Guest blogger Dr Tim Rawson (bio below) writes…

With antimicrobial resistance taking its place alongside climate change on the global political agenda, the role of antimicrobial stewardship in healthcare has come to the forefront. Being a good steward of antibiotics goes beyond simply possessing the technical ability to maintain the effectiveness of antimicrobials. It requires an understanding of why we all, as healthcare providers, should practice stewardship and an ability to confront many of the social and behavioural barriers preventing good practice. Whilst the infection community and some policy makers are now highly engaged with antimicrobial resistance, there is very little evidence to support engagement with AMS-AMR within other clinical specialties.

But why is this a problem if infection specialists and key policy makers are engaged?

The problem is that the majority of antimicrobial prescribing is performed by prescribers who are not infection specialists. For example, in the UK primary care physicians prescribe nearly three quarters of all antimicrobials and specialties like intensive care and haematology are responsible for using huge amounts of broad spectrum antimicrobials. Furthermore, as the role of a good steward requires more than simply adhering to a guideline or policy (which if, many of the antimicrobial audits are correct, is challenging enough), it becomes clear that AMS-AMR agendas must be embedded within the culture and environment of these different clinical specialties and not simply dictated to them by the few specialists and policy makers within their organisations. This requires promoting strong leadership of AMS from within the specialty, driving engagement and action.

Our group has performed cross-sectional analyses to explore the current level of specialty engagement with AMS-AMR, focusing on two areas that may serve as potential proxy indicators for levels of engagement. These are (i) analysis of state-of-the-art scientific conferences, and (ii) analysis of specialty postgraduate training curricula.

(i) Cross specialty engagement at state-of-the-art scientific conferences

We selected the largest international and UK based scientific conferences for 23 clinical specialties, extracting their conference abstract booklets for 2014. Abstracts were then interrogated to identify all abstracts relating to antimicrobial stewardship and/or resistance. These results were then compared to “risk scores” (high, medium, or low) for the level of antimicrobial usage and rate of healthcare-associated infections present within that specialty. This was generated using the ECDC point-prevalence survey data.

(ii) Analysis of specialty postgraduate training curricula

Using a similar methodology and search criteria, all UK postgraduate training curricula were extracted and interrogated to identify all learning points and curriculum topics related to AMS-AMR. Identified learning points were then rated based on the “quality” of outcome expected on completing this learning point. Namely, does the trainee demonstrate knowledge, knowledge linked to clinical context, a behaviour in a controlled environment, or a behaviour in clinical practice. This was based on an adaption of Miller’s Pyramid for the assessment of clinical competency.

Our findings:

Well, unsurprisingly infection (ID/micro) as a specialty had a significantly greater proportion of AMS-AMR abstracts and learning points compared to all other specialties assessed within the studies (see Figure below).

However, there were also a number of other key findings that require consideration. Highlights of these include:

1. In the UK, specialties with high rates of antimicrobial usage such as primary care, who prescribe nearly three quarters of all antimicrobials need focus. Only about 1% of their state-of-the-art scientific conference abstracts had anything to do with AMS-AMR and within a comprehensive training curriculum containing about 1370 learning points, only two of these points were AMS-AMR related. The same is very similar for other specialties with high rates of antimicrobial usage and healthcare-associated infections, such as haematology and nephrology.
2. In the UK, there is a ‘top-down’ expectation of AMS, with the majority taught to specialists within the field of infection (who we know are not responsible for large amounts of antimicrobial usage). Very little training is provided to physicians as they progress through their foundation, core, and/or general training before reaching a specialty training pathway.
3. Regardless of whether the specialty had high levels of coverage or not, all specialties learning outcomes in their curricula tended towards lower quality outcomes of learning, with about 60% of all learning points only requiring demonstration of knowledge in some form. Very few learning points required the demonstration of AMS behaviours in clinical practice.

There are undoubtedly several limitations to applying these two approaches as proxy indicators for a specialties level of engagement with AMS-AMR. We selected the largest state-of-the-art conferences within the UK and internationally. This may of meant that the range of abstracts/research presented was narrowed due to the conference organisers key agendas. However, by selecting the largest conference from these areas, we hoped that it may provide a broad representation of attributable importance to AMS-AMR within the specialty. Furthermore, both these approaches fail to identify local educational and research opportunities that may be provided across different specialties and never makes it to their conferences or into the national postgraduate training curricula. There was also a possibility that certain learning points & abstracts may have been missed by the search criteria employed. To address this, several search iterations were tested and broad, wildcard searches finally used to provide maximum sensitivity to identify relevant abstracts and curriculum learning points.

So, whilst AMS-AMR isn’t only engaged with at the two levels explored within our studies, we feel that these were interesting and appropriate starting points to begin to try and build a better picture of the current level of engagement with AMS-AMR outside of the infection community. Perhaps with a better understanding of the current situation in these areas we may be able to identify potential interventions from which to promote engagement with the AMS agenda across a wider breath of clinical specialties, thus helping to develop leadership and self-governance from within.

Bio: Dr Tim Rawson

Tim is a junior doctor, who has taken time out of medical training to undertake a PhD with the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London. His research interests are around methods of enhancing antimicrobial stewardship interventions. Much of his work to date has focused on exploring the level of engagement of different clinical specialties with antimicrobial stewardship programmes and understanding the different behavioural norms within these. Tim is currently leading a project exploring the utility of a clinical decision support system, which incorporates machine learning to support antimicrobial prescribing and houses a patient and public engagement module to promote patient engagement with decision making during infection management in secondary care pathways. Tim hopes to continue his career working as a clinical academic in the field of infection.