Understanding and improving antimicrobial prescribing in care homes: a multidisciplinary approach

Bacteria that cause common infections are becoming increasingly resistant to currently available antibiotics. Antibiotics are essential in modern healthcare but their use drives the development of resistance as bacteria develop ways of surviving their effects. Previous research has found that antibiotics are often used when they are not needed, which increases the development of resistance in bacteria. Older people living in care homes are prescribed many more antibiotics than average and as a result often get antibiotic resistant infections later, which are then harder to treat. The amount of antibiotics used in different care homes varies a lot but we don't really know why. Most research on finding ways to safely reduce antibiotic use has been carried out in hospitals or GP surgeries rather than care homes. There is general agreement that antibiotic use in care homes could and should be safely reduced. However, to design effective approaches to reducing antibiotic prescribing for care home residents we need to understand more about how, when and why they get prescribed, from the perspectives of nurses, carers, GPs, and residents and their relatives.

Researchers with different areas of expertise will work together in a four-stage project:

1. Measuring patterns of antibiotic use (epidemiology): We will analyse information on antibiotic prescribing and antibiotic resistance for all care home residents in two Scottish health board regions. As well examining the link between antibiotic prescribing and later antibiotic resistance, this will help us better understand how common antibiotic use is, which residents are prescribed, and variation in prescribing between care homes. This information will also be used to invite care homes with different patterns of antibiotic use to participate in the next stages of the project.

2. Understanding how and why antibiotic prescribing happens in different care homes (sociology and social anthropology): We will work with staff, GPs, residents and relatives in eight care homes. We will observe how staff and GPs work together and react to residents being unwell, and how this leads to antibiotic prescribing. We will also interview staff, GPs, residents and relatives to understand how the way the care home and general practices are organised influences the care different residents receive. This will help us identify new approaches to improving antibiotic prescribing decisions.

3. Identifying staff behaviours that could be changed to reduce antibiotic prescribing (health psychology): We will also carry out more focussed interviews and questionnaires to find out specific reasons why carers, nurses and GPs perform certain actions, and investigate what might encourage or discourage these actions. For example, what causes a nurse to phone a GP to request a prescription for a resident? Why might the GP sometimes write a prescription without reviewing the patient first? This will help us identify specific changes in behaviour which could improve antibiotic prescribing decisions.

4. Creating and testing new approaches to changing antibiotic prescribing (intervention development and testing): We will use all the information from the first three phases, and evidence from other situations (e.g. hospital or GP antibiotic studies) to create an intervention that we will try out in a small number of care homes to see if it is acceptable to staff and residents, and whether it is feasible to do alongside normal work. The intervention will include different elements, such as education for care home staff and GPs, and feedback about how many antibiotics are being used in each care home. At the end of the study, we will have created new and useful knowledge about antibiotic prescribing and its consequences in care homes, but we will also have pilot-tested a new intervention. The next stage of our research programme will be testing it in a large-scale trial to see if it 'works'.

The proposed research is grounded in theory and informed by empirical research. As well as shorter-term significant contribution to theory and knowledge, there is a clear pathway to future real-world impact on antimicrobial use and resistance through the development of a complex intervention ready for evaluation in a randomised trial. In the shorter term, involvement in, and outputs from, the research proposed are of potential benefit care home residents and staff, general practitioners, the wider social care sector, the general public, the NHS, and other policy makers, as well as academia (see Academic Beneficiaries). To ensure these benefits are realised, key stakeholders have been consulted in the preparation of this proposal and have committed to participation in the fieldwork, the Study Team and the Study Advisory Group (see Letters of Support). Members of the Study Team also have relevant clinical positions (BG is a GP, CM is an ID Physician, CH & JS are pharmacists) which will enhance professional engagement. We have also planned a programme of engagement with stakeholders, policy makers and the public (see Pathways to Impact), and stakeholder and user participation, including co-creation of the intervention, is integral to the whole proposal (see Case for Support).

The following groups have potential benefits:

Care home residents: In the participating care homes, residents (with their relatives if appropriate) will have the opportunity to make positive contributions to informing and co-creating tools designed to improve quality, safety and equity of care for their peer group. In the future, the research programme aims to safely reduce unnecessary antimicrobial exposure specifically in this group, reducing side effects and the emergence of resistant difficult-to-treat infections.

Care home staff and general practitioners: Staff in, and GPs providing care for, the study care homes will have the opportunity to engage with and participate in research, while contributing to the co-creation of an intervention to help them deliver safer and more equitable care. In addition to the intrinsic benefits of this positive contribution, involvement can contribute to continuing professional development and revalidation for trained nurses and GPs.

Social care sector: Compared to other settings the social care sector has rarely been the focus for healthcare innovation. In addition to the benefits of participation and the knowledge gained, this research, with co-development of an intervention, should facilitate good working relationships between academia and the social care sector for future research and improvement activity. This will become increasingly relevant as the integration of health and social care proceeds.

General public: The ultimate aim is to reduce antimicrobial use and AMR to benefit broader public health, with impact achieved through a successful intervention. In the shorter term, the outputs will increase knowledge and understanding around AMR, with impact on other stewardship activity through our planned knowledge exchange activity (see Pathways to Impact).

NHS stakeholders: Care homes are not currently run by the NHS in the UK, but medical care and prescribing are provided by NHS GPs. This organisational model is similar across all four UK administrations, so the study outputs will be generalisable in informing NHS antimicrobial stewardship.

Policy stakeholders: Study findings will inform policy and strategy development for: the Scottish Antimicrobial Prescribing Group (JS is project lead), the Scottish Microbiology and Virology Network, NHS Education for Scotland, the NHS Scotland Infection Intelligence Platform, the British Society for Antimicrobial Chemotherapy, Health Protection Scotland, Public Health England, Public Health Wales, the Public Health Agency and the Farr Institute.