How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation

Many antimicrobial stewardship (AMS) interventions have been implemented in England, facilitating decreases in antibiotic prescribing. Nevertheless, there is substantial variation in antibiotic prescribing across England and some healthcare organizations remain high prescribers of antibiotics. This study aimed to identify ways to improve AMS interventions to further optimize antibiotic prescribing in primary care in England. Stakeholders representing different primary care settings were invited to, and 15 participated in, a focus group or telephone interview to identify ways to improve existing AMS interventions. Forty-five intervention suggestions were generated and 31 were prioritized for inclusion in an online survey. Fifteen stakeholders completed the survey appraising each proposed intervention using the pre-defined APEASE (i.e., Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity) criteria. The highest-rated nine interventions were prioritized as most promising and feasible, including: quality improvement, multidisciplinary peer learning, appointing AMS leads, auditing individual-level prescribing, developing tools for prescribing audits, improving inductions for new prescribers, ensuring consistent local approaches to antibiotic prescribing, providing online AMS training to all patient-facing staff, and increasing staff time available for AMS work with standardizing AMS-related roles. These prioritized interventions could be incorporated into existing national interventions or developed as stand-alone interventions to help further optimize antibiotic prescribing in primary care in England.


Box S3. Summary findings from stakeholder consultation: relevant to out-of-hours
In addition to similar influences on prescribing as in general practice (as above), the following were identified as specific to OOH: Facilitating/helping to change antibiotic prescribing and implement interventions:  Manual audit of individual prescribing decisions and specific feedback to prescribers (e.g., links to guidelines).

Barriers to changing antibiotic prescribing and implementing interventions:
 If the patient is re-consulting and the 'story' they present (e.g., how many times were already seen by a healthcare professional).  Lack of awareness of local guidelines as in OOH there are often prescribers from various places and their inductions are very quick.  Lack of communication from the CCG (e.g., about guidelines updates, training opportunities).  Audit of prescribing in OOH is difficult as OOH providers don't have specific geographical areas or population.  Not using unique prescriber codes, making automated prescribing audits not possible.  Lack of accountability for prescribing as prescribing is not monitored by the CCG.  Lack of incentives or training offered to OOH (such as those offered to general practices).  Lack of follow-up of patients to see if the treatment worked stifling learning and confidence in decision making.  Difficult access to patients' notes due to different computer systems.  Lack of access to lab results.  Lack of accountability for using broad-spectrum antibiotics.

Suggestions for intervention improvements or new interventions:
 Developing or improving tools/system/software to audit prescribing and give personalized advice (e.g., pointing out to specific guidelines).  Audit of individual prescribing to identify inappropriate prescribing and provide personalized advice and/or training.  Improving dissemination of prescribing guidelines and guideline updates to OOH providers and prescribers.  Making AMS training (e.g., provided by CCGs, NHS) available to OOH staff.  Improving dissemination of information about AMS training opportunities to OOH.  Improving induction of new prescribers in OOH.

Box S4. Summary findings from stakeholder consultation: relevant to community pharmacy
Barriers to changing antibiotic prescribing and implementing AMS interventions:  Lack of access to point-of-care diagnostics to check whether illness is minor or serious.  Differences in which services are commissioned by the NHS to those offered in private pharmacies (e.g., point-of-care diagnostics, such as throat swabs offered to patients for a fee in private pharmacies but not commissioned by the NHS).  Concern about the use of point-of-care diagnostics increasing prescribing for financial benefit.  Limited influence of the NHS/PHE over private services.  Many different providers and computer systems that are not always compatible.  Lack of incentives to change, e.g., to use patient leaflets.
 Low use of patient records in pharmacies (unclear why); easier to access patient records if the pharmacy is on the practice premises and they have a practice computer with access to patient records which helps with collaborative working.

Influences on antibiotic prescribing (may be barriers or facilitators):
 Availability of professionals with varying degrees of training and experience in pharmacy teams (e.g., pharmacist prescribers, dispensers, assistants, pharmacy technicians).  Degree of confidence and skills of pharmacy staff in asking the right questions and making a decision about what to advise the patient (e.g., to self-care, see a GP or go to a hospital).  Confidence to give self-care advice is often low leading to over safety-netting and telling too many patients to see a GP.  How patients present their 'story' and their expectations of treatment: o How patients describe their symptoms influences the perception of illness and what to advise. o Patients may know who in the pharmacy can prescribe and ask them specifically for antibiotics. o Patients may expect free-of-charge medicines. o Community pharmacists advising patients to see a GP creates a patient expectation for antibiotics (then harder for GPs to say no).

Suggestions for intervention improvements or new interventions:
 Providing training in giving self-care advice to the whole pharmacy teams in order to: o ensure a good level and mix of skills within pharmacy teams (considering varying roles and levels of experience/training); o develop confidence to give self-care advice and not automatically prescribe antibiotics or direct patients to a GP; o ensure consistent messages about self-care and antibiotics; o manage patient expectations for antibiotics.  Providing training to pharmacy staff that includes: o structured way(s) of asking patients the right questions and identifying red-flags; o support/encouragement to pharmacy staff to provide self-care advice; o consistent ways of providing self-care advice; o promoting the use of patient leaflets on symptom duration; o promoting the signposting patients to self-help advice online.  Promoting the use of patient records to review whether antibiotics were prescribed appropriately and encouraging pharmacists to identify and challenge inappropriate decisions.  Providing access to point-of-care diagnostics to address the lack of confidence in identifying whether illness is minor or serious; this would need to be used together in training on how to use the tests and guidelines.