The Scottish Government

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3. The Scottish Management of Antimicrobial Resistance Action Plan ( ScotMARAP)

The Healthcare Associated Infection ( HAI) Task Force set up a Steering Group on the Antimicrobial Resistance Strategy and Scottish Action Plan in 2006, with the remit of:

• assessing progress with the implementation of the 2002 Antimicrobial Resistance Strategy and Scottish Action Plan¹ and producing a successor document
• assessing progress with the implementation of the 2005 Scottish Medicines Consortium/ HAI Task Force document Antimicrobial Prescribing Policy and Practice² ( APP&P) and identifying outstanding actions required to achieve the goals of:
  • Reducing antimicrobial resistance
  • Promoting prudent antimicrobial prescribing
  • Developing a strategic approach to the systematic identification and containment of future resistant organisms.

The Steering Group fully endorses the conclusions of the Antimicrobial Prescribing Policy and Practice document ² and notes that NHS Boards are moving towards implementing at least some of the major recommendations. The Steering Group notes however that progress in this area has been slow and patchy. In addition, this report focused solely on the acute, hospital setting and did not address the 'out of hospital' care environment. The present report includes all situations whether 'in hospital' or 'out of hospital' care.

The Steering Group believes that progress towards full implementation should be accelerated despite the many competing demands on NHS Board resources. The issue is of great concern to clinical, public health and other healthcare professionals, and to patients and their carers. Moreover, there is increasing public concern surrounding the perceived increase in frequency of healthcare associated infection associated with resistant organisms ('superbugs'), particularly in the hospital environment. This concern also now extends to Clostridium difficile infection, which is related to antibiotic use though not strictly a 'resistant' organism: the principles expressed in the current document apply in large part to prevention and control of C. difficile infection.

The Group believes that it is now time to bring together several strands of information relevant to antimicrobial resistance. These include data on current and past levels of resistance in various sites within NHS Scotland, and data on antimicrobial prescribing patterns within the same environments. Such information should be collected, collated and analysed in a standardised manner, and thereafter communicated at appropriate regular intervals directly both to NHS Boards, their Area Drugs and Therapeutics Committees and Antimicrobial Management Teams and, through them, to prescribers.

This current document will detail a strategy for Scotland to take forward key recommendations from the Antimicrobial Prescribing Policy and Practice document ² and meet National and European recommendations in:

• promoting prudent prescribing of antimicrobials through improved diagnostics, feedback of surveillance data to prescribers, and education of staff
• collating, analysing and reporting, in a standardised manner, local and national trends in antimicrobial resistance to allow early identification of serious antimicrobial resistance within hospitals and the community
• collating, analysing and reporting, in a standardised manner, local and national trends in antimicrobial utilisation in primary and secondary care to monitor and improve antimicrobial use
• linking data on antimicrobial utilisation and antimicrobial resistance
• monitoring the success of interventions to reduce the level of resistance.

Education of the public is also important and should be considered, albeit with due caution around possible unintended consequences ²⁸. Further research to provide sound evidence on the safety and effectiveness of public media campaigns and other approaches in this area is clearly required.

The Steering Group recommendations follow. These incorporate the six original key areas identified in the Antimicrobial Prescribing Policy and Practice¹⁵ publication, but are broadened, and where appropriate, cover both hospital and 'out of hospital' care settings. The recommendations cover antimicrobial resistance, antimicrobial utilisation, and education of NHS staff (and of the general public as appropriate) on use of antimicrobials. These recommendations are specifically detailed for each responsible organisation, team and individual. In order, the action points are listed for the following agencies:

• Scottish Government Health Directorates (previously the Scottish Executive Health Department)
• Scottish Medicines Consortium ( SMC)
• NHS Quality Improvement Scotland ( QIS)
• Health Protection Scotland ( HPS)
• National Medicines Utilisation Unit ( NMUU)
• NHS Education for Scotland ( NES)
• NHS Boards
• NHS Board Antimicrobial Management Teams ( BAMT)
• Diagnostic services
• Individual prescribers, including supplementary and independent prescribers.

The Steering Group recognises that, in order for all national groups to fulfil these recommendations, there will be resource implications.

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