Stemming the tide of antimicrobial resistance

Antibiotic resistance is a major threat to public health with a high media profile, and the issue is of great concern to citizens, clinicians, policy makers and politicians.
Previous interventions aimed at removing one of the drivers of resistance, inappropriate antibiotic prescribing in primary care, have had disappointing effects. These interventions have often simply bombarded clinicians with generalised information about the extent of the problem, rather than providing opportunities to consider locally relevant data and acquire new, feasible skills for doing things differently. The Star Program was built on insights gained from interviewing clinicians and patients and ongoing qualitative studies involving these groups will lead to refinements of the intervention.
The new skills acquired in the STAR Program enhance the quality of communication with patients during the consultation for common infections. Patients and the public have a key role to play, and the intervention seeks to engage patients about their feelings, ideas and expectations about antibiotic treatment. Instead of clinicians second guessing what they think patients want or expect, explicit strategies are used to assess patients knowledge and interest and meet these appropriately.
The training program includes group-learning and self-directed learning using on-line learning and a website. The site will be continuously updated with relevant emerging clinical evidence. There will be a moderated section of this web site that will be accessible to the general public which will outline key relevant research evidence in accessible ways, advice about appropriate self-management, and information about the clinical course of illnesses and events that should trigger re-consultation. STAR study findings will also be published on this website.
Study findings will be published in academic journals and presented at scientific meetings. In addition, we will inform key players (DH, MRC, Scottish Executive Health Department, Welsh Assembly Government, Health Authorities, PCOs, Trust Managers, Royal Colleges, BMA, Undergraduate and Postgraduate Deans) of the study results. Other creative opportunities will be used by the investigators to engage professionals and public alike. For example, the PI of the STAR Study is a founding member of the General Practice Respiratory Infections Network, and has been consulted by agencies of national governments, and participated in the development of the World Health Organisation s strategy to contain antimicrobial resistance. Some of this work has had a direct impact on policy and public campaigns. Similar opportunities and forums will be used by all the investigators to engage both professionals and the public.

Microbiological sensitivity is a precious international resource that is being depleted, and no new antibiotic class is expected on the market in the medium term. Conserving antibiotic sensitivity through more appropriate use of antibiotics is therefore an urgent imperative. About 85-90% of all antibiotics are prescribed in primary care, with approximately 50% of questionable value. Both at the level of many general practices, and nationally, considerable further gains could be made in lowering inappropriate antibiotic prescribing. Our proposal builds on a unique system that integrates prescribing and microbiological data at a practice level, a strong theoretical background of behaviour change theory, seminal qualitative studies examining antibiotic prescribing from clinicians? and patients? perspectives, pilot studies of interventions, studies of novel approaches to skills acquisition, and using software to support self-directed learning. These innovations are combined into the STAR Educational Programme for prescribers. The program takes practice teams through a certified 4.5-hour manual-supported course in which they work together towards appropriate prescribing over an initial period of three weeks, followed by a maintenance phase. Initial engagement is via e-learning (Stage 1), followed by an on-site seminar (Stage 2), and simulated (Stage 3) and real-life practice (Stage 4). Maintenance is encouraged via ongoing web exchanges with colleagues, patients and educators (Stage 5). The course uses a wide range of replicable learning methods (didactic, interactive, reflective learning in groups and as individuals) focused on two themes, practice prescribing and resistance, and learning new ways of handling everyday consultation challenges. Access to e-learning is via the web, and each clinician will work on an unfolding portfolio that combines their e-learning and reflections. The primary research question is: does exposing prescribers in general practices to the STAR Educational Programme result in fewer antibiotics being dispensed to the practice?s patients? The study will be a RCT with general practices as the unit of randomisation and analysis. Practices will be randomised to account for practice size and prior antibiotic prescribing. The primary outcome will be change in the total number of dispensed oral antibiotics (with examination of trend by quarter) per 1000 registered patients, for the year subsequent to the practice being exposed to the STAR Programme, compared to the previous year, using PARC data. Secondary outcomes will include: economic evaluation, complications from common infections, quality indicators for antibiotic prescribing, rates of microbiological sampling and rates of resistant organisms in microbiology samples, and a qualitative process evaluation.