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Antimicrobial Resistance Strategy and Scottish Action Plan

The tasks Involved: The UK and Scottish Action Plans

This section is concerned with how the Government intends to deliver on the Strategy to meet its aims and objectives. It expands on the commitment given in the Government's response to the House of Lords report (which includes acceptance of the SMAC Committee Recommendations on Clinical Prescribing). It also recognises the recommendation of the House of Lords to decrease the overall use of antimicrobials and hence reduce the exposure of micro-organisms to them. Scottish and UK-wide actions are listed under the relevant objectives, which, as before, are divided into eight action areas.

General

1.1 Implementation of the strategy will be overseen and co-ordinated in Scotland by the Scottish Executive (SE) Steering Group on Antimicrobial Resistance (Annex 1) and the Scottish Executive Advisory Group on Infection (AGI). SE representation on the UK Interdepartmental Steering Group will achieve UK-wide co-ordination. A number of other mechanisms as detailed below will ensure appropriate Scottish input to UK-wide implementation.

1.2 The Scottish Executive Environment and Rural Affairs Department (SEERAD) Animal Health Veterinary Unit (AHVU) is represented on the Department of Environmental Food and Rural Affairs (DEFRA) Antimicrobial Resistance Co-ordination (DARC) Group which first met in March 1999. Annex 2 details the group's remit.

1.3 A UK Expert Advisory Committee was established during 2001 to advise government on its future strategy; this Committee will relate to the Scottish Executive in line with interdepartmental concordats.

1.4 The Scottish Executive Health Department (SEHD) will engage with the English Department of Health (DoH) to provide input to the European Commission's scientific steering committee and argue for the future framework for European action in the field of public health to make antimicrobial resistance a priority for action.

Surveillance

2.1 SEHD established a subgroup of the Advisory Group on Infection (AGI) to develop proposals for a co-ordinated programme for the surveillance of healthcare acquired infection (HAI) and antimicrobial resistance patterns, and associated surveillance of antimicrobial prescribing patterns. The programme they have recommended, and which is currently being implemented, builds on the findings of the 1999, Scottish Office Department of Health (SODoH) publication "Hospital Acquired Infection: A framework for a national system of surveillance for the NHS in Scotland". It will run alongside, and in conjunction with, national audits of practice in relation to HAI and AMR overseen by SEHD and the CSBS, and will include:

• the establishment and development of appropriate national surveillance systems, and incorporate further development of Methicillin-Resistant Staphylococcus Aureus (MRSA) surveillance;

• work to explore the feasibility of including prescribing data, as well as organism/drug susceptibility data, in the roll out of clinical information and technology (IM/IT) systems (especially those used in intensive care units);

• explore ways of establishing surveillance of antibiotic prescribing in the GP community and of monitoring the effect of secondary care prescribing on the community;

• work to promote consistency of laboratory AMR testing and reporting by addressing methodological and definitional issues;

• development of priority areas for collaboration between human and veterinary AMR surveillance. Existing use of the same systems and methodologies (and the same Scottish Reference Laboratory) for salmonella resistance testing provides a basis for collaboration. SEHD will, in consultation with SEERAD (AHVU), the Scottish Centre for Infection and Environmental Health (SCIEH) and the Scottish Agricultural College (SAC), discuss further priority areas for surveillance.

2.2 All Trusts were asked to collect first-tier HAI surveillance data (MRSA bacteraemia rates) from Autumn 2001. National data were compiled and the first set of data were published in April 2002. These data will be publicly available on a regular, ongoing basis.

2.3 The planned development of enhanced MRSA surveillance systems will provide a model for the establishment of future surveillance activity which will become necessary as the emergence of AMR problems in other groups of micro-organisms, such as extended- spectrum beta-lactamases, is increasingly identified.

2.4 SCIEH in collaboration with SE, professional groups, NHS Trusts, and NHS Boards, and through an appointed project steering group, has begun to establish and develop a co-ordinated national AMR and HAI surveillance programme. An HAI surveillance system will be implemented across NHS Scotland by mid 2002, with electronic laboratory reporting using ECOSS in place during 2002.

2.5 HAI surveillance data will be used as one of a number of "indicators" to monitor the quality of infection control services in NHS Scotland. Monitoring of the implementation of, and compliance with, guidance in both hospital and community settings (GPs and dentists) will be overseen by the Clinical Standards Board for Scotland, in conjunction with SEHD. Systems are in place to achieve this in 2002.

2.6 SEHD will work with the Healthcare Associated Infection Surveillance Steering Group (HAISSG), established by DH, and with colleagues from the other devolved administrations to coordinate the development of HAI surveillance in the UK, in line with the recommendations in the House of Lords Report.

2.7 SCIEH will continue to work closely with the Public Health Laboratory Service (PHLS), the Communicable Disease Surveillance Centre (CDSC) and CDSC, Northern Ireland to provide compatible UK-wide databases. The first publicly available data were those for MRSA, in early 2002.

2.8 Antiviral resistance monitoring will be undertaken by PHLS through the new Antiviral Susceptibility Reference Unit. Scotland will be represented on the PHLS working group on antiviral drug resistance to ensure data are representative and can be used in Scotland.

2.9 The ongoing review of public health legislation in Scotland will incorporate work to bring forward a statutory scheme of reporting by laboratories in both the NHS and local authority sectors.

2.10 The majority of food samples taken for control and surveillance purposes and submitted for microbiological examination are taken by local authorities in Scotland. This activity is co-ordinated nationally by The Scottish Food Co-ordinating Committee (SFCC). Antimicrobial resistance is currently mainly tested for in isolates of foodborne pathogens from food samples that are submitted to the National Reference Laboratories. Formal mechanisms will be established nationally for reporting this information to SCIEH. The Food Standards Agency (FSA) will liaise with the SFCC and SCIEH in developing complementary systems to monitor antimicrobial resistance in micro-organisms isolated from food samples with the aim of having arrangements in place by late 2002.

2.11 DEFRA work to improve collection and reporting of AMR data at the point of slaughter in relation to foodborne pathogens will be undertaken on a GB basis. Initial data on foodborne pathogens were reported in December 2000 and data on AMR were made available in early 2002.

2.12 SCIEH will liaise with PHLS in relation to the involvement of Scottish labs in European and World Health Organization (WHO) drug resistance surveillance projects.

2.13 SEHD will collaborate with DoH in continuing to press for priority to be given to AMR surveillance in the new EU communicable disease network.

2.14 SEHD will address issues surrounding collation of prescribing and clinical data as part of the "Strategic programme for modernising information management and technology in the NHS in Scotland", including through research. This includes moving to standard drug dictionaries and the development of ward level computerised prescribing systems. The ability to capture an individual's Community Health Index number, associated with prescriptions, and to link this with clinical data, will underpin this work. The continuing development of the General Practice Administrative System for Scotland (GPASS) will facilitate monitoring of trends in antibiotic usage at local level. The potential to include the collection of AMR data as a development of the ongoing Continuous Morbidity Reporting (CMR) project in general practice will also be explored. Consideration has already been given to extending the number of practices participating in CMR to ensure that coverage is more representative at a national level.

2.15 The Scottish Agricultural College Veterinary Science Division, SAC (VSD) has a standard protocol for AMR testing. To ensure consistency of approach between SAC (VSD) and the Veterinary Laboratories Agency (VLA) of DEFRA there should be discussion to standardise surveillance methodologies on a UK basis. These discussions should centre on SAC (VSD) participation in the DARC subgroup on the surveillance of veterinary pathogens. Cost implications of any changes to surveillance systems will be developed between SEERAD (AHVU) and SAC (VSD).

2.16 Scotland will be involved in a DEFRA-commissioned baseline survey of patterns of antimicrobial use as veterinary medicine and growth promoters. SAC (VSD) together with Aberdeen University have been commissioned by DEFRA to undertake an examination of antimicrobial usage in pig production.

2.17 SCIEH, SEERAD (AHVU), and SAC (VSD) are undertaking exploratory work to develop a programme of AMR reporting by mid 2002. The FSA will liaise with these bodies in taking this work forward. The review of public health legislation in relation to the statutory notification of organisms will facilitate this development.

Prudent antimicrobial use in humans

3.1 SEHD will continue to press for greater coverage of this subject in undergraduate and post graduate curricula (medical, dental, nursing and pharmacy), and in continuing professional development through the Scottish Royal Colleges, and the newly established NHS Education Board for Scotland (which has subsumed the Scottish Council for Post-graduate Medical and Dental Education, ^{* **} the National Board for Nursing, Midwifery and Health Visiting for Scotland and the Scottish Centre for Post qualification Pharmaceutical Education), ² and the NHS (NHS Boards, Trusts and Local Health Care Co-operatives - (LHCCs)). A plan for undergraduate medical teaching in Scottish Medical Schools will be developed during 2002.

3.2 Scottish clinical effectiveness work undertaken by the Scottish Intercollegiate Guidelines Network (SIGN) supports good antibiotic prescribing practice, for example in the published evidence-based guidelines on the management of sore throat, for antibiotic surgical prophylaxis, the management of unerupted and impacted 3rd molar teeth, and the management of lower respiratory tract infection. SEHD will continue to promote the development and promulgation of evidence-based national guidelines, suitable for adaptation for local use, for the management of certain infections. The role of the Health Technology Board for Scotland and that of CRAG, in supporting implementation and audit of SIGN guidelines, will be explored. SEHD will work with SIGN to support implementation of the relevant guidelines and develop appropriate new guidelines. As part of its monitoring role the CSBS will seek to ensure that clinical standards guidelines are implemented routinely.

3.3 The establishment of a new body, the Scottish Medicines Consortium (SMC), brings together Area Drugs and Therapeutics Committees (ADTCs), and the pharmaceutical industry. This new body will co-ordinate across Scotland work done to evaluate (in terms of clinical and cost effectiveness) new medicines, new formulations and new indications for existing medicines, including antimicrobial agents. The possibility of it being used to provide a forum in which antibiotic prescribing policies across Scotland can be co-ordinated will be explored.

3.4 In line with commitments in "Our National Health: a plan for action, a plan for change" the Clinical Standards Board for Scotland (CSBS) will have an important role in ensuring compliance with good practice, as set out in the service standards being developed for infection control, antimicrobial prescribing and laboratory services.

3.5 The Faculty of General Dental Practitioners (UK) a branch of The Royal College of Surgeons of England's Faculty of General Dental Practitioners, commissioned guidance on antimicrobial prescribing in dental practice. Adult Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners was produced in collaboration with the British Society for Antimicrobial Chemotherapy and was published in 2000, and the contents include:

1. Antimicrobial resistance

2. Indications for the use of antimicrobials

3. Choice of antimicrobials

4. Prophylactic antimicrobials for medically-compromised patients (a highly comprehensive section)

All recommendations are supported by evidence where this is available, or on consensus on best clinical practice after wide consultation with appropriate groups. SEHD will encourage ways of making this document more widely available.

3.6 Infection control and the appropriate use of antimicrobials are important clinical governance issues. SEHD will provide the necessary information, tools and support to NHS Boards, LHCCs, NHS Trusts and prescribing advisers in their quest to use clinical governance arrangements to support improved antimicrobial prescribing. Specifically, compliance with evidence-based relevant SIGN guidelines will be used as one of the monitoring standards in the new control of infection performance management framework.

3.7 Drug and Therapeutics Committees are key in the development, implementation and review of formularies and policies on the management and appropriate use of antimicrobials. These formularies and policies will be informed by national initiatives including SIGN guidelines, the work of the Health Technology Board and the Scottish Medicines Consortium.

Goals for the NHS to combat resistance to antibiotics and other antimicrobial agents were issued to the service in 1999 (MEL (1999)46). Optimising antimicrobial prescribing was identified as important in achieving success and NHS Boards need to ensure that the necessary action is taken.

In February 2002, the Executive published its Strategy for Pharmaceutical Care in Scotland. The Strategy commits pharmacists to work with Area Drug and Therapeutics Committees to review and monitor local guidelines on antibiotic prescribing by December 2002.

3.8 As part of the structure for implementing the 'Strategy for Information' the Chief Pharmaceutical Officer will develop standards for electronic prescribing in hospitals by December 2003.

3.9 SEHD will continue to monitor, and feed back electronically to the service through Primary Care Trusts, trends in prescribing and will explore the provision of electronic access to prescribing information at GP and individual practice level.

3.10 The Scottish Prescribing Advisors Association Group will gather data and audit optimal prescribing in line with SMAC recommendations in Scotland.

3.11 New guidance will ensure that relevant elements of the national framework for infection control are included in the clinical governance arrangements for NHS Trusts, LHCCs and NHS Boards.

3.12 Part-funded by the SEHD Primary Care Development Fund, SCIEH, with the University of Highlands and Islands, will develop a distance learning modular MSc in infection control.

Primary care

3.13 SEHD work with NHS Boards, Primary Care Trusts and LHCCs will continue to encourage innovative approaches to prescribing support in primary care. ³ The quality of antibiotic prescribing is an important clinical governance issue in primary care and will also continue to be a feature of primary care performance management. ⁴ The Accreditation Scheme for General Practice already includes a section on prescribing and they will be approached to ensure that antibiotic prescribing is covered as part of their accreditation arrangements. This scheme is endorsed by the CSBS.

3.14 General practitioners should work with community pharmacists to implement policies and guidelines, monitor and review antibiotic prescribing.

3.15 The Primary Care Information Unit has recently established a new data warehouse and is working on the development of routine production of prescribing information in the format of Defined Daily Doses (DDDs) per head of practice population. The Unit should introduce the routine reporting of prescribing information, using the DDD format, as soon as possible. This will facilitate the routine analysis of the use of antibiotics at practice, LHCC, PCT, NHS Board and national level.

3.16 SEHD will, through GPASS, support the development of computerised "prescribing menus", incorporating local antibiotic formularies, for use in primary care.

The 2002 Clinical Outcome Indicators Report, due to be published in June, includes a section on prescribing indicators in primary care. The report includes trends in antibiotic prescribing (1998-2001), both nationally and by NHS Board, using both crude population estimations and Arbuthnott-adjusted data. Antibiotic prescribing follows cyclic trends with peaks occurring in the winter quarters (October to March). At a national level, defined daily doses per 1000 patients per month have fallen. Every NHS Board also shows falling trends, generally in line with the national average. It should also be noted that the winter peaks have been decreasing over the above period.

3.17 Access to care management screens, which facilitate data collection for audit, is available to practices using GPASS Versions 4 and 5, other GP computer systems and other complementary Clinical Decision Support Software (CDSS). SEHD will work with Scottish Clinical Information Management in Primary Care (SCIMP) to ensure that this facility supports work on antimicrobial resistance.

3.18 SEHD will continue to feed back examples of good practice, in order to support prescribing monitoring, audit, performance management and feedback.

3.19 SEHD will continue to work with the NHS through NHS/Primary Care Trust Prescribing Advisers to encourage optimal prescribing.

3.20 The SEHD Reference Laboratory Working Group will encourage the appropriate use of expensive antiviral resistance tests. The potential role of the Health Technology Board for Scotland in this area will also be explored.

3.21 The national surveillance project (see paras 2.1-2.2 above) will involve work to promote consistency of laboratory AMR testing and reporting by addressing methodological and definitional issues.

3.22 Roll out of the ECOSS project will enhance timeliness and consistency of reporting to NHS Boards and SCIEH, thus contributing to surveillance and outbreak identification and management. ECOSS should become operational during 2002. In the next stage of development ECOSS will be adapted to collect antimicrobial resistance/sensitivity data.

3.23 Enhanced access to laboratory services and the timely reporting of patient specimen results would facilitate evidence based antibiotic prescribing. In keeping with action outlined in MEL(1999)46, NHS Boards, with LHCCs, NHS Trusts and SCIEH should ensure adequate and effective clinical and public health microbiology services and thereby maximise the potential role of laboratories in this respect.

3.24 SEHD will, in liaison with DoH, plan the introduction of near-patient tests so that quality is assured and surveillance is not jeopardised.

SEHD will:

3.25 Run a sustained publicity campaign encouraging greater involvement of patients in decisions about their care, including expectations of antibiotic prescription and addressing issues of compliance. ⁵

3.26 Provide supporting information for the public/patients and professionals and consider ways of promoting AMR messages via NHS 24.

3.27 Encourage local initiatives.

3.28 The Health Education Board for Scotland (HEBS) will be asked to consider ways of promoting understanding of the issues to the whole school community.

3.29 "Nursing for Health", the report of the Chief Nursing Officer's Review of the Contribution of Nurses to Improving the Public's Health, reinforces the important role of nurses as a source of advice and information to the public and recommends the development of local public health networks to ensure that nurses have ready access to the most up-to-date sources of information.

3.30 Existing health education guidelines offer opportunities to raise the issue of antimicrobial resistance. SE will consider, in association with HEBS (as at para 3.30 above), any additional support/ information that teachers require. The launch of the Scottish Health Promoting Schools Unit, in May 2002, may also offer opportunities, in the longer term, to offer support.

3.31HEBS will be asked to explore other innovative ways of increasing public awareness of the problem of antimicrobial resistance.

The following action, undertaken by the Medicines Control Agency (MCA) is reserved and will be progressed with the UK Interdepartmental Steering Group on AMR:

3.32 Develop guidance to pharmaceutical industry to support the choice of dosage regimen in phase III trials of antibacterials.

3.33 Seek improvements in the consistency, and regular updating of summaries of product characteristics.

3.34 Review the legal status of antimalarial, antiviral and antifungal agents currently available without prescription in the UK.

3.35 Promote adherence to prescription only status for antibacterials within the EU and elsewhere.

3.36 The Medical Devices Agency (MDA) to monitor and evaluate, if indicated, the need for action to restrict dressings containing antibiotics in the UK (and educate health professionals about the potential dangers of their use).

Prudent antimicrobial use in animals

4.1 UK-wide work with partners and led by the Veterinary Medicine Directorate (VMD) of DEFRA will encourage professional education through the development of codes of practice and guidelines for farmers on the responsible use of antimicrobials in particular animal species.

4.2 SEERAD (AHVU) will continue to ensure there is significant emphasis on AMR in the undergraduate training of veterinary surgeons in the two veterinary medicine schools in Scotland.

4.3 UK-wide work with partners, and led by VMD, will review appropriate usage of antimicrobials, including as growth promoters in light of the Advisory Committee on the Microbiological Safety of Food's (ACMSF) advice, the Veterinary Products Committee advice and EU decisions.

The following action by VMD is reserved:

4.4 Critically assess existing products at the time of renewal of marketing authorisations and ensure that data sheets and product characteristics summaries are appropriate and consistent (with those for other products containing the antibacterial active ingredient).

4.5 In the authorisation process for new antimicrobials, require the development of optimised dosing rates and strategies based on recent advances in pharmacokinetic and pharmacodynamic data and, where necessary, require new dose rates and strategies for currently authorised antimicrobials.

Prudent antimicrobial use in other spheres

5.1 There is no use of antimicrobials in arable agriculture and horticulture in Scotland. Scotland will maintain that position along with the rest of the UK and support action to reduce inappropriate use in Europe and elsewhere.

5.2 Antibiotic resistance marker genes have been used as part of the process in the development of genetically modified crops. The CMO (England) recommended in his report "The Health Implications of Genetically Modified Foods" that those who are developing foods using genetic modification should be encouraged to phase out the use of antibiotic resistance marker genes as soon as possible as part of the process. SEERAD and the FSA are collaborating with other UK Government departments and agencies to achieve this aim.

Infection control

6.1 SEHD in conjunction with the CSBS and SCIEH will continue to lead the development of performance standards and targets for HAI (including MRSA) and community control of infection in Scotland, and put in place arrangements for ensuring implementation and compliance.

6.2 The SODoH Advisory Group on Infection "Scottish Infection Manual" (July 1998) provides guidance on core standards for the control of infection in hospitals, health care premises, and at the community interface.

6.3 SEHD will act on recommendations in this area arising from the Chief Medical Officer's (CMO (Scotland)) Review of the Public Health Function to strengthen the NHS board communicable disease and environmental health function and ensure good regional level links between public health medicine, veterinary medicine and environmental health practitioners.

6.4 SEHD and CSBS will seek and ensure improvements in infection control practices in the NHS and other care settings through the clinical governance framework.

6.5 The former NHS Management Executive (NHS ME) emphasised the importance of infection control in the Priorities and Planning Guidance for 1999-2002. Performance Management Division (in collaboration with CSBS) have developed appropriate targets and standards to monitor implementation of appropriate action through the new performance monitoring arrangements.

6.6 SEHD will review the need for further action in light of the recent National Audit Office survey of infection control in acute hospitals in England and the review work of the CSBS.

6.7 The needs of infection control will be addressed by the Review of Public Health Legislation.

6.8 SEHD and SCIEH will link with the relevant EC actions concerned with the control of nosocomial infection.

6.9 SEERAD will encourage the development of voluntary health schemes to control and prevent animal infections on farms.

6.10 SEERAD, through the State Veterinary Service, will continue to take action to control notifiable animal diseases on farms.

6.11 SEERAD, in conjunction with SAC, will provide advice to medical colleagues on the investigation and control of non-notifiable zoonotic infections on farms.

6.12 SEERAD, through professional veterinary bodies, will encourage best practice by veterinary surgeons in the use of veterinary medicines on farms to control infections.

6.13 SEERAD will link with relevant EU initiatives for infection control in animal production.

Information technology

To ensure that developing information systems take account of the needs of antimicrobial resistance surveillance and prescribing monitoring and support, and that they allow effective international co-operation in this field

7.1 Implementation of the "Strategic Programme for Modernising Information Management and Technology in the NHS in Scotland" will provide a range of compatible electronic-based clinical support systems, and attention will be given, both nationally and locally, to a number of issues relevant to supporting work on antimicrobial resistance including:

• Information for patients and the public

• Information for clinicians

• Information for management

• Surveillance and public health

• Infrastructure issues

• Implementation issues (including training).

7.2 The second stage of development of the ECOSS system will include collection of AMR data.

7.3 SEHD will explore use of the Internet to disseminate information regarding AMR to both professionals and the public.

7.4 The Electronic Clinical Communication Implementation (ECCI) programme will facilitate efficient secondary/primary care communication (particularly relevant are the microbiology laboratory, primary care and Consultants in Public Health Medicine (CPHM) interfaces).

Research

To encourage the development of relevant new technologies

8.1 SEHD will participate in UK-wide liaison to ensure a co-ordinated approach between the major Government funding bodies, in which the relevant clinical and public health issues related to antimicrobial resistance are appropriately addressed, including through the Chief Scientist Office (CSO) and SEERAD research programmes

8.2 The Advisory Group on Infection will prioritise areas for AMR research in Scotland, taking note of the findings of the subgroup of the UK Interdepartmental Steering Group for AMR, and capitalising on the particular research, epidemiological and commercial context in Scotland. CSO and SEERAD will collaborate in this area, jointly funding research initiatives as appropriate.

Specific areas of research mentioned in reports include:

• Basic mechanisms of resistance and its spread

• Drivers of resistance and effects of interventions

• Research to support development of surveillance in this field and answer hypotheses raised by surveillance data

• Optimum dosing and duration of antimicrobials

• Links between prescribing patterns and AMR

• Community vs hospital patterns of AMR

• Clinical research into what was prescribed and why, to better inform clinical prescribing practice

• Impact of resistance on clinical outcome (and costs)

• Rapid, affordable, diagnostic and susceptibility tests

• Use of delayed prescriptions

• Vaccine development

• Infection control: factors favouring cross-infection and best practice for control

• The role of commercially available antibacterials in selection for AMR

• Alternative means of animal husbandry to allow discontinuation of antibiotics as growth promoters

• Development of partnerships with the pharmaceutical industry for development of novel agents for human and animal use.

8.3 The programme of veterinary research into AMR will continue in Scotland. This includes collaboration in GB-wide research funded by DEFRA, as well as projects funded by SEERAD. A large programme of animal research started in 2000 following a call for proposals in the Animal Health and Welfare Research Requirements document, and through the Veterinary Medicines Research Requirements. This will include work to track resistant bacteria through the food chain in collaboration with the FSA.

8.4 Scotland participated in a major DEFRA-funded slaughterhouse survey into zoonotic agents in cattle, sheep and pigs which includes an AMR resistance component. The results of the survey were made public in 2001.

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