Research and analysis

ESPAUR report 2022 to 2023: lay summary

Updated 5 January 2024

Chapter 1. Introduction: Why surveillance is important

ESPAUR is an acronym for the English Surveillance Programme for Antimicrobial Utilisation and Resistance.

It aims to collect data on the use of, and resistance to, antimicrobial medicines, which are designed to treat infections that are caused by microorganisms such as:

• bacteria
• viruses
• fungi
• parasites

Those antimicrobial medicine types include antibacterials or antibiotics, antivirals, antifungals and antiparasitics (Figure 1).

The most widely recognised type of antimicrobial medicine are antibiotics, which are used to treat bacterial infections.

Figure 1 shows various types of antimicrobials used to prevent and treat infections caused by microorganisms in humans, animals, and plants. Antibiotics (antibacterials) prevent and treat bacterial infections like cellulitis, urinary tract infections, and sexually transmitted infections such as gonorrhoea. Antivirals prevent and treat viral infections like colds, flu, chickenpox, COVID-19, and HIV. Antiparasitics prevent and treat parasites such as malaria, threadworm, and headlice. Antifungals prevent and treat fungal infections like thrush, ringworm, and athlete’s foot.

Figure 1. An overview of the different types of antimicrobials and the type of microorganisms they are used to treat

Antimicrobial resistance occurs when microorganisms responsible for these infections evolve to develop mechanisms to evade and survive against these medicines. By collecting data about these organisms, ESPAUR supports the aim of reducing antimicrobial resistance and improper antimicrobial use, which is one of the main drivers. It is important to know that resistance can result in untreatable or harder to treat infections, which is why it has been acknowledged as an urgent global threat.

This report comprises of chapters covering antimicrobial resistance, antimicrobial consumption, antimicrobial stewardship, improvement and assurance schemes that NHS England implement, as well as research initiatives, and activities that members of the ESPAUR oversight group are undertaking to contribute to tackling antimicrobial resistance.

Chapter 2. The rise of antimicrobial resistance

In this chapter, findings from the antimicrobial resistance surveillance are presented as well as how different factors affect the spread of infections due to antibiotic-resistant bacteria and other antimicrobial-resistant organisms in England.

Following the lifting of COVID-19 pandemic restrictions, certain infections have made a resurgence. These include infections like:

• community-onset E. coli bacteraemia
• bacterial pneumonia
• Group A Streptococcus
• the fungus Candida auris

In 2022, as in previous years, E. coli was responsible for the majority of the 16,643 cases of antibiotic-resistant bloodstream infections, making up 82.0% of the total.

All of these infections had decreased during the pandemic, due to various factors such as reduced socialising and improved hand and respiratory hygiene as well as healthcare seeking behaviours. In 2022, there was also a 6.0% increase in patient episodes of bloodstream infections in England compared to 2019, the year prior to the start of the COVID-19 pandemic. The most common causative organisms were E. coli and S. aureus.

By calculating the burden of antimicrobial resistance, it is possible to track progress to reduce antimicrobial-resistant infections by 10% by 2025 from the 2018 baseline as set out in the UK government’s 5-year action plan for antimicrobial resistance 2019 to 2024 target. In 2022, there was a 1.6% reduction in England, compared to the 2018 baseline. This followed the 11.1% reduction observed in 2020, which exceeded the target, reflecting the substantial reduction in E. coli cases during the pandemic. This improvement was however, short-lived, as antimicrobial resistance rebounded, when E. coli bloodstream infections, particularly those acquired in communities, began to rise again.

This year’s report also presents data on factors commonly associated with health inequalities such as ethnicity and deprivation levels.

The highest number and rate (cases per 100,000 people) of bloodstream infection episodes were observed among individuals of the white ethnic group. In this group, 83.6% of bloodstream infections were recorded, and out of those, about 18.7% were resistant to at least one of the main antibiotics.

However, the highest percentage of antibiotic resistant infections was noted in the Asian or Asian British ethnic group, with about a third of these infections showing resistance.

Additionally, deprivation levels were looked at using something called the Indices of Multiple Deprivation (IMD), which is used to measure level of deprivation across various domains including income, employment, health and education, within different geographical areas within the UK.

It was reported that areas with higher levels of deprivation had a greater burden of antibiotic-resistant infections, as well as those that were bloodstream infections. This pattern was similar for carbapenemase-producing Gram-negative bacteria, that is, bacteria resistant to our antibiotics of last resort, by deprivation levels.

The general public can play an important role in keeping the level of infections low. Simple habits like regular handwashing, practicing good respiratory hygiene, taking care of our dental health and keeping hydrated, all make a difference.

But the fact that antimicrobial resistance is still a problem shows that we have work to do in terms of using antibiotics and other antimicrobial medicines more responsibly. The next chapter on antimicrobial consumption provides additional information.

Chapter 3. Curbing the consumption of antimicrobials

Antimicrobial medicines are necessary for multiple health conditions, but every time an antimicrobial is prescribed, there is a risk that antimicrobial resistance could develop or worsen. This is why it is so important that antimicrobial medicines like antibiotics are used effectively. In short, they should be prescribed at the right times and for the right reasons, because each type of antimicrobial should only be reserved for the specific type of dangerous, or otherwise deadly type of microorganism that may be causing an infection.

The action plan for antimicrobial resistance, following research on the levels we can get to nationally, provides a national goal to reduce antibiotic use in humans by 15% by 2024. This goal should help to keep prescribers working hard to reduce the amount of inappropriate antimicrobial medicines being used. Because of this, UKHSA will aim to keep a close eye on how often antimicrobial medicines are being prescribed and what conditions and infections they are being used for.

In 2022, there was a change in how antibiotics were used in England. After years of being prescribed less and less, there was an 8.4% increase in antibiotic use compared to 2021. Most places where antibiotics are given, like GP surgeries, hospitals, and the community, saw more antibiotic use in 2022 compared with 2021, but there was a decrease in antibiotic use in dental practices. This was the first time there has been an overall annual increase since 2014, but it’s important to know that antibiotic use is still lower than it was in 2019.

A total of 80% of all antibiotics used are prescribed through GP practices. Because of this, GPs are important places to study to make sure that antibiotics are being prescribed effectively. Prescriptions in GPs increased by 13.0% in 2022 and are now nearly high as they were in 2018, before the COVID-19 pandemic.

There was also an annual increase in hospital prescribing in 2022, but not as much as in GP surgeries. Antibiotic use increased by 4.3% in hospitals but is still lower than it was in 2018.

The patterns and trends of prescriptions also differ for different types of antibiotics, and this can assist researchers clues about what changes can be implemented. One type of antibiotic, penicillin, was used much more in 2022 compared with 2021, particularly in GP surgeries. Much of this prescribing is thought to be made inappropriately in response to viral infections such as influenza (flu). This is problematic because antibiotics should not be routinely used and are not effective against viral infections. This is therefore one area where more responsible prescribing could lead to important reductions in antibiotic use.

It is difficult to understand what these figures mean because of the impact of the COVID-19 pandemic. Data that are collected in future years will help us to understand whether antibiotic prescriptions in GP surgeries are truly decreasing over time, and how much further work is needed to make sure this happens.

Chapter 4. Protecting antimicrobials: the importance of antimicrobial stewardship

To tackle antimicrobial resistance it is important to act on several fronts so that we use these medicines wisely and reduce the spread of resistant infections. One aspect of this effort is antimicrobial stewardship. This supports healthcare workers in carefully selecting the most appropriate antimicrobial medicine, accurate dose and treatment length. These strategies also contribute toward another UK government action plan target of reducing antimicrobial use in humans by 15% by 2024. In the efforts to use antimicrobials wisely and effectively, several helpful tools and resources have been developed. This chapter provides a summary of the main national primary and secondary care antimicrobial stewardship interventions.

One example is the TARGET toolkit, which is an acronym for Treat Antibiotics Responsibly and focuses predominantly on antibiotics in terms of guidance, education and tools.

Included in TARGET, there are now posters available for clinicians that provide evidence-based approaches for discussing antibiotics with patients and considering backup or delayed prescriptions. These tools can guide doctors in making the right decisions about when and how to prescribe these life-saving antibiotics to ensure they are used appropriately.

In GP settings, an effective initiative has been using SMS (text) messaging to send patients online leaflets featuring a range of topics that are related to infection risks and which can have a serious impact on different patient or disease groups before, during, and after a consultation. Among these leaflets, the most widely shared one has been about urinary tract infections in women aged under 65 years.

Additionally, resources have been developed to support community pharmacies implement antimicrobial stewardship principles. Pharmacy healthcare professionals play a crucial role in this effort, particularly, due to their expertise in medications and direct patient interactions. These tools are designed to help pharmacists and other professionals understand and communicate about antibiotics effectively.

There have also been improvements in resources related to managing specific conditions, like acne that can make patients more susceptible to infections. By providing guidance on how to manage acne with antibiotics, healthcare professionals may feel more confident in their ability to make informed decisions about treatment as well as empower patients with education to help reduce the risk when they need to care for their conditions themselves.

In addition, updates to the Start smart then focus: antimicrobial stewardship toolkit for inpatient care settings have been developed based on feedback from healthcare professionals. These updates emphasise fostering a culture of antimicrobial stewardship and further integrating these practices into clinical care.

By following these guidelines, we can preserve the effectiveness of antimicrobial medicines like antibiotics, ultimately benefiting patient-centred care and public health. Additionally, it’s important to consider factors like deprivation and specific clinical conditions when managing infections to address health inequalities and improve outcomes for everyone.

Chapter 5. NHS England: improvement and assurance schemes

NHS England works on different programmes to improve healthcare to ensure antimicrobials are used wisely. They have schemes to encourage healthcare providers to use these medicines carefully to benefit patients and prevent antimicrobial resistance. These include the:

• NHS Oversight Framework for Primary Care Networks
• Pharmacy Quality Scheme for community pharmacies
• NHS Standard Contract for acute hospitals
• Commissioning for Quality and Innovation framework for acute hospitals

To take the NHS Oversight Framework as an example, they set targets for antibiotic prescribing in primary care, and they monitor how well different areas are meeting these targets. They use 2 main metrics:

• number of antibiotics being prescribed in primary care
• the percentage of broad-spectrum antibiotics being prescribed in primary care

Broad-spectrum antibiotics, like a multi-purpose tool, can treat a wide range of bacteria – useful when doctors are unsure which bacteria is causing the infection – but must be used with caution as they can also harm good bacteria in the body and increase risk of antibiotic resistance. In the past year, some areas met these targets, while others didn’t, which was partly due to more cases of infections that needed antibiotics.

In the Pharmacy Quality Scheme, community pharmacies collect data about patients with infections like urinary tract or respiratory infections to help improve care. In the NHS Standard Contract, they aim to reduce the use of certain antibiotics, but some hospitals are still using them more than they should.

All these efforts are part of a bigger plan to make sure antibiotics are used properly and that patients get the right treatment and outcome.

Chapter 6. Professional education, training and public engagement

In the UK, healthcare professionals are actively working to educate and train other stakeholders, such as patients and the public, about the responsible use of antibiotics. They held webinars, including one about skin infections, where hundreds of people signed up to learn more about antimicrobial resistance, particularly antibiotic resistance. The feedback from participants was overwhelmingly positive, with 100% of them rating the webinar as ‘excellent’ or ‘good’. Additionally, healthcare professionals organised the TARGET Train the Trainer Antimicrobial Stewardship Training event, attended by healthcare leaders, and since then, 366 people across 14 different healthcare organisations have been trained.

In addition, there is also a campaign called Antibiotic Guardian, which encourages healthcare organisations, GP practices, hospitals, community pharmacies, farmers, patients and the public to pledge towards responsible use of antibiotics. In 2022, 89 organisations, including some from abroad, registered their efforts on the Antibiotic Guardian website.

The influence of the pledge can involve trainee pharmacists and even schools in the effort to raise awareness. For instance, the Antibiotic Guardian Schools Ambassadors Programme has seen many colleagues registering to become ambassadors, including some from other countries. These ambassadors are working hard to make sure that everyone, from healthcare professionals to students, understand the importance of responsible antibiotic use.

Programmes such as Antibiotic Guardian raise the level of professional understanding around antibiotic use and will help us address some of the main problems at the heart of antimicrobial resistance.

Chapter 7. Recent research initiatives

While progress has been made in recent years to reduce inappropriate antibiotic use in the UK, it is important that this continues so we can make sure the best outcomes are provided for patients in future. This can be achieved partly by implementing what we already understand about healthcare-associated infections and antimicrobial resistance, but it is also vital that scientists and healthcare professionals continue to improve their understanding of these areas through scientific research.

Healthcare-associated infections and antimicrobial resistance have been the subject of many important UK research projects over the last year and have resulted in over 50 scientific papers from UKHSA, each one reviewed and approved by experts in the field. These papers cover various important topics outlined in the UK national action plan for antimicrobial resistance including:

• testing and tracking antibiotic resistance (5 projects)
• preventing infections in hospitals (6 projects)
• Using antibiotics wisely and effectively (5 projects)
• developing new tests, treatments and vaccines for infectious diseases (7 projects)

This commitment to improving scientific knowledge is reflected in the funding of 2 specialist research units dedicated to studying healthcare-associated infections and antimicrobial resistance, one at Oxford University and the other at Imperial College London. The research conducted at these units aims to improve public health policies and practices and is essential for keeping patients and the public safe and healthy.

Importantly, this research has also started to focus more on how we can address inequalities in health. Understanding how different groups of people are affected by healthcare-associated infections and antimicrobial resistance can help us to improve outcomes for everyone in future.

Chapter 8. Support from stakeholders

Producing the ESPAUR report has been a large undertaking that has required the input of experts from various organisations, each of whom have brought diverse perspectives to the table. In total, 18 different organisations have contributed to this year’s report:

• British Dental Association
• British Infection Association
• British National Formulary
• British Society for Antimicrobial Chemotherapy
• Care Quality Commission
• College of General Dentistry
• ESPAUR Dental Subgroup
• National Institute for Health and Care Excellence
• Royal College of General Practitioners
• Royal College of Nursing
• Royal Pharmaceutical Society
• Rx-info
• Specialist Pharmacy Service
• Veterinary Medicines Directorate and Department for Environment, Food and Rural Affairs
• Scottish One Health Antimicrobial Use and Antimicrobial Resistance
• Public Health Agency Northern Ireland
• Public Health Wales
• NHS England

As well as contributing information to the report, these stakeholders perform other activities that support the national effort to tackle healthcare-associated infections and antimicrobial resistance. These activities include:

• running programmes to help improve the effective use of antimicrobial medicines
• publishing guidance and providing tools for healthcare professionals
• engaging with the public and patients to help improve understanding of the issues related to preventing and managing antimicrobial resistance
• organising conferences, workshops and other events

Writing the ESPAUR report with the input of stakeholders from various organisations with their own unique experiences of performing activities aiming to tackle antimicrobial resistance is helping us all to build a more strategic agenda and plan to improve outcomes in future.

Acknowledgements

Fran Husson, Vanessa Carter, Zahin Amin-Chowdhury, Matt Wilson, Tehreem Mohiyuddin, Diane Ashiru-Oredope.