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11. Action Plan: Antimicrobial Management Teams ( AMT)

The role of the Antimicrobial Management Team in improving standards of antimicrobial use includes supporting staff education and clinical governance, promoting application of hospital antimicrobial policies, and enabling audit and feed back of these policies. In the context of single system working, hospital and 'out of hospital' care are both included in the remit of the Antimicrobial Management Team.

The Antimicrobial Prescribing Policy and Practice document ² highlighted concern about insufficient liaison between microbiologists, clinicians and pharmacists. The Infection Control Manager, lead physician, microbiologist and pharmacist for antimicrobial prescribing should take responsibility to ensure the Antimicrobial Management Team(s) are set up and fully functional as soon as practical. The Antimicrobial Management Team including lead antimicrobial physician, lead microbiologist, lead antimicrobial pharmacist and other appropriate professionals should work supportively and collaboratively to promote prudent antimicrobial use through the actions outlined in this section.

Larger NHS Boards may wish to establish local hospital antimicrobial management teams, to facilitate the implementation of the recommendations.

Reporting Local and National Trends on Antimicrobial Resistance and Antimicrobial Utilisation

All Antimicrobial Management Teams should ensure that the relevant recommendations are adopted from Antimicrobial Prescribing Policy and Practice². These are:

• For the purpose of appropriate patient management and antimicrobial resistance surveillance, blood cultures should be submitted before antimicrobial administration in all patients with possible bacteraemia
• MIC or zone sizes must be measured for all clinically relevant bacterial isolates
• Susceptibility to non formulary or restricted agents should not routinely be reported by microbiology departments
• Standard systems should be in place for bringing antimicrobial resistance alerts to the notice of the infection control team and clinicians/prescribers
• The institution laboratory susceptibility data should be published annually. Duplicate isolates should be removed from the analysis. Local susceptibility data should be used to inform prescribers, policies and formularies.
• All acute hospitals should analyse and report antimicrobial use using the World Health Organization Defined Daily Doses numerator and total occupied bed days as the denominator
• The use of key antimicrobials should be analysed and evaluated on a monthly to 3 monthly basis for each hospital, group of hospitals, directorates and specific wards
• The Antimicrobial Management Team should liaise and co-ordinate with the Area Drug and Therapeutics Committee on controlling the introduction and the use of new antimicrobial medication.

In addition, all Antimicrobial Management Teams:

• should receive, and ensure implementation of, advice from the Scottish Medicines Consortium at local level about antimicrobial resistance patterns and antimicrobial utilisation in a timely manner
• should ensure that information sent from Scottish Medicines Consortium is disseminated in a timely manner to all relevant parties
• should co-ordinate the work across hospital and 'out of hospital' care areas
• link with the Scottish Medicines Consortium in determining new risk factors and drivers for resistance. Where risks are identified, Antimicrobial Management Teams should work with local infection control teams and area drug and therapeutics committees, clinical governance and risk committees to minimise emergence of resistance.
• monitor the burden of disease caused by antimicrobial resistant strains and antibiotic-related infections (initially targeted at key organisms e.g. MRSA bacteraemias, pneumococcal bacteraemia and Clostridium difficile infection).

Education of staff

To ensure quality and safety objectives are achieved, Antimicrobial Management Teams should help ensure the implementation of multi-professional educational programmes developed by NHS Education for Scotland for contracted and employed staff, including staff in the independent sector. These will relate to healthcare associated infection, antimicrobial resistance and prudent antimicrobial prescribing, working in collaboration with infection control committees and Infection Control Managers.

Clinical Governance in Antimicrobial Utilisation and Measures for Improvement

Appropriate use of antimicrobials is an important clinical governance issue. The Antimicrobial Management Team should ensure compliance with evidence based infection related Scottish Intercollegiate Guideline Network ( SIGN) guidelines and audit recommendations within these guidelines, which should be used to monitor quality of prescribing practice in hospitals and community.

Antimicrobial management teams should also feed back to Scottish Medicines Consortium information on effective actions and good practice which promote prudent antimicrobial prescribing and reduction in antimicrobial resistance.

Infection Control Managers, working with the Antimicrobial Management Team, will have managerial responsibility for ensuring implementation of, compliance with, and review of, prudent antimicrobial prescribing policies. Together they will implement, deliver and supervise:

• specific competencies and capabilities for each healthcare professional group based on national core competencies as defined by NHS Education for Scotland;
• identification of an education facilitator or education subgroup within their institution. This person or group should oversee the achievement and maintenance of specific competencies and capabilities for antimicrobial prescribing for individual prescribers and groups of prescribers.

In terms of clinical governance for antimicrobial utilisation and measures for improvement, data relating to antimicrobial performance indicators should be fed back to risk management and clinical governance bodies to help ensure best standards of good quality and safe care.

In relation to hospital policies and audit, the Antimicrobial Management Team should ensure that:

• where appropriate, all new staff are aware of antimicrobial policies at induction
• all microbiologists, pharmacists and prescribers are aware of hospital policies relating to antimicrobial use and antimicrobial resistance
• antimicrobial policies are regularly updated, with stated review dates, to reflect local antimicrobial resistance patterns and inform appropriate treatment
• compliance with antimicrobial policies is audited regularly and results fed back to local users
• information on unexplained departures from prescribing policies is fed back to prescribers and to the risk management and clinical governance groups in order to optimise patient care
• working with the infection control manager they are active in ensuring that national and local policies are followed in the boarding-out of potentially or actually infected patients. Generally such patients should not be boarded to other wards except for clinical reasons and in major emergencies.

All Antimicrobial Management Teams should ensure that they have adequate public representation as fully engaged and involved members.

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