HSE antimicrobial stewardship (AMS) guidance for all healthcare settings – August 19th 2022

New updates on Antibiotic Stewardship with resources and audit tools available at: HSE antimicrobial stewardship (AMS) guidance for all healthcare settings 

Antimicrobial stewardship (AMS) refers to any action that promotes responsible use of antimicrobials. AMS can also be defined as a set of coordinated interventions designed to improve and measure the appropriate use of antimicrobials. The purpose of AMS is to: 

• support delivery of the right antimicrobial, at the right time, dose and duration to meet patients’ needs
• protect patients from avoidable harm related to inappropriate antimicrobial use
• ensure that antimicrobials remain effective for the future by limiting the emergence of antimicrobial resistance

AMS is an integral component of any patient safety programme. All healthcare professionals are antimicrobial stewards. Knowledge, awareness, and participation of everyone involved in the care of patients, in all care settings, is key to creating a culture that support staff to understand antimicrobials and generates behaviours that improve their use. 

What is antimicrobial resistance (AMR)? 

Antimicrobials are medicines used to prevent and treat infections in humans, animals and plants. Antimicrobials include antibacterials (most commonly referred to as antibiotics), antivirals, antifungals and antiparasitics. 

HSE RESIST Antimicrobials Infographic.pdf (size 146.8 KB)

Antimicrobial resistance (AMR) occurs when the microorganisms change or mutate over time and get to a point where they no longer respond to medicines previously used to treat them. AMR is driven by high rates of antimicrobial prescribing and it is critical that we work to reduce unnecessary antimicrobial use.

A One Health response at global and local level is essential in order to address the challenge of AMR. The One Health approach recognises that the health and well-being of people is connected to the health and welfare of animals, biodiversity, and the environment. We need to use less antimicrobials in every sector and use them more appropriately when we need to use them. 

One health Infographic (2021, Department of Agriculture, Food and Marine & Department of Health) (size 276.2 KB)

To learn more about the One Health approach view Ireland’s Second One Health National Action Plan on Antimicrobial Resistance 2021-2025. 

Why is antimicrobial stewardship (AMS) important? 

Antimicrobial resistance (AMR) has been recognised as one of the greatest potential threats to human and animal health over the last decade. Over the last 20 to 30 years we have seen many antimicrobials become less effective or even not effective at all for treatment of some bacterial infections due to AMR.  This pushes us to use different antimicrobials that may be more toxic, more difficult to use and more costly. Patients with antimicrobial resistant infections are sicker for longer and require more complex care.  Effective antimicrobials are essential to the practice of modern medicine.

High levels of antimicrobial use and inappropriate use of antimicrobials causes increasing AMR as well as other patient harms.  Antimicrobial stewardship (AMS) is vital in limiting and potentially reversing the development of AMR so that antibiotics are kept effective for future generations. 

Practices that support good AMS 

All healthcare professionals can support AMS by adhering to the 8 principles of good AMS;

1. Recognise clinical evidence of infection. For example, consider the signs and symptoms and whether they might represent infection.
2. Avoid unnecessary antimicrobial use. For example, recommend symptom relief for self-limiting infections, with safety netting advice, and direct patients and carers to www.undertheweather.ie
3. Choose an antimicrobial that will have the most benefit and cause the least harm. For example, use best-practice treatment guidelines on www.antibioticprescribing.ie, using a ‘green’ antimicrobial in preference to a ‘red’ antimicrobial if an antimicrobial is needed.
4. Optimise the dosing regimen and route. For example, ensure patient is prescribed correct dose, frequency and route.
5. Minimise the duration. For example, avoid unnecessary prolonged courses of antimicrobials.
6. Assess response to treatment. For example, review any available microbiological sample results to guide treatment.
7. Communicate effectively about antimicrobials. For example, discuss the issue of AMR with patients
8. Prevent infection. For example, arrange vaccination and use IPC measures.

Healthcare professionals can also engage in regular education relating to AMS and participate in local or national quality improvement audits for antimicrobial use.

AMS Patient Resources

• The HSE Health Care Associated Infection and Antimicrobial Resistance webpage contains links to patient information on topics such as “How to take your antibiotics”, “Be infection aware”, C. difficile, Multi Drug Resistant Organisms, etc 
• Undertheweather.ie is a patient self-help website advising patients on how to manage common self-limiting infections.
• The HSE Health A-Z website provides information for patient on symptoms, conditions and treatments.
• The HPSC website contain many patient information leaflets for the general public 
• You can order printed resources such as patient information leaflets and posters from Healthpromotion.ie
• HSE video: Keep antibiotics working for the future.
• Further patient information leaflets found on this website are collated on the Patient Information Leaflets Page

General AMS resources:

• HSE AMRIC antimicrobial stewardship guidance for all healthcare settings v1 Published August 2022 (PDF/ 2.6 MB)
  
  This guidance gives AMS teams and managers the guidance and tools needed to start and run AMS programmes. This document also contains guidance for the development of educational materials such as curricula, courses and training programmes.
• Ireland’s Second One Health National Action Plan on Antimicrobial Resistance 2021-2025. Published Nov 2021 
• HSE Antimicrobial Resistance and Infection Control (AMRIC) Action Plan 2022-2025. Published Nov 2021 
• HiQA National Standards for infection prevention and control in community services. Published Sep 2018 
• HSELAND AMRIC IPC & AMR eLearning programme has an accredited courses on antimicrobial stewardship including Antimicrobial Stewardship in Practice, Prevention and Management of Urinary Tract Infection and Clostridioides difficile
• HSE video: Protecting antibiotics – a message for prescribers.

Community-related AMS resources: 

• Pharmacist Antimicrobial Stewardship Network (PAMS-net): A network for pharmacists working across all settings with an interest in responsible use of antimicrobials. To become a member of the network, go to the “Courses and Events” page on the Irish Institute of Pharmacy website.
• Preferred antibiotic use in the Community Green/Red Table 
• HSE posters for primary care
  • If your doctor says you don’t need an antibiotic, that’s ok
  • Think you need an antibiotic? Think again
• Under the weather stickers for children
• IIOP/AMRIC elearning module on AMS for Community Pharmacists 
• Articles on Antimicrobial Stewardship in Primary Care
  • Antimicrobial Stewardship in Primary Care: An introduction to antimicrobial stewardship for community pharmacists (PDF/645.9KB)
  • Antimicrobial Stewardship in Primary Care: Part II an update on urinary tract infection management for community pharmacists (PDF/430.1 KB)
  • Antimicrobial Stewardship in Primary Care: Part III considerations for special populations in the context of antimicrobial stewardship (PDF/582.8 KB)

Hospital-related resources: Please visit the hospital related guideline page

Audit Tools

Preferred antibiotic audit tool

The Preferred antibiotics audit tool involves a self-audit of 10 antimicrobial prescriptions, and encourages general practitioners to reflect on their prescribing behaviour relative to current best-practice guidelines.

An example of a quality improvement project that used this audit tool model is the Out of Hours Antibiotic Stewardship Improvement Project.

• Demonstrating Quality improvement in Action : Audit tool 
• Improving the quality of antibiotic prescribing through an educational intervention delivered through the out of hours general practice service in Ireland

Antibiotic UTI prophylaxis audit tool 

The aim of this UTI prophylaxis audit tool is to enable review of patients currently prescribed antimicrobials for prophylaxis of urinary tract infections (UTIs). Further instructions and guidance can be found within the tool. You can download and use the antibiotic UTI prophylaxis audit tool here:

• Audit UTI Prophylaxis (Excel Tool).xlsm (size 79.3 KB) which has auto-analysis. Please note the electronic tool is a macro-enabled file. Depending on your version of excel, you may receive prompts to ‘Enable Editing’ and ‘Enable Content’ for optimal functionality.
• Audit Tool for UTI Prophylaxis (Word Version).pdf (size 261.9 KB)

Azithromycin prophylaxis in adults with respiratory disease audit tool 

The azithromycin prophylaxis audit tool is available to support healthcare professionals reviewing patients on azithromycin prophylaxis. For more information, visit the azithromycin prophylaxis in adults with respiratory disease guideline page.

Surgical antibiotic prophylaxis audit tool 

An excel audit tool and a YouTube video explaining its use are available to support the implementation of the joint position statement on surgical antibiotic prophylaxis as part of a quality improvement project. For more information visit the Surgical Antibiotic Prophylaxis page.