenets of AMS are: correct diagnosis, optimal drug/dose choice, correct route of administration, optimal duration, timely de-escalation, correct disposal.

The National Action Plan is committed to supporting clinicians in making these judgements through the use of clinical decision support tools that can utilise large data sets; as well as algorithms and local resistance patterns to provide the best possible picture for healthcare workers deciding which antimicrobial to prescribe (or not to prescribe). These tools will also help to empower patients and drive shared care decision making that will reduce the expectation of antibiotics by patients.

Practice at end of life

An example of how AMS principles can be applied to clinical practice are available at Scottish Antimicrobial Prescribing Group (SAPG) who have formulated some Good Practice Recommendations for Antibiotics at End of life.

Advanced care planning

Advanced care planning discussions with the patient and, where appropriate, family, could include the future use of antibiotics in terms of benefits or risks but also the patient’s priorities and preferred place of care. Intravenous antibiotics may involve a hospital admission, the subcutaneous route might allow Outpatient Parenteral Antimicrobial Therapy (OPAT) or oral therapy which can be given at the hospice or home might be more appropriate.

Shared decision making

Clarity around goals and limits of therapy should be established with the patient or family. This would include whether the antibiotic is to be used to cure an infection or for symptom control. The risks of treatment such as c.difficile should be discussed as well as the perceived benefits.
Treatment should not usually be initiated in response to positive microbiology tests unless there is a clear symptom related goal.
Consideration should also be given to whether symptoms can be controlled without the use of antibiotics.

Antibiotic choice and review

If an antibiotic is to be prescribed; dose, route and choice of antibiotic should be in line with local guidance and reviewed regularly. Always document on the prescription the reason for prescribing and enter a stop date or a review date. Reviews can be for switching a broad-spectrum antibiotic to a more specific product in line with microbiology results or switching from parenteral to oral treatment. If the antibiotic is prophylactic this should also be clearly documented to allow an informed decision to be taken during medication reviews.
If there is no benefit seen, side effects are an issue or the patient’s condition progresses reconsider the decision to use antibiotics. Consider a differential diagnosis and other contributing factors; delirium and terminal agitation may be wrongly attributed to infection.

Administration

All principles of IPC should be followed and ANTT (aseptic non-touch technique) used.

Disposal

Dispose of antibiotics and consumables according to the waste disposal policy. If at home counsel the patient or relatives how to dispose of unused medicines correctly.