ARK-Hospital and the National CQUIN for Antimicrobial Resistance and Antimicrobial Stewardship

Antibiotic Reduction and Konservation (ARK) in Hospitals (ARK-Hospital) is an NIHR-funded research programme. Its overarching aim is to reduce the incidence of serious infections caused by antibiotic-resistant bacteria in the future, through substantially and safely reducing antibiotic use in hospitals now.

There are currently two National Commissioning for Quality and Innovation (CQUIN) goals which will impact hospital antibiotic prescribing in England. The first, titled ‘Antimicrobial resistance and antimicrobial stewardship,’ incentivises hospitals to reduce their total antibiotic consumption vs. 2013/2014 levels, as well as their use of the broad-spectrum agents carbapenem and piperacillin-tazobactam. Concurrently, a second CQUIN titled ‘Timely identification and treatment for sepsis’ aims to ensure that all patients with suspected sepsis are administered intravenous antibiotics within one hour of presentation. This is likely to significantly increase the number of prescriptions for broad-spectrum antibiotics.

There is a clear tension between the need to ensure that patients who are potentially very sick – such as those with suspected sepsis – are appropriately treated, and the need to reduce the volume of antibiotics prescribed. The ARK programme seeks to address this issue.

The Department of Health guidance, Start Smart then Focus, recommends early (24-72h) antibiotic prescription ‘review&revise’ as a key strategy to reduce broad-spectrum antibiotic use. Indeed, to meet the sepsis CQUIN hospitals must undertake an empiric antibiotics review within 3 days of prescription, and the antimicrobial resistance CQUIN includes a component tied to the percentage of antibiotic prescriptions reviewed within 72 hours.

However, audits demonstrate that barriers to implementation of ‘review&revise’ result in poor compliance with this approach and limit its effectiveness. From these audits, we estimate that optimally implementing ‘review&revise’ could reduce hospital antibiotic use by 20%.

The research will

  • develop feasible, inexpensive interventions to increase prescriber compliance with antibiotic ‘review&revise’ strategies in acute/general medical inpatients, and patient acceptability of shorter antibiotic therapy durations driven by them
  • evaluate their safety and cost-effectiveness

Similar approaches have been highly effective in primary care (GPs), exemplified by the GRACE-intro project (Little P et al Lancet 2013) and STAR.

The key components of the ARK-Hospital programme are:

  • Summary of the published evidence for the effectiveness and safety of shorter antibiotic courses in hospitalised patients
  • Observational analyses investigating associations between antibiotic course duration and outcomes
  • Qualitative studies with healthcare professionals and patients/carers to understand better their perceptions and experiences of antibiotic prescribing and to identify barriers to change
  • Development and piloting of a ‘review&revise’ intervention package for patients/carers and healthcare professionals
  • Large ‘stepped-wedge’ hospital randomised trial, to evaluate the intervention’s effectiveness and safety
  • Health-economic evaluations

If you are a healthcare or other NHS professional and are interested in finding out more about the ARK Programme, or would like to take part, then please contact elizabeth.darwin@ndm.ox.ac.uk

The research is funded by NIHR Programme Grants for Applied Research RP-PG-0514-20015. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health