Stemming the tide of antimicrobial resistance

Lead Research Organisation: Cardiff University
Department Name: School of Medicine

Abstract

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.

Technical Summary

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.
 
Description NIHR Postdoctoral Fellowship
Amount £337,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 10/2007 
End 09/2010
 
Title STAR Educational Intervention 
Description The software platform for the intervention was enhanced for use in other studies. The intervention itself is being modified for use in a further international trial to assess impact of a slightly streamlined version across a number of countries. 
Type Of Material Improvements to research infrastructure 
Year Produced 2009 
Provided To Others? Yes  
Impact A new international study as part of the GRACE Network of Excellence will start in 2010 
 
Description 3 trials project 
Organisation Smile-on
Country United Kingdom 
Sector Academic/University 
PI Contribution We have worked in collaboration with the software company to develop these online programmes. We commissioned the company to develop the platform on which the different trials interventions were developed. Our team contributed to design and contributed the academic input to the development process.
Collaborator Contribution Working with Smile-on has enabled us to develop software for educational interventions for clinicians in 3 different trials. Smile-on and our team have worked together with excellent results which were recognised by an Innovation Award in 2007. Some of our team have been working with Smile-on on a newly funded project developing a psychoeducational intervention for patients with bipolar disorder.
Impact Working with Smile-on has enabled us to develop software for educational interventions for clinicians in 3 different trials. Smile-on and our team have worked together with excellent results which were recognised by an Innovation award in 2007. Some of our team are now working with Smile-on on a NIHR funded project developing and evaluating a psychoeducational intervention for patients with bipolar disorder. We have published four articles related to these studies (PubMed ID 18844993, 19309493, 19674448, 19646190).
Start Year 2006
 
Description GRACE collaboration 
Organisation University of Southampton
Department School of Medicine Southampton
Country United Kingdom 
Sector Academic/University 
PI Contribution Experience from the STAR study has assisted in the development of an intervention that is currently being trialed in Europe aimed at reducing antibiotic prescribing by the EU funded Network of Excellence called (Genomics to combat Resistance Against Community acquired LRTI in the community in Europe) GRACE (https://www.grace-lrti.org/portal/en-GB).
Collaborator Contribution We have collaborated with colleagues in Southampton to produce the intervention which is now being trialled in the GRACE project.
Impact This project is currently underway and as yet has not outputs.
Start Year 2010
 
Description Workpackage leader in EU FP7 Euros 24.5M Platform foR European Preparedness Against (Re)-emerging Epidemics (PREPARE) collaborative project 
Organisation University of Antwerp
Country Belgium 
Sector Academic/University 
PI Contribution We contributed to the development of the proposal. It was successful. We will lead one Workpackage and pay a major role in another
Collaborator Contribution Our partners will be leading other work packages and contribution to the consortium
Impact Euros 24.5 M funding for reseach into infections including appropriate antimicrobial use on primary care: we will lead a trial of neuramidase inhibitors for influenza like illness
Start Year 2013
 
Title STAR Educational Programme 
Description We have developed a theory based educational programme which includes both online and offline aspects. 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted 2012
Licensed Yes
Impact A SME, Smile On, has signed a contract with Cardiff University to further develop the learning program. Chris Butler has worked with them this year to do more filming and updating. This update is nearly complete and the learning program will soon be marketed.
 
Title STAR Educational Programme 
Description Ther intervention is designed to address appropriate antiobiotic prescribing in primary care. It is an educational intervention for GPs and nurse practitioners. 
Type Management of Diseases and Conditions
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2009
Development Status On hold
Impact The intervention has been tested in the funded RCT. It is still early days yet as the study has only just completed. However, it has been used to to develop an intervention in a large European Trial. 
 
Title STAR Learning program update and development 
Description The online learning program developed by the STAR Study has been further developed in partnership with The Health Care Learning Company. The 'EVIDENCE" pages have been updated, new videos made and the new version will be online soon. This academic/commercial partnership will make this enhanced version of the program available to GPs in the UK. The first version is part of the Royal College of GPs Antibiotics Toolkit resources, and is available for GPs to us. 
Type Of Technology Webtool/Application 
Year Produced 2016 
Impact This will be available to GPs to use to enhance their communication skills and antibiotic prescribing 
URL http://clients.healthcare-learning.com/star/review_16_10_2013/story.html
 
Title STAR learning program is update and in regular use on the Royal College of General Practitioner's TAGRET Website 
Description The online learning program that was developed and evaluated in the STAR Study has been updated and is available online on the Royal College of General Practitioner's TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) . Learners are directed to the Health Care Learning Company Website to access the module (http://www.healthcarecpd.com/course/star-stemming-the-tide-of-antibiotic-resistance) 
Type Of Technology Webtool/Application 
Year Produced 2016 
Impact The program was previously available but this is an updated version available free to GPs online 
URL http://www.healthcarecpd.com/course/star-stemming-the-tide-of-antibiotic-resistance
 
Description 'State of the Art' lecture: "Improving antibiotic use in primary care" R-Gnosis Final Workshop, Paris France. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact I gave an overview of research and new systematic reviews from my group about improving antibiotics prescribing in primary care to a group of international researchers who are part of the R-GNOSIS consortium, funded by the EU.
Year(s) Of Engagement Activity 2017
 
Description 2014 Jenner Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Invited speaker: The Toxic Storm of unnecessary antibiotic prescribing in primary care: Cause, effects and solutions

The 2014 Jenner Symposium, St Georges University Medical School.
Year(s) Of Engagement Activity 2014
 
Description BBC Radio 4 program presented by Mark Porter on antibiotic resistance 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact BBC Radio 4 program presented by Mark Porter on antibiotic resistance.

Increased awareness regarding the problem of antimicrobial awareness and the link with antibiotic prescribing.
Year(s) Of Engagement Activity 2009
 
Description BBC Radio Wales interview about the study 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact The STAR study has been publicised on BBC Radio Wales as well as BBC online.

Raised awareness of the STAR study.
Year(s) Of Engagement Activity 2008
 
Description BMA News in depth interview of STAR PI about STAR and broader topic 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact There was a three page feature that focussed on antibiotic resistance and the STAR study. The BMA news is distributed to all British Medical Association members with the BMJ.

CME providers have contacted the PI for further information and are exploring uptake of the intervention more widely.
Year(s) Of Engagement Activity 2009
 
Description British Dental Association 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The STAR Program: Applicability to general dental practice". The British Dental Association.
Year(s) Of Engagement Activity 2014
 
Description ESCMID Invited Plenary Lecture 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Health professionals
Results and Impact This was an invited Keynote Address presenting the STAR Study to the European Society for Microbiology and Infectious Diseases. About 150 researchers, practitioners and policy makers attended.

Title "Educational Interventions in Primary Care Antibiotic Prescribing"
Selsdon Park Hotel, Croydon, Surrey
30/03/12

Requests for access to the online learning program were made. We are working with a software learning company to update the learning program and make it available to a wide range of users in the UK and worldwide.
Year(s) Of Engagement Activity 2012
 
Description European Antibiotic Awareness Day event in the Science Museum, London 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact The PI was invited to speak at the European Antibiotic Awareness Day event in the Science Museum, London, in 2008 and the STAR Study was covered during the presentation, generating much interest.

Increased awareness and discussion around antibiotic prescribing and resistance.
Year(s) Of Engagement Activity 2008
 
Description European Centre for Disease Control Film 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact The PI was also featured in a film made by the European Centre for Disease Control with content relevant to STAR.

Increased awareness and discussion around antibiotic prescribing and resistance.
Year(s) Of Engagement Activity 2008
 
Description Feature on ITV Tonight 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Approximately 3 million TV viewers saw thew PI of the STAR study comment on antibiotic use and also he was filmed managing two patients with respiratory tract infections using the STAR approach and this was broadcast.

Wider recognition of the importance of antibiotic stewardship and appropriate antibiotic use
Year(s) Of Engagement Activity 2013
URL http://www.itv.com/news/2013-10-24/tonight-when-the-drugs-dont-work/
 
Description General Practice Infections Network Invited Plenary Lecture 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact There is interest in using the learning program

The learning program generated interest and has informed another antibiotic stewardship initiative
Year(s) Of Engagement Activity 2015
 
Description Invited Keynote; "Introduction to behaviour change in community prescribing." South African Antibiotic Stewardship Program, 24 February 2017, Johannesburg. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact I gave a keynote address to the South African Antibiotic Stewardship Conference about strategies for promoting stewardship using the example of the STAR study and other studies I have done. The following day, I gave a presentation and led discussions on "Communication that builds on principles of motivational interviewing." Many of the audience were front- line wopromessionals engaged in antibiotic stewardship activities in hospitals and said they they were inspired and had new techniques to use now. The lead for antibiotic stewardship for a large hospital chain now plans to take forward these ideas and implement them in over 40 hospitals.
Year(s) Of Engagement Activity 2017
 
Description Invited Seminar, Population Health Sciences, University of Dundee, "Common infections in primary care: the implications of two decades of research for clinical method, antimicrobial stewardship and sustainability." 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact I spoke to researchers involved int he field of antibiotics use and resistance and stimulated collaborative research and further study questions; I covered a range of the the research studies that I am involved with that are supported by the NIHR. Lessons learned and insights from here studies were shared.
Year(s) Of Engagement Activity 2016
 
Description Invited keynote: "Responsible use of antibioitcs: ideas into action." Responsible Use of Medicine in Animals (RUMA-VMD) conference, London, 03.11.2015. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact I presneted findings from the STAR study and consider how they might be relevant to improving prescribing for veterinarians
Year(s) Of Engagement Activity 2015
 
Description Invited symposium presenter, Royal College of GPs Conference "Expanding Horizons of Care." Glasgow 1 October. "Tackling antibiotic resistance: Solutions from research." 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact About 100 GPs attended a talk on managing infections and lively debate followed about clinical care.
Year(s) Of Engagement Activity 2015
 
Description Panellist; "Reducing The Unnecessary Use of Antimicrobials". Reducing Demand, Raising Awareness, Preparing for the Future. Policy-UK Antimicrobial Resistance Forum. Royal Society of Chemistry, Burlington House, Piccadilly, London. 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact I reviewed behaviour change approaches to antibiotic presiding for an audience of clinicians and policymakers. Vigorous discussion followed about antibiotic resistance and behaviour change strategies that could be implemented in the UK
Year(s) Of Engagement Activity 2016
 
Description Plenary presentation, Federation of Infection Societies Conference, Manchester Central, 2011 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact This was a plenary talk where the intervention of the STAR study was presented, including video coverage.

Title: What patients really want: STAR project

EAAD conference, Manchester
18/11/11

Several requests were made by antimicrobial pharmacists and representatives of primary care organisations for access to the intervention. The STAR Intervention was described and featured in another plenary talk delivered by a antimicrobial pharmacist from a primary care organisation.
Year(s) Of Engagement Activity 2011
 
Description Presentation to Cwm Taf Health Board R&D day 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Local
Primary Audience Health professionals
Results and Impact The STAR study was featured in the keynote address for this R&D conference as part of a cycle of research that identified a problem, develops interventions and then evaluates the interventions.

Title - "Identifying and addressing unhelpful variation in disease and health care delivery".

Cwm Taf Research & Development Conference
Prince Charles Hospital, Merthyr Tydfil
19/10/12

Access to the intervention was requested by the primary care quality improvement lead.
Year(s) Of Engagement Activity 2011
 
Description RCGP Wales conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact It will be featured in a presentation to RGCP Wales on 26.11.1010

RCGP Wales conference


Nothing notable.
Year(s) Of Engagement Activity 2010
 
Description Radio 4 interview: womens hour 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact An interview was conducted with Chris Butler PI on R4 womens hour where the intervention was mentioned.

I had feedback via email from interested listeners.
Year(s) Of Engagement Activity 2011
 
Description Radio 4: "The path of least resistance" feature of STAR intervention 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Chris Butler was interviewed on a program on Radio 4 on antibiotic resistance. The STAR STUDY was prominently featured, with parts of the intervention broadcast to illustrate innovation approaches to tackling the complex challenge of antimicrobial stewardship in primary care

This Radio 4 program was broadcast twice. Once at 9pm and one a few weeks later at 4.30pm. The program was also featured on the BBC website and received many hits. Chris Butler was contacted by clinicians, primary care organizations and teachers for further information about the intervention and access to the intervention. One teacher asked for and was given a recording of the program of use in the science curriculum for network of schools.
Year(s) Of Engagement Activity 2011
 
Description Respiratory Update Day: Presentation to GPs in North Wales 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach National
Primary Audience Health professionals
Results and Impact Delivered a session on the STAR study and what the aims of the study were as well as illustrating the software developed for the intervention.

Other than raising awareness about the STAR study the session encouraged reflection around prescribing amongst attendees.
Year(s) Of Engagement Activity 2008
 
Description Royal Pharmaceutical Society 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Invited keynote presentation; "Making the Difference in Primary Care". Antimicrobial Resistance, meeting the challenges. Royal Pharmaceutical Society in collaboration with Royal Colleges and Department of Health
Year(s) Of Engagement Activity 2014
 
Description Scottish Antimicrobial Prescribing Group, Glasgow 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact Stemming the Tide of Antimicrobial Resistance
Scottish Antimicrobial Prescribing Group, Scottish Medicines Consortium on Improving the Quality of Primary Care Prescribing.
6th March 2012 in Glasgow.
The event included GPs, academics and prescribing advisors from across Scotland. Both the talk and the workshop were based on the STAR programme, the paper for which was also recently published in the British Medical Journal.

.
Year(s) Of Engagement Activity 2012
 
Description Talk to Richard Doll Society, University of Oxford 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Undergraduate students
Results and Impact I presented the STAR study with results and a description of the intervention to University of Oxford medical students
Year(s) Of Engagement Activity 2018
 
Description Talk to Wales Antimicrobial Forum 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Approximately 100 attendees who were mainly clinicians and policy makers interested in antimicrobial stewardship attended the talk and contributed to discussions on antimicrobial stewardship in primary care.

Requests were made for access to the learning program.
Year(s) Of Engagement Activity 2011
 
Description University of Bristol, 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Local
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Stemming the Tide of Antimicrobial Resistance
Presented at University of Bristol, School of Social and community Medicine Seminar Programme
10th May 2012.

.
Year(s) Of Engagement Activity 2012
 
Description Wales Antibiotic Reference Group 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact The study was presented to the Wales Antibiotic Reference Group.

N/A
Year(s) Of Engagement Activity 2010