How can guidelines be optimised to help achieve the rational use of antibiotics after the Covid-19 pandemic?

This PhD project aims to use a mixed-methods approach to understand how guidelines can be optimised for improving antibiotic use after Covid-19, providing new insights to be used by guideline setters and implementers.

Antimicrobial resistance (AMR) has been increasing globally, in part due to high rates on antibiotic use in healthcare settings. Guidelines play a pivotal role in influencing antibiotic use, particularly in primary care settings where prescribing is based on clinical judgement rather than a precise diagnostic test. One guideline that has potential to influence antibiotic use is the AWaRe Index. AWaRe was created by the World Health Organization (WHO) in 2017 as a way of categorising antibiotics in the Essential Medicines List into three groups: Access (first- and second-choice antibiotics for treating most common infections), Watch (antibiotics with a higher potential for developing resistance) and Reserve (last resort treatments). These categories are intended to guide stewardship programmes by being the basis of measures and targets for systems, facilities and prescribers. In the UK, AWaRe is part of the 2019-2024 AMR National Action Plan (NAP), is used for monitoring by Public Health England (PHE) and in research in both primary and secondary care settings. However, it is not yet clear if or how AWaRe is translated into primary care clinical practice.

This research project will draw on the complementary strengths of epidemiological and anthropological methods to understand how guidelines can be optimised for improving antibiotic use after Covid-19 in the UK, providing new insights to be used by guideline setters and implementers.

The epidemiological (quantitative) aspect of this project will use antibiotic prescribing data from electronic health records. I will compare patterns in prescribing between England and Ireland in order to quantify the effects of the AWaRe Index. AWaRe was implemented in the UK's 2019-2024 AMR National Action Plan, but is not yet in Ireland's National Action Plan, so I will be able to determine if AWaRe has had an impact on prescribing in England by assessing changes in antibiotic use over time (before and after it was implemented in England), and compared to a control country (Ireland).

The anthropological (qualitative) aspects of this project will involve key informant interviews and ethnographic fieldwork. Key informant interviews will be conducted with 3 individuals who are involved in national antibiotic use policy settings and will be repeated throughout the project to enable the co-production of this research. The ethnographic fieldwork will be conducted at 2 general practices in the UK and where I will observe meetings between Medicine Management Teams (who have been the focal points for UK AMR stewardship interventions), clinical staff and pharmacists.

The qualitative and quantitative findings will be merged into one final interpretation, where I will identify areas of agreement and disagreement between the different elements of this research.