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Antimicrobial stewardship: changing risk-related behaviours in the general population

Overarching principles

The following recommendations are for directors of public health:

  • Work with health and wellbeing boards, commissioners and local authorities to ensure that the following are a priority locally:
  • Ensure that:
    • local authorities and clinical commissioning groups work collaboratively to provide consistent information and advice to:
      • the public
      • healthcare professionals, including GPs, other prescribers and community pharmacists
    • health and social care practitioners and organisations that commission, provide or support the provision of care are:
      • aware of NICE’s guideline on antimicrobial stewardship
      • supported to implement it

Local system-wide approaches to reducing inappropriate antimicrobial demand and use

The following recommendations are for clinical commissioning groups

  • Ensure resources are available for healthcare professionals to use with the public to provide information about self-limiting infections. These resources should be used to encourage people to manage their infection themselves at home if it is safe to do so. The resources should include information on:
    • how someone can recognise whether they, or someone they are caring for, have a self-limiting infection (for example, by checking the NHS Choices website)
    • how to seek further advice if they not sure whether their infection is self-limiting; for example, by:
      • contacting a community pharmacy
      • calling 111 or a local advice line or helpline
      • using other local triaging arrangements such as practice nurses
    • where to seek advice on managing self-limiting infections; for example, from:
      • community pharmacists
      • other reliable health resources, such as NHS Choices
      • other local triaging services
    • the natural course of self-limiting infections, including the length of time symptoms are likely to last
    • how people can self-care (for example, by resting, drinking plenty of fluids and taking over-the-counter preparations to relieve their symptoms, if needed)
    • explicit advice on when to seek medical help, which symptoms should be considered red flags and safety-netting advice
  • Ensure resources and advice are also available for people who are prescribed or supplied with antimicrobials, to ensure they take them as instructed by their healthcare professional (see NICE’s guideline on medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence). This should include taking the correct dose for the time specified and via the correct route
  • Ensure the resources advise people not to:
    • use or take prescription-only antimicrobials without a prescription and advice from a suitably qualified healthcare professional
    • keep leftover antimicrobials for use another time
    • share, or give, prescription-only antimicrobials to anyone other than the person they were prescribed or supplied for
    • use or take antimicrobials prescribed for animals
    • use or take prescription-only antimicrobials or give them to others if they have been obtained from anywhere other than their healthcare professional or pharmacist (for example, prescription-only antimicrobials bought online without a prescription)
    • ask for antimicrobials as a preventive measure against becoming ill or as a ‘stand-by’ measure; for example, when going on holiday (unless the person has a specific condition that makes this necessary or there is a specific risk; for example, if travelling to areas where malaria is endemic [see the antimalarial medication section on NHS Choices] or there is a high risk of travellers’ diarrhoea)

The following recommendations are for local authority public health teams

  • Consider linking to awareness-raising initiatives for the public on reducing inappropriate antimicrobial demand and use and antimicrobial resistance (for example, European Antibiotic Awareness Day and Public Health England’s Antibiotic Guardian)
  • Use opportunities that may arise through other local authority activities to distribute information about antimicrobial resistance (for example, waste disposal and recycling information could include advice not to flush leftover antimicrobials down sinks or toilets but to return them to a community pharmacy for safe disposal)

Local system-wide approaches to preventing and limiting the spread of infection

The following recommendations are for local authority public health teams

  • Ensure information and advice directed at the general public aims to prevent and reduce the spread of infections. Resources such as posters, leaflets and digital resources should be made available through multiple routes to provide a coordinated system of information
  • Ensure information is available in a variety of formats to meet people’s literacy and language needs and the needs of people with sensory disabilities
  • Consider distributing information and advice through facilities and services operated by local authorities, such as leisure centres and libraries
  • When deciding where to distribute information, prioritise settings in which people are more vulnerable to infection or where there is a high risk of transmitting infection to others, for example:
    • childcare settings
    • residential and day care settings for older people
  • Give people information on handwashing that emphasises why it is necessary and effective to thoroughly wash and dry hands to reduce the risk of getting an infection, or passing infection on to their family and other people. Include information on:
    • when hands should be washed and dried; for example, after using the toilet, before eating meals or snacks and after being in close contact with people with colds or other infections
    • how hands should be washed and dried, including the need to use liquid soap and tepid running water (a handrub can be used if soap and water are unavailable). See the standard principles in NICE’s guideline on infection control
  • Use resources shown to be effective in helping people develop and use personalised plans to increase handwashing. (See putting this guideline into practice for examples of resources that may be helpful)
  • Give people advice on food hygiene and signpost them to resources. Include information on:
    • key points at which it is particularly important to thoroughly wash and dry hands; for example:
      • before eating or preparing food
      • after using the toilet or touching the bin
      • before and after handling raw food
    • safe food preparation and cooking methods (this includes ensuring food is cooked at the right temperature and properly heated throughout before eating)
    • how to store food safely, including advice on:
      • fridge temperatures
      • ‘use by’ and ‘best before’ dates
      • freezing, defrosting and refreezing food
    • using food leftovers safely
  • See the food safety section on NHS Choices for more advice on food safety and how to prevent infections from spreading

Prescribers, primary care and community pharmacy teams

This section should be read alongside the recommendations on prescribing in NICE’s guideline on antimicrobial stewardship. See also NICE’s guideline on sepsis: recognition, diagnosis and early management

  • When people ask about managing self-limiting infections:
    • share advice on self-care for each of the symptoms
    • use and share resources that provide written advice to encourage people to change their behaviour 
    • verbally emphasise the key messages given in the written resources
    • display resources that provide or signpost to advice and information about self-care; for example, NHS Choices, 111 and local advice or helplines
    • signpost them to further information to read at home, such as online advice
    • discuss with them whether taking or using an antimicrobial is the most appropriate option (see the recommendation on discussions with patients and family members or carers under ‘antimicrobial prescribing’ in NICE’s guideline on antimicrobial stewardship)
    • raise awareness of community pharmacists as an easily accessible first point of contact for advice about managing a self-limiting infection
  • Consider using computer prompts or decision support aids to prompt healthcare professionals to share information with people on the appropriate use of antimicrobials, self-care and safety netting (see NICE’s guideline on antimicrobial stewardship)

If antimicrobials are prescribed or supplied

  • Share verbal advice and written information that people can take away about how to use antimicrobials correctly, including:
    • not sharing prescription-only antimicrobials with anyone other than the person they were prescribed or supplied for
    • not keeping them for use another time
    • returning unused antimicrobials to the pharmacy for safe disposal and not flushing them down toilets or sinks
  • If the person has been given a back-up (delayed) prescription, tell them:
    • how to self-care to manage their symptoms
    • what the antimicrobials would be used for, if needed
    • how to recognise whether they need to use the antimicrobials, and if so:
      • how to get them
      • when to start taking or using them
      • how to take or use them

If antimicrobials are not prescribed or supplied

  • Give people verbal advice and share written information that they can take away about how to manage their infection themselves

General advice in primary care and community pharmacies

  • Share safety-netting advice with everyone who has an infection (regardless of whether or not they are prescribed or supplied with antimicrobials). This should include:
    • how long symptoms are likely to last with and without antimicrobials
    • what to do if symptoms get worse
    • what to do if they experience adverse effects from the treatment
    • when they should ask again for medical advice

Terms used in this guideline

Antimicrobial resistance

  • Loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines

Antimicrobial stewardship

  • An organisational or healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness

Capability, opportunity and motivation

  • A theory of behaviour change that can guide interventions to change individual behaviour patterns. For any change in behaviour to occur, a person must:
    • be physically and psychologically capable of performing the necessary actions
    • have the physical and social opportunity to make the change
    • be more motivated to adopt the new, rather than the old behaviour, whenever necessary

Handrub

  • A preparation applied to the hands to reduce the number of viable microorganisms. This guideline refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol)

Inappropriate antimicrobial demand and use

  • ‘Inappropriate antimicrobial demand’ refers to people asking for antimicrobials for conditions against which they are ineffective (for example, antibiotics to treat a viral infection such as a cold) or for self-limiting infections that will resolve on their own, with no long-term harm to the person’s health
  • ‘Inappropriate antimicrobial use’ refers to the way in which people may misuse antimicrobials that they have been prescribed or supplied with, and which may result in the antimicrobials becoming ineffective in treating infections. This is because the bacteria, virus, fungus or parasite they are designed to treat may become resistant to the antimicrobial. Examples of inappropriate use include not taking or using the antimicrobials as prescribed and sharing them with others

Local triaging arrangements

  • Services that can advise people whether they have a self-limiting infection that they can safely manage themselves or whether their infection needs medical attention. Examples include community pharmacies, practice nurses, 111, other locally developed advice and helplines, and emergency and out-of-hours primary care services

Red flags

  • Signs and symptoms of a more serious illness or condition

Resources

  • Evidence-based materials that have been developed through a research-based approach with the target audience, wherever possible. They may be in a variety of formats, including posters, leaflets, digital and online resources

Safety-netting advice

  • Advising people what to do if their condition deteriorates or does not improve within a certain time, or if they develop adverse effects as a result of the treatment

Self-care

  • Approaches a person can use to look after themselves in a healthy way; for example, drinking plenty of fluids and getting sufficient rest when you have a cold

Self-limiting infection

  • An infection that resolves on its own and has no long-term harmful effect on a person’s health (assuming that they are not immunosuppressed). Examples include colds, flu, oral thrush, winter vomiting bug

© NICE 2017. Antimicrobial stewardship: changing risk-related behaviours in the general population. Available from: www.nice.org.uk/guidance/NG63. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: June 2017.

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Read the Guidelines in Practice article Educating patients on antimicrobial use is key to combating resistance for more information on implementing the NICE guideline on Antimicrobial stewardship: changing risk-related behaviours in the general population