Scottish dentists cut antibiotic prescribing

 

Scotland’s dentists are reporting a cut of almost one fifth in prescriptions for antibiotics since 2015 as the profession works to tackle the growing number of bacteria developing resistance to commonly used antibiotics.

 

Official statistics in the most recent annual report for Antimicrobial Resistance and Healthcare-Associated Infection in Scotland revealed 82.9% of all antibiotic use in 2019 was in primary care – 7.2% of which was prescribed by dentists.

 

Now analysis by the Scottish Antimicrobial Prescribing Group (SAPG) is showing that the rate of antibiotic used by dentists has reduced by 17.7% since 2015.

 

The chair of SAPG’s dental stewardship subgroup, Andrew Smith, Professor of Clinical Bacteriology at NHS Greater Glasgow and Clyde, says while dentists are managing to reduce unnecessary antibiotic prescribing, there is still a long way to go:

 

“Antibiotic prescribing by dentists in primary care in Scotland has been steadily decreasing year on year since 2015, which is a positive step in the right direction,” he says.

 

“However, there is evidence that the majority of drug-resistant infections in Scotland originate in the community, so optimising antibiotic use in primary care is a major target for antimicrobial stewardship in Scotland.

 

“Although dental antibiotic use is reducing, we must continue to work hard in this area. Antibiotic resistance poses an urgent threat to human health, with some infections becoming more difficult or even impossible to treat.”

 

Between them, amoxicillin (68.0% of prescribing) and metronidazole (28.8%) account for almost all dental antibiotic use.

 

SAPG’s dental stewardship subgroup is now focusing on promoting the reintroduction of phenoxymethylpenicillin (penicillin V) as an alternative to amoxicillin, as the first-line antibiotic in dental infections when antibiotics are unavoidable.

 

The move to the more narrow-spectrum penicillin, reducing the risk of developing resistance, reverses a trend seen in the 1990s to using broad-spectrum antibiotics which were considered superior to penicillin V, which was gradually replaced by amoxicillin in dental practice.

 

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Safeguarding antimicrobial use in a pandemic

Dr Jacqueline Sneddon, head of the Scottish Antimicrobial Prescribing Group.

 

Although the COVID-19 pandemic is still with us, many parts of the NHS in Scotland are restarting work that had to be paused, while keeping their focus on the virus.

 

Dr Jacqueline Sneddon – lead for the Scottish Antimicrobial Prescribing Group (SAPG), part of Healthcare Improvement Scotland – reflects on the big part played by a small group in responding to the pandemic and looks at what’s next.

 

“The impact of the COVID-19 pandemic brought challenges and opportunities for the SAPG.

 

“Our group works with NHS boards across health and care settings in Scotland to safeguard antibiotics against the global threat of antimicrobial resistance. When both the group’s committee and project group meetings were paused, it meant that that routine work for the group was also suspended.

 

“We’re a small and agile team of just three employees, including me, plus one day per week from our Chair, Dr Andrew Seaton from NHS Greater Glasgow and Clyde, but with a committee of national experts and clinical staff from across Scotland, as well as several project steering groups.

 

“Initially I was seconded to support first the Medicines and Pharmacy team within Healthcare Improvement Scotland (of which SAPG is a part), and then to NHS Lothian to support the ICU pharmacy service.

 

“Marion Pirie, our team’s Project Officer, took on part-time work with NHS 24 supporting staff training by role-playing real-life patient calls.

 

“Meanwhile, Lesley Cooper, our Health Service Researcher, devoted her time to finalising evidence reviews for two of our projects – penicillin allergy de-labelling and use of antibiotics towards the end of life – which have now been submitted for publication.

 

“There was also time to write up our findings from global health partnership work we’d just recently completed with two hospitals in Ghana for future publication.”

 

Covid-19 and antibiotics

 

“But we couldn’t entirely take our eye off COVID-19.

 

“The pandemic meant that we needed to be sure that the use of antibiotics was still appropriate and that clinicians had the information they needed.

 

“Literature reports of overuse of antibiotics in other countries led to SAPG producing advice to support antimicrobial teams in NHS boards to maintain stewardship of antibiotics in hospitals and care homes.

 

“We recognised an opportunity and need to explore the impact of COVID-19 on hospital antibiotic prescribing, given emerging data form China and other parts of the UK, so SAPG led a point-prevalence survey audit examining epidemiological, clinical and prescribing data from eight boards.

 

“Data was captured from over 800 patients with suspected or proven COVID-19 across 15 acute hospitals (about one-third of all hospitalised patients with COVID-19 in Scotland at the time) during the last ten days in April.

 

“The study generated a huge amount of data that Lesley and colleagues in Public Health Scotland analysed and this provided reassurance that antibiotic use in Scotland was compliant with local guidelines, with lower use in COVID-19 patients than reported elsewhere.

 

“Thankfully there was no increased use of broad-spectrum antibiotics that drive resistance although the emerging problem of secondary bacterial infections in critical care was observed.

 

“One paper has been submitted for a publication focused on the epidemiology of antibiotic prescribing in COVID-19 and a second on the management of suspected respiratory infections in the context of COVID-19 is underway.”

 

Emerging from lockdown

 

“As we gradually emerge from lockdown, SAPG work has restarted with our first virtual committee meeting recently attended by 32 members. On the agenda, as well as the hospital audit data, was a discussion of data on GP practice antibiotic prescribing during COVID-19, and hearing about the challenges that antimicrobial teams had faced.

 

“All of this information will allow us to continue to learn and will inform the SAPG work programme to ensure the NHS in Scotland continues to use antimicrobials optimally to preserve antibiotics for future generations.

 

“We then turned our attention to our project groups on penicillin allergy and end-of-life antibiotics, to finalise outputs and agree plans for implementation as well as publications on our project development processes.

 

“We’re now working with our SAPG Public Partners to produce a patient version of recommendations for use of antibiotics towards the end of life to support patients and their families in shared decision making.

 

“As I reflect on the lessons of the pandemic and the way forward for the group, it strikes me just how much COVID-19 has brought people together – we see that in society, but also within organisations like our own.

 

“Our team is contributing to cross-organisational work on older peoples’ systems and primary care where our experience of working with care homes, and with GP Practices will help to inform and support future priorities. 2020 marked 12 years since SAPG was formed and since I joined the organisation.

 

“We’ve achieved so much by working in partnership with health and care professionals across the country. Although it’s been a difficult year for everyone, we can only look forward, to continue the fight against antimicrobial resistance, and to face whatever new challenges lie ahead.”

 

The Scottish Antimicrobial Prescribing Group is part of Healthcare Improvement Scotland.

 

This story has been supplied through our partnership with our friends at healthandcare.scot. Click here to head over and have a look if you haven’t already.

Subscription-style contracts for pharma to fund new antibiotics

 

A scheme to provide new antibiotics to NHS patients by offering to pay pharmaceutical companies upfront for their work will start this week.

 

The NHS is offering two contracts to pay pharmaceutical companies at the start of their work for access to innovative antibiotics, incentivising them to bring new classes of the drugs to patients across the UK for the first time in almost 30 years.

 

Of particular interest are antibiotics that can provide alternative treatment options for serious infections, such as bloodstream infections, sepsis and hospital-acquired pneumonia.

 

The high cost and low returns associated with antibiotic research and development make it commercially unattractive. This is why the drugs will be paid for by the world’s first ‘subscription-style’ payment model for antibiotics and will be made available to UK patients as soon as possible, potentially as early as 2022.

 

The payment model, which was launched in July 2019, will pay pharmaceutical companies upfront for access to their antibiotic product, based on a product’s value to the NHS, rather than how much is used.

 

This aims to incentivise companies to invest in researching and developing new antibiotics, helping secure much-needed alternative treatment options for NHS patients.

 

Two drugs that have proven to be both safe and effective will be selected to undergo health technology assessment (HTA) by the National Institute for Health and Care Excellence (NICE) throughout 2021 using adapted methods for antimicrobials. The HTA will be used to decide the level of the subscription payment.

 

Health Secretary Matt Hancock said:

 

“The incredible discovery of antibiotics nearly 100 years ago transformed the health of our nation and our ability to combat infections. Diseases that were once a death sentence are now treated in just one small step.”

 

“But resistance to antibiotics is increasing and it’s imperative we take urgent action on a national and global scale to protect future generations.

 

“This new way of buying antibiotics for patients in the NHS breaks down restrictive barriers to offer companies a vital springboard to foster innovation and develop potentially life-saving new products.

 

Professor Dame Sally Davies, UK Special Envoy on Antimicrobial Resistance, said:

 

“Antibiotics underpin modern medicine and are integral for global health security. Governments and industry must work together to produce new antibiotics and ensure that we can continue to treat common diseases.

 

“The UK is leading the way by encouraging companies to produce new antibiotics to stay one step ahead of life-threatening diseases.”

 

Professor Stephen Powis, National Medical Director, NHS England said:

 

“Staff across the NHS are already working with patients to ensure the antibiotics we have are used in the right way at the right time, and this new scheme is further important progress to develop new, life-saving antimicrobial medicines.

 

“People’s lives depend on us having effective antibiotics and steps like this further reinforce how the NHS is leading the way in efforts to safeguard against the rise of superbugs.”

 

Professor Gill Leng, Chief Executive, NICE, said:

 

“We are witnessing the effects of one global pandemic, which has highlighted the threat of communicable disease.  Alongside the threat of coronavirus is the increasing risk posed by antimicrobial resistance, exacerbated by a sparse antimicrobial development pipeline.

 

“That is why we need to incentivise investment in innovative antimicrobial drug development as soon as possible. Along with our key partners, we have committed to develop and test innovative models for the evaluation and purchase of antimicrobials, applying advanced evaluation methods that recognise their full value to public health.

 

“We hope that this project will inspire healthcare systems across the world to consider adopting similar models so that collectively, we deliver meaningful incentives that reinvigorate the global antimicrobial pipeline.”

 

This circular is being shared under the Open Government Copyright licence.

 

Antibiotics: How much is too much?

 

New research has, for the first time, provided guidance on the amount of antibiotics that can safely be prescribed without generating resistant superbugs.

 

The study, led by NHS Grampian in collaboration with Professor Ian Gould, Honorary Professor at the University of Aberdeen uses data modelling to calculate the risk/benefit ratio for several different types of antibiotics.

 

Antibiotics play a crucial role in healthcare but overuse can cause bacteria to become resistant to them which can lead to the rise of superbugs such as MRSA.

 

Until now there has been no clear guidance as to the maximum level of antibiotics that individuals can tolerate without bugs developing this resistance. Published in Nature Microbiology, this study has developed a way to determine this threshold for several different types of antibiotic.

 

Controlling prescribing can ensure antibiotics remain effective for those who need them most. However, until now, there have been no clear guidelines on the maximum number of antibiotics that can be used in a hospital population or community, before resistance starts to increase.

 

The study involved research teams from across Europe, using data gathered from five major hospitals which demonstrated that their method could be applied to a variety of different clinical populations.

 

Professor Ian Gould explained:

 

“In simple terms, it is commonly thought ‘the less antibiotics the better’ but this is not the correct approach as most of the restricted antibiotics are safe, effective and life-saving. It is important to understand how much of the life-saving antibiotics are actually associated with resistance itself. So rather than restricting the use of life-saving antibiotics as much as possible, on an arbitrary basis as it is done currently, this work identifies safe thresholds at which the antibiotics should be used without fuelling resistance.”

 

Dr Timothy Lawes, Welcome Fellow and ST5/senior registrar in Paediatrics in NHS Grampian clarified:

 

“Normally, we think about the risk of antibiotic resistance in a linear way- so that more antibiotics equals more resistance – but our research took a different approach. Borrowing techniques from economics, our research had found a way to find these thresholds using simple data. It is hoped that our work could offer a way to balance the need to use antibiotics with the need to stop resistance in Scotland, and around the world.”

 

You can read the full study here.