Preserving Antibiotics through Safe Stewardship: PASS

Lead Research Organisation: University College London
Department Name: Institute of Health Informatics


Since the discovery of Penicillin in the 1940s, antibiotics have transformed our ability to treat bacterial infections allowing us to live healthier, longer lives. However, we have been overusing antibiotics for decades to treat mild infections that would usually get better on their own. This overuse makes bacteria evolve so that they can survive the effect of an antibiotic making infections much harder to treat. If we are to preserve antibiotics for the future, we need to make sure that they are used carefully and not wasted. This careful use of antibiotics, making sure that those who need them can benefit but that they are not over-used is known as "antibiotic stewardship". This proposal will provide the information necessary to design approaches that can support safe antibiotic stewardship.

In the first set of studies, we will measure how the public and healthcare professionals use antibiotics in the United Kingdom. We will invite people to take part in a survey called "Bug Watch." This survey will allow us to measure what different people usually do when they get common infections, for example, whether or not they visit their GP, take an antibiotic or take some other treatment. We will also use electronic patient records from a range of health settings to understand how healthcare staff are using antibiotics in general practice, hospitals and nursing homes for the elderly. Whenever we analyse medical records, they will be anonymous such that we cannot tell whose records they are. In addition to measuring how healthcare staff use antibiotics, the analyses will allow us to understand better which patients most need antibiotics to prevent complications of infection and which patients can safely not use antibiotics. Scientists who are experts in the use of electronic health records will lead this work.

In the next set of studies, we will interview members of the public, patients, parents, doctors and other healthcare staff to provide a deeper understanding of what influences decisions about antibiotic use. The interviews will focus on the aspects of prescribing identified as needing improvement in the earlier work. We will also visit GP practices, nursing homes and hospital wards to observe how healthcare staff use antibiotics. The science of behaviour change allows us to understand human behaviour and how best to change this. Scientists who are experts in studying health behaviour will lead this work.

A large number of studies have already tested different approaches to reducing unnecessary antibiotic use. We will summarise these studies to show what has worked in the past. We will use behavioural science theory to explain why some attempts to reduce prescribing have been successful while others failed.

Our detailed analyses of how and why we use antibiotics in different settings and of what has worked in the past will help us design new combinations of approaches that can be used to improve antibiotic use across the community and health service. We will develop these new approaches to antibiotic stewardship in partnership with patients, members of the public and healthcare staff. We will also design studies to find out how well these new strategies work.

We will work with designers to develop a website to explain the results of our work and to act as a practical tool to help the public, health care staff and health service planners improve antibiotic use.

The work, which involves scientists from many different backgrounds, will provide excellent opportunities for training young researchers. These scientists will increase our future ability to tackle the growing problem of antibiotic resistance.

Planned Impact

The advent of antibiotics in the 1940s had a profound impact on health. In the pre-antibiotic era infections were a leading cause of death in all age groups in the UK and other developed countries. Five percent of children died in the first years of life, many from infections. One in every 250 women died during childbirth, a third of these deaths were due to infection. Infected scratches could lead to bloodstream infections with case fatality rates of around 80%. Community-acquired pneumonia had a case fatality rate of around 30%.

The global economic and human costs of antimicrobial resistance (AMR) are already substantial and are set to increase. Antibiotic resistant infections can be hard to treat, often require the use of toxic drugs, increase the length of hospital stay and can lead to permanent disability and death. Despite the vital role that antibiotics play in treating severe infections we have taken antibiotics for granted, frequently using them for mild infections which would get better without treatment, or using broad spectrum antibiotics which promote resistance when simpler antibiotics would be effective. The expectation of antibiotic treatment for common infections means that infections are the leading cause of general practice consultation diverting resource away from more pressing health problems.

Every time an antibiotic is used to treat an infection one hundred, thousand billion bacteria that live in our gut and on our skin are exposed to this antibiotic. When antibiotics are used widely across society or repeatedly in individuals, this exerts enormous evolutionary pressure for the development of resistance. As new antibiotics come to market the question is not so much whether resistance will develop, but how quickly it will happen and how widespread the resistant strains will become? We can and will develop new drugs, diagnostics, and vaccines but we also need to reduce society's reliance on antibiotics. Preserving the lifespan of our existing treatments for future generations depends on achieving a safe balance between the potential individual and population-level harms of prescribing antibiotics and risks to the individual of not prescribing. This antibiotic "stewardship" will require comprehensive action across health services and communities internationally to change public and professional behaviour.

The Preserving Antibiotics through Safe Stewardship (PASS) collaborative research framework will underpin future UK strategy and provide valuable insights for international actions. We will provide vital information on how we use antibiotics across society and the health system. We will develop an in-depth understanding of the factors driving antibiotic use in different settings, of what approaches effectively reduce unnecessary prescribing and of why they work. We will work with health care practitioners and the public to develop packages of broad-ranging interventions to tackle the problem across different settings. Our work will produce immediate benefits for the public by providing better information on common infections supporting safe self-management and highlighting which patients are most likely to benefit from antibiotics. There will be benefits to the taxpayer and users of general practice through the reduction of unnecessary GP visits. Patients in nursing homes and hospitals will benefit from avoidance of over-treatment and improved selection of treatment regimes. Ultimately the greatest benefits will be through preserving the effectiveness of antibiotics for the future. The work will, therefore, be of particular importance to those most likely to develop severe infections: infants and young children, those with chronic illness, those who are immunosuppressed through disease or treatment, those undergoing surgery and the elderly.


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Rockenschaub P (2020) Antibiotic Prescribing Before and After the Diagnosis of Comorbidity: A Cohort Study Using Primary Care Electronic Health Records. in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

Description We have developed much better understanding of who gets antibiotic prescrioptions accross primary and secondary care and in the community
Exploitation Route we are using them to develop interventions
Sectors Healthcare

Description We established a collaboration with a large chain of nursing homes for this work. This relationship allowed us to rapidly investigate COVID transmission in nursing homes early in the pandemic and led to intensification of control measures and funding of the VIVALDI core studies programme
First Year Of Impact 2020
Sector Communities and Social Services/Policy,Healthcare
Impact Types Policy & public services

Description AMR PhD studentships - Storytelling and Antibiotic Resistance
Amount £150,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 08/2018 
End 09/2022
Description COVID-19: Burden and impact in care homes - a mixed methods study
Amount £172,203 (GBP)
Funding ID ES/V003887/1 
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 04/2020 
End 05/2021
Description ESRC AMR top up funding
Amount £10,000 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 06/2018 
End 11/2018
Description Precision antibiotic prescribing for urinary tract infection in hospital
Amount £1,127,093 (GBP)
Funding ID CS-2016-16-007 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 02/2017 
End 01/2023
Description Stewardship of Antimicrobials using Real-Time Artificial Intelligence (SamurAI) - Phase 1
Amount £120,524 (GBP)
Funding ID AI_AWARD01828 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 12/2020 
End 05/2022
Description Vivaldi - National Core Covid study of COVID transmission and immunity in nursing homes
Amount £5,000,000 (GBP)
Organisation Government of the UK 
Department Department of Health and Social Care
Sector Public
Country United Kingdom
Start 06/2020 
End 04/2023
Title Bugwatch dataset 
Description Community survey of healthy people in the community who are followed up for 6 months. Information is captured each week on symptoms of infection and healthcare seeking behaviour in addition to baseline information on individuals knowledge/attitudes around antibiotic prescribing. The dataset includes c. 2000 adults and children. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact A protocol paper has been submitted for publication. 
Description Visit to Care Home 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact 10-20 individuals including relatives and healthcare workers from one of Four Seasons Healthcare care homes attended an open evening and members of the PASS team presented at this event.
The aim was to describe the project and to engage with relatives and healthcare workers to understand how we should conduct interviews and ethnography in the setting.
We also aimed to identify individuals who might be keen to join a stakeholder group to support intervention design.
Year(s) Of Engagement Activity 2018