The influence of non-medical prescribers on antimicrobial stewardship: a national evaluation of the prescribing of antibiotics by non-medical prescribers in England from 2016 to 2021 (part 1)
Non-medical prescriber numbers have increased rapidly over the last 10 years, with increasingly diverse roles and backgrounds. Previous evaluations of their antibiotic prescribing demonstrated it was generally of a high quality and guideline-driven, but recent evidence is lacking and the data are not easily accessible.
To describe changes in the non-medical prescriber population and patterns in dispensed antibiotic volumes between 2016–2021, highlighting evidence of good antimicrobial stewardship and where further interventions may be required.
An analysis of retrospective non-medical prescriber prescribing data was performed, to determine the numbers of independent non-medical prescribers and the patterns of prescribed community-dispensed antibiotics in England between 2016–2021.
Between 2016–2021, it was found that independent non-medical prescriber numbers in England rose by 54%. Whilst they remain predominantly nurses (76%), the numbers of pharmacists and allied health professionals have increased. Non-medical prescribers were responsible for 10.6% of all dispensed antibiotic items prescribed in primary care in England. However, the proportion of dispensed antibiotic items prescribed by these non-medical prescribers reduced by over 50%. Prescribing in 2020 differed from previous years, with increased high-risk antibiotic prescribing.
The quality of prescribing generally appears good and in accordance with national guidelines and principles of good antimicrobial stewardship. The 2020 COVID-19 pandemic prompted changes in antibiotic prescribing behaviour.
The overuse of antibiotics in medicine through inappropriate prescribing contributes significantly to bacterial resistance, a serious and current global health threat (World Health Organization (WHO), 2021). Most antibiotic prescribing takes place in primary care (71.4% in general practice; 4.1% in other community settings; 3.4% in dental practice (Public Health England (PHE), 2020)). Changes in service delivery models mean more non-medical prescribers (NMPs) are involved in prescribing. A previous retrospective analysis of dispensed antibiotic prescriptions written by NMPs in primary care in England demonstrated a 38.5% rise in NMP numbers from 2011 to 2015, with 29 000 NMPs responsible for 7.6% of all dispensed antibiotic prescriptions by 2015 (Courtenay et al, 2017). By 2019, this had risen to 55 000 (Chater et al, 2020); therefore, it can be assumed that their volume of prescribing has also increased.
The UK government's previous 5-year action plan (Department of Health and Social Care (DHSC), 2013), released as part of its 20-year vision for antimicrobial resistance (AMR) (DHSC, 2019a), focussed on optimising prescribing practices and improving professional education about AMR. Despite a 17% decrease in antibiotic prescribing in primary care between 2013–2018, there was still a 7% increase in severe antibiotic-resistant infections between 2017–2018 (Drug Therapy Bulletin Team, 2020). The government has released a new 5-year AMR strategy plan, from 2019 to 2024 (DHSC, 2019b), which aims to reduce the use of antimicrobials in humans by 15% in the UK. However, this strategy fails to include and consider the growing NMP population, considering only the development of community pharmacist roles (Courtenay et al, 2019).
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