The Programme

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Background

Increasingly, bacteria (germs) no longer respond to antibiotics. This means antibiotics have begun to stop working as well as they should. This can result in patients experiencing more severe infections, lasting longer than they previously did, and may, in some cases, lead to an increased risk of dying from infections. This is due to too much inappropriate use of antibiotics. The UK Government and World Health Organization believe this is an extremely important issue to tackle.

To improve antibiotic prescribing, "6Rs" should be followed; patients should be given:

1. the Right antibiotic;

2. at the Right dose;

3. by the Right route;

4. for the Right infection;

5. at the Right time; and

6. for the Right duration.

The reasons for overuse of antibiotics include doctors not having relevant information (e.g. on resistance patterns) when prescribing antibiotics, concerns about missing possibly serious infections, and time pressures/lack of continuity of care, limiting opportunities for doctors to review diagnoses and stop antibiotics if no longer needed. Our literature review and discussions with experts found that hospital electronic prescribing (ePrescribing) systems can be used as a type of software that can be used to support new ways of working designed to safely reduce inappropriate antibiotic prescribing. Most of this work however comes from the United States. There is very little UK experience of developing such interventions to achieve the 6Rs.

Aim

To develop and evaluate a multifaceted intervention (ePAMS+) that incorporates technical, behavioural and organisational components to safely reduce inappropriate antibiotic use in adult medical in-patients.

Questions

• What are the main challenges and facilitators to reducing inappropriate antibiotic use in adult medical inpatients? (WP1)
• In what ways can our new intervention (ePAMS+), which incorporates technical, behavioural and organisational components, promote antimicrobial stewardship (AMS)? (WP1)
• How is ePAMS+ best delivered? (WPs1&2)
• What are suitable secondary outcomes and process measures? (WPs1&2)
• Is ePAMS+ acceptable and feasible to implement (for healthcare workers and patients)? (WP2)
• Are our planned trial procedures acceptable and feasible? (WP2)
• How much patient-level variability is there in the co-primary outcomes? (WP2)
• Is ePAMS+ effective in safely reducing inappropriate antibiotic use? (WP3)
• What are the mechanisms of action and unintended consequences of ePAMS+? (WPs1-3)
• Is ePAMS+ cost-effective? (WP4)

Objectives

• Understand the challenges and facilitators to achieving AMS (WP1)
• Iteratively develop a multifaceted intervention incorporating technical, behavioural and organisational components (WP1)
• Establish the best way of delivering ePAMS+ (WPs1&2)
• Agree appropriate secondary outcomes and process measures (WPs1&2)
• Confirm that ePAMS+ is acceptable and feasible to implement (for healthcare workers and patients) (WP2)
• Confirm the acceptability and feasibility of our trial procedures (WP2)
• Estimate patient-level variability in the co-primary outcomes (WP2)
• Establish the effectiveness of ePAMS+ in safely reducing inappropriate antibiotic use (WP3)
• Determine the mechanisms of action and unintended consequences of ePAMS+ (WPs1-3)
• Establish the cost-effectiveness of ePAMS+ (WP4)
• Assess likely generalisability and sustainability (WPs1-4)

Methodology

Our Programme comprises four inter-related work-packages (WPs):

• WP1: a) Planning, developing and optimising all elements of the complex ePAMS+ intervention and b) Carrying out qualitative feasibility and longitudinal process studies of the implementation of ePAMS+
• WP2: Agreeing secondary outcome measures and establishing the feasibility of evaluating ePAMS+ through a hybrid cluster-randomised stepped-wedge trial 
• WP3: Evaluating the effectiveness of ePAMS+ in safely reducing inappropriate antibiotic use
• WP4: Estimating the cost-effectiveness of ePAMS+ in reducing inappropriate antibiotic use

Funding

This programme has been funded by the National Institute for Health Research (Programme Grants for Applied Research, Development and evaluation of a complex ePrescribing-based Antimicrobial Stewardship (ePAMS+) Intervention for hospitals, RP-PG-0617-20009).