Introduction
Who is this guideline for?
Recommendations
- 1.1 All antimicrobials
- 1.2 New antimicrobials
Implementation: getting started
Research recommendations
Other information
About this guideline
Appendix
Guideline (.pdf)
Appendix (.pdf)
Tools and resources
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Published November 2017

Guideline Tools and resources Guideline (.pdf) Appendix (.pdf)

Introduction

The UK’s National Institute for health and Care Excellence (NICE) provide evidence-based guidance and advice to improve health and social care.

Clinical guidelines are recommendations by NICE on the most effective ways to diagnose, treat and care for people with specific conditions with the NHS and beyond. They are based on the best available evidence of clinical and cost effectiveness. While clinical guidelines help health professionals and others in their work, they do not replace their knowledge and skills.

Good clinical guidelines aim to improve the quality of healthcare and reduce inequalities and variation in practice. They can change the process of healthcare and improve outcomes for patients. Clinical guidelines:

Help professionals and patients make decisions about the most appropriate treatment and care for specific clinical circumstances
Can be used to develop standards to assess the clinical practice of individual health professionals
Can support the education and training of health professionals and others
Can improve communication between patients and health professionals.

The Best Practice Advocacy Centre New Zealand (bpac^nz) has an agreement with NICE to contextualise recently published NICE clinical guidelines for the New Zealand health care sector. The contextualisation process is described in detail on the bpac^nz website. As part of this bpac^nz will convene a Guideline Review and Contextualisation Group (GRCG) for each guideline. The GRCG will carefully consider the NICE guideline recommendations, taking into account the differences between the UK and New Zealand health care systems to produce a guideline that is relevant to those delivering and managing care in New Zealand.

The development of a profusion of antimicrobial medicines since the middle of the twentieth century has been one of the greatest advances of medical science. Antibiotic therapy has reduced the mortality and morbidity of almost all serious infections. Furthermore the use of antibiotics to prevent or treat infections has dramatically reduced the risks associated with many medical and surgical procedures, such as the treatment of leukaemia, organ transplantation, and joint replacement surgery. In the absence of effective antibiotic therapy many of these procedures would have unacceptably high risks of failure or death.

Unfortunately, for decades antibiotics have been very widely prescribed for conditions in which they provide no clinical benefit – most commonly for patients with self-limiting respiratory tract infections. High levels of antibiotic use in recent decades have accelerated the evolution and spread of bacteria that are very resistant to many antibiotics. Most alarming has been the emergence of infections caused by microbes resistant to all available antibiotics. Such untreatable infections are expected to increase in the near future, and unless we can dramatically slow this process, by 2050 antimicrobial resistant infections will cause more deaths globally than currently are caused by cancer.

All nations have responded to the threat of antimicrobial resistant infections by implementing antimicrobial stewardship strategies to ensure, not only that patients with serious infections receive the most effective treatment, but also that unnecessary antimicrobial use is dramatically reduced. There is no reason to be complacent about antimicrobial use in New Zealand. We have very high levels of use and rapidly rising levels of antimicrobial resistance. Improved antimicrobial stewardship needs to be a national health priority. This guideline provides comprehensive, carefully considered, evidence based recommendations to support antimicrobial stewardship in New Zealand.

What is this guideline about and who is it for?

Purpose of this guideline

The purpose of this guideline is to provide good practice recommendations on systems and processes for the effective use of antimicrobials.

Audience for this guideline

All healthcare providers.
All organisations funding, providing or supporting the provision of care.
Adults, young people and children (including neonates) using antimicrobials or those caring for these groups.
It is anticipated that the MoH, District Health Boards (DHBs) and all healthcare providers will need to work together to ensure that patients benefit from the good practice recommendations in this guideline.

Scope of this guideline

The bpac^nz guideline covers the effective use of antimicrobials as part of all publicly and privately funded human healthcare provided throughout New Zealand.

The guideline does not cover:

specific clinical conditions (although some evidence identified included patients with a specific infection such as community acquired pneumonia)
named medicines
public health awareness of antimicrobial resistance
research into new antimicrobials
immunisation and vaccination
antimicrobial household cleaning products
antimicrobial use in animals and plants, including veterinary/animal health, agricultural/aquaculture/horticultural
hand hygiene, decolonisation and infection prevention and control measures
medicines adherence, except where there are specific issues for all healthcare providers to address relating to antimicrobials
access to medicines, including local decision making for medicines not included on local formularies
medicines shortages, including supply issues and discontinued medicines
prescription charges
waste medicines
Identification of antimicrobials currently being overused in human health care.
Introduction of funding or prescribing restrictions on the use of antimicrobials.
International treaties, rules and governance.

In the New Zealand setting, it is expected that many of these issues will be extensively discussed elsewhere (including in the New Zealand National Antimicrobial Resistance Group).

All NICE guidelines are developed in accordance with the NICE equality scheme.

Person-centered care

This guideline offers best practice advice on the effective use of antimicrobial medicines.

Patients and health professionals have rights and responsibilities as set out in the Code of Health and Disability Services Consumers Rights.Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their health professionals. If the person is under 16, their family/whānau or carers should also be given information and support to help the child or young person to make decisions about their treatment. If it is clear that the child or young person fully understands the treatment and does not want their family/whānau or carers to be involved, they can give their own consent. Health professionals should follow the advice on consent provided by the Health and Disability Commissioner and Ministry of Health.

If a person does not have capacity to make decisions, all healthcare providers should follow the code of practice outlined by the Health and Disability Commissioner and the Ministry of Health. All health professionals should follow the recommendations in the Code of Health and Disability Services Consumers Rights. In addition, all healthcare providers working with people using adult mental health services should follow the recommendations in the Code of Health and Disability Services Consumers’ Rights. If a young person is moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Code of Health and Disability Services Consumers’ Rights and Consent in Child and Youth Health: Information for Practitioners. Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people and diagnosis and management should be reviewed throughout the transition process. There should be clarity about who is the lead clinician to ensure continuity of care.

1. Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as ‘offer’ and ‘consider’) denotes the certainty with which the recommendation is made (the strength of the recommendation).

Terms used in this guideline

Antimicrobial stewardship

The term ‘antimicrobial stewardship’ is defined as ‘an organisational or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness’.

Antimicrobial resistance

The term ‘antimicrobial resistance’ is defined as the ‘loss of effectiveness of any anti infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines’.

Antimicrobials and antimicrobial medicines

The term ‘antimicrobials’ and ‘antimicrobial medicines’ includes all anti infective therapies, (antiviral, antifungal, antibacterial and antiparasitic medicines) and all formulations (oral, parenteral and topical agents).

Organisations

The term ‘organisations’ (also known as the ‘service’) is used to include all funders (including MoH, District Health Boards, PHARMAC, Accident Compensation Corporation) and providers (hospitals, Primary Health Organisations, general practitioners (GPs), out of hours services, dentists and other community based providers) of healthcare services, unless specified otherwise. Occasionally, in order to make a recommendation more specific to the intended care setting, the setting is specified; for example, the recommendation will state ‘hospital’.

Healthcare Providers

The term healthcare providers is used to define the wider care team, including but not limited to, case managers, care coordinators, GPs, hospital doctors, microbiologists, midwives, pharmacists, nurses and social workers.

1.1 All antimicrobials

Recommendations for organisations

Antimicrobial stewardship programmes

1.1.1

The Ministry of Health should consider establishing a New Zealand antimicrobial resistance group (NZ AMR Group) which (among other roles) will provide national leadership and take responsibility for fostering antimicrobial stewardship across all healthcare settings.

1.1.2

The NZ AMR Group should consider the provision of the following antimicrobial stewardship activities throughout New Zealand:

monitoring and evaluating antimicrobial prescribing and how this relates to local resistance patterns
providing regular feedback to individual prescribers in all care settings about:
- their antimicrobial prescribing, for example, by using professional regulatory numbers for prescribing as well as by relevant prescriber groups such as clinical teams (within hospitals) or practice groups (within the community)
- patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable life threatening infections, infections with Clostridium difficile or adverse drug reactions such as anaphylaxis
providing education and training to all healthcare providers about antimicrobial stewardship and antimicrobial resistance
integrating audit into existing quality improvement programmes.

1.1.3

The NZ AMR Group should ensure that roles, responsibilities and accountabilities are clearly defined within a national antimicrobial stewardship programme.

1.1.4

The NZ AMR Group should encourage lead healthcare providers to establish processes for developing, reviewing, updating and implementing national or regional antimicrobial guidelines informed by local prescribing data and resistance patterns.

1.1.5

The NZ AMR Group should consider developing systems and processes for providing regular updates (at least every year) to individual prescribers and prescribing leads on:

individual prescribing benchmarked against local and national antimicrobial prescribing rates and trends
local and national antimicrobial resistance rates and trends
patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable life threatening infections, infections with C. difficile or adverse drug reactions such as anaphylaxis.

1.1.6

The NZ AMR Group should consider developing systems and processes for identifying and reviewing whether hospital admissions are linked to previous prescribing decisions in patients with potentially avoidable infections (for example, rheumatic fever, Escherichia coli bacteraemias, mastoiditis, pyelonephritis, empyema, quinsy or brain abscess).

Antimicrobial stewardship teams

1.1.7

Each District Health Board (DHB), if necessary through regional collaboration, should establish an antimicrobial resistant team (DHB AMR Team) and should ensure that the team includes the relevant competencies (including where feasible, an infectious diseases physician, an antimicrobial pharmacist, a medical microbiologist, and a primary care representative) and can co-opt additional members depending on the care setting and the antimicrobial issue being considered. The areas of interest for each DHB AMR Team should encompass all antimicrobial stewardship activities in all healthcare settings within that DHB

1.1.8

The NZ AMR Group and the DHB AMR Teams should develop processes that promote antimicrobial stewardship and allocate resources, to:

review prescribing and resistance data and identify ways of feeding this information back to prescribers in all care settings
promote education for prescribers in all care settings
advise decision-making by PHARMAC, advised by its Pharmacology and Therapeutics Advisory Committee and its Anti-infective Subcommittee) on antimicrobials listed on the NZ Pharmaceutical Schedule, including access criteria/restrictions for new and existing listings
update local formulary and New Zealand Formulary prescribing guidance
help advise PHARMAC about antimicrobial use activities
work with prescribers to explore the reasons for very high, increasing or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in regional (where available) or national guidelines
provide feedback and advice to prescribers who prescribe antimicrobials outside of relevant guidelines when it is not justified.

Antimicrobial stewardship interventions

1.1.9

The NZ AMR Group and the DHB AMR Teams should consider using the following antimicrobial stewardship interventions:

review of prescribing by antimicrobial stewardship teams to explore the reasons for increasing, very high or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in local (where available) or national guidelines
promotion of antimicrobials recommended in local (where available) or national guidelines
IT or decision support systems
education based programmes for all healthcare providers,(for example, academic detailing, clinical education or educational outreach).

1.1.10

The NZ AMR Group and the DHB AMR Teams should consider providing IT or decision support systems that prescribers can use to decide:

whether to prescribe an antimicrobial or not, particularly when antimicrobials are frequently prescribed for a condition but may not be the best option
whether alternatives to immediate antimicrobial prescribing may be appropriate (for example, back up [delayed] prescribing or early review if concerns arise).

1.1.11

The NZ AMR Group and the DHB AMR Teams should consider developing systems and processes to ensure that the following information is provided when a patient’s care is transferred to another care setting:

information about current or recent antimicrobial use
information about when a current antimicrobial course should be reviewed
information about who a patient should contact, and when, if they have concerns about infection.

1.1.12

The NZ AMR Group and the DHB AMR Teams should consider prioritising the monitoring of antimicrobial resistance, to support antimicrobial stewardship across all care settings, taking into account the resources and programmes needed.

1.1.13

PHARMAC’s contracts with suppliers should consider specifying the supply of antimicrobials in pack sizes that correspond to local (where available) and national guidelines on course lengths.

1.1.14

The NZ AMR Group and the DHB AMR Teams, with ESR, should consider evaluating the effectiveness of antimicrobial stewardship interventions by reviewing rates and trends of antimicrobial prescribing and resistance.

Communication

1.1.15

The NZ AMR Group and the DHB AMR Teams, with PHARMAC should encourage and support prescribers only to prescribe antimicrobials when this is clinically appropriate.

1.1.16

The NZ AMR Group and the DHB AMR Teams, with PHARMAC should encourage all healthcare providers across all care settings to work together to support antimicrobial stewardship by:

communicating and sharing consistent messages about antimicrobial use
sharing learning and experiences about antimicrobial resistance and stewardship
referring appropriately between services without raising expectations that antimicrobials will subsequently be prescribed.

1.1.17

The NZ AMR Group and the DHB AMR Teams should consider developing local networks across all care settings to communicate information and share learning on:

antimicrobial prescribing
antimicrobial resistance
patient safety incidents.

1.1.18

The NZ AMR Group and the DHB AMR Teams should consider developing local systems and processes for peer review of prescribing. Encourage an open and transparent culture that allows health professionals to question antimicrobial prescribing practices of colleagues when these are not in line with relevant guidelines and no reason is documented.

1.1.19

The NZ AMR Group and the DHB AMR Teams should encourage senior health professionals to promote antimicrobial stewardship within their teams, recognising the influence that senior prescribers can have on prescribing practices of colleagues.

1.1.20

The NZ AMR Group and the DHB AMR Teams should raise awareness of current local guidelines on antimicrobial prescribing among all prescribers, providing updates if the guidelines change.

Laboratory testing

1.1.21

The NZ AMR Group and the DHB AMR Teams, with ESR, should ensure that laboratory testing and the order in which the susceptibility of organisms to antimicrobials is reported is in line with:

national and local treatment guidelines
the choice of antimicrobial in the New Zealand Pharmaceutical Schedule and the New Zealand Formulary
the priorities of medicines management and antimicrobial stewardship teams.

Recommendations for prescribers and other healthcare providers

Antimicrobial guidelines

1.1.22

All healthcare providers should support the implementation of antimicrobial guidelines and recognise their importance for antimicrobial stewardship.

Recommendations for prescribers

Antimicrobial prescribing

1.1.23

When prescribing antimicrobials, prescribers should follow regional (where available) or national guidelines on:

selecting the most appropriate antimicrobial agent
prescribing the shortest effective course
the most appropriate dose
route of administration

1.1.24

When deciding whether or not to prescribe an antimicrobial, take into account the disease profile and particular health consequences of the infectious disease in high risk sub populations and the risk of antimicrobial resistance and other potential adverse effects for individual patients and the population as a whole.

1.1.25

When prescribing any antimicrobial, undertake a clinical assessment and document the clinical diagnosis in the patient’s record and clinical management plan.

1.1.26

For patients in hospital who have suspected infections, take microbiological samples before prescribing an empiric antimicrobial and review the prescription when the results are available.

1.1.27

For patients in primary care who have recurrent or persistent infections, consider taking microbiological samples when prescribing an antimicrobial and review the prescription when the results are available.

1.1.28

For patients who have non severe infections, consider taking microbiological samples before making a decision about prescribing an antimicrobial, providing it is safe to withhold treatment until the results are available.

1.1.29

Consider point of care testing in primary care for patients with suspected lower respiratory tract infections as described in the NICE guideline on pneumonia

1.1.30

Prescribers should take time to discuss with the patient and/or their family/whānau members or carers (as appropriate):

the likely nature of the condition
why prescribing an antimicrobial may not be the best option
alternative options to prescribing an antimicrobial
the views of the patient and/or their family/whānau or carers on antimicrobials, taking into account their priorities or concerns for their current illness and whether they want or expect an antimicrobial
the benefits and harms of immediate antimicrobial prescribing
what they should do if their condition deteriorates (safety netting advice) or they have problems as a result of treatment
whether they need any written information about their medicines and any possible outcomes.

1.1.31

When an antimicrobial is a treatment option, document in the patient’s records (electronically wherever possible):

the reason for prescribing, or not prescribing, an antimicrobial
the plan of care as discussed with the patient, their family/whānau member or carer (as appropriate), including the planned duration of any treatment
the results of any relevant laboratory test.

1.1.32

Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a self limiting condition.

1.1.33

If immediate antimicrobial prescribing is not the most appropriate option, discuss with the patient and/or their family/whānau members or carers (as appropriate) other options such as:

self care with over the counter preparations
back up (delayed) prescribing
other non pharmacological interventions, for example, draining the site of infection.

1.1.34

When a decision to prescribe an antimicrobial has been made, take into account the benefits and harms for an individual patient associated with the particular antimicrobial, including:

possible interactions with other medicines or any food and drink
the patient’s other illnesses, for example, the need for dose adjustment in a patient with renal impairment
any drug allergies (these should be documented in the patient’s record)
the risk of selection for organisms causing healthcare associated infections, for example, C. difficile.

1.1.35

When prescribing is outside local (where available) or national guidelines, document in the patient’s records the reasons for the decision.

1.1.36

Do not issue repeat prescriptions for antimicrobials unless needed for a particular clinical condition or indication. Generally avoid issuing repeat prescriptions for longer than 3 months without review and ensure adequate monitoring for individual patients to reduce adverse drug reactions and to check whether continuing an antimicrobial is really needed.

Prescribing intravenous antimicrobials

1.1.37

Use an intravenous antimicrobial in line with regional or national guidelines for a patient who needs an empirical intravenous antimicrobial for a suspected infection but has no confirmed diagnosis.

1.1.38

Review intravenous antimicrobial prescriptions at 48–72 hours in all health and care settings (including community and outpatient services). Include response to treatment and microbiological results in any review, to determine if the antimicrobial needs to be continued and, if so, whether it can be switched to an oral antimicrobial.

1.2 New antimicrobials

Recommendations for the NZ AMR Group, DHB AMR Teams, PHARMAC and Medsafe

1.2.1

Consider establishing processes to plan for the release of new antimicrobials.

1.2.2

When evaluating a new antimicrobial for inclusion in the New Zealand Pharmaceutical schedule, take into account:

the need for the new antimicrobial
its clinical effectiveness
the population in which it will be used
the specific organisms or conditions for which it will be used
dose, dose frequency, formulation and route of administration
likely tolerability and adherence
any drug interactions, contraindications or cautions
rates and trends of resistance
the ecological impact of the antimicrobial on the host microbiome
whether use should be restricted and, if so, how use will be monitored
any additional monitoring needed
any urgent clinical need for the new antimicrobial
any plans for introducing the new antimicrobial.

These evaluation features are relevant to PHARMAC’s funding and defunding decisions and complement and are directly or indirectly incorporated into, PHARMAC’s Factors for Consideration decision-making framework

1.2.3

Decision making groups should assess the benefits and risks of restricting access to a new antimicrobial. This is part of PHARMAC’s decision-making framework.

1.2.4

If access to a new antimicrobial is restricted:

document the rationale for and the nature of the restriction, and ensure that this information is publicly available
review the restriction regularly to determine that it is still appropriate.

1.2.5

Ensure that formularies, prescribing guidelines and care pathways are updated when new antimicrobials are approved for use.

1.2.6

Ensure that there is a plan for the timely introduction, adoption and diffusion of a new antimicrobial when this has been recommended for use.

1.2.7

Discuss with the NZ AMR Group early in the approval process if funding concerns for a new antimicrobial are likely to cause delay in its introduction, adoption and diffusion.

1.2.8

Consider using multiple approaches to support the introduction of a new antimicrobial, including:

electronic alerts to notify prescribers about the antimicrobial
prescribing guidance about when and where to use the antimicrobial in practice
issuing new or updated formulary guidelines and antimicrobial prescribing guidelines
peer advocacy and advice from other prescribers
providing education or informal teaching on ward rounds
shared risk management strategies for antimicrobials that are potentially useful but may be associated with patient safety incidents.

1.2.9

Indicate where prescribers can find accurate, evidence based and up to date information about the new antimicrobial, such as the:

1.2.10

Once a new antimicrobial has been funded and approved for use, organisations should consider ongoing monitoring by:

conducting an antimicrobial use review (reviewing whether prescribing is appropriate and in line with the diagnosis and national guidelines)
costing the use of the new antimicrobial
reviewing the use of non formulary antimicrobial prescribing
evaluating prescribing and resistance patterns
reviewing clinical outcomes such as response to treatment, treatment rates, emerging safety issues, tolerability and length of hospital stay.

2. Implementation: getting started

This section highlights interventions for changing prescribing practice (education and feedback, and information systems to support data collection and feedback), as these could have a big impact on practice and be challenging to implement. The NICE guideline development group identified these with the help of healthcare providers including GPs and pharmacists, commissioners and Guideline Development Group (GDG) members ( see section 9.4 of the manual).

2.1 The challenge: changing prescribing practice for antimicrobials

The benefits

Reducing the use of antimicrobials where they are not indicated will:¹

slow down the emergence and spread of antimicrobial resistance
ensure that antimicrobials remain an effective treatment for infection
improve clinical outcomes for the population as a whole
conserve healthcare resources.

1. The World Health Organization (2015) Factsheet on antimicrobial resistance [www.who.int/mediacentre/factsheets/fs194/en/]

2.1.1 Using education and feedback to change prescribing practice

See recommendations 1.1.3, 1.1.6, 1.1.9, 1.1.10, 1.1.17, 1.1.18, 1.1.19

Education and feedback have been recommended as a way of changing prescribers’ attitudes and supporting antimicrobial stewardship. Potential barriers that may affect prescribers acting on messages about antimicrobial stewardship include:

the possible risk of adverse outcomes from not treating
not seeing the direct impact of their prescribing on antimicrobial resistance
lack of critical evaluation, review and reflection on their own prescribing practice.

DHB, PHARMAC and PHO decision makers could support a change in prescribing practice by:

allocating resources for education and feedback in their local area and nationally
using governance processes such as audit so that prescribers follow antimicrobial guidelines
creating an open and transparent culture so that prescribers can question prescribing when this doesn’t follow antimicrobial guidelines
providing regular updates across the service on individual prescribing, antimicrobial resistance and patient safety incidents
including antimicrobial stewardship interventions in education programmes which are designed for the setting in which they are to be used
encouraging prescribers to reflect on their personal practice
including objectives for antimicrobial stewardship in prescribers’ annual reviews
signposting prescribers to relevant resources (see Further resources, Page 18 for details of resources you may wish to include)
using the NICE baseline assessment tool [ www.nice.org.uk/guidance/ng15/resources] to evaluate current practice and plan changes
ensuring that prescribers have the training and skills for antimicrobial stewardship
ensuring that there are programmes for education and feedback on antimicrobial prescribing and resistance
ensuring that providers have data about rates and trends of antimicrobial prescribing (for example, summary data from the ESR Surveillance Report on community antimicrobial consumption in New Zealand
encouraging local learning networks, possibly across clinical areas or services, linking to DHB AMR Teams and the NZ AMR Group.

Those responsible for planning pre- and post registration training for prescribers could support a change in prescribing practice by:

including information about antimicrobial stewardship in training courses
providing opportunities for prescribers to demonstrate via continuing professional development (CPD) that they are following the principles of antimicrobial stewardship.

2.1.2 Using information systems to change prescribing practice

See recommendations 1.1.3, 1.1.6, 1.1.10, 1.1.11, 1.1.12

Information systems can help antimicrobial stewardship by capturing data to allow feedback on:

rates and trends of antimicrobial prescribing
rates and trends of antimicrobial resistance
patient use of standard and back up (delayed) prescriptions.

However the relevant data are not always captured or easily accessible.

The NZ AMR Group and DHB AMR Teams could support the use of information systems to change prescribing practice by:

supporting the development of a central facility, which presents national and local data on hospital antimicrobial prescribing and resistance in a format that is easy to use
encouraging the introduction of electronic prescribing where systems are not in place
commissioning the planning and designing of information systems to support antimicrobial stewardship by establishing working groups (to include IT specialists) across all services; this will need coordination and subgroup working to address differences between the various primary and secondary care services.

DHB and PHO decision makers could support the use of information systems to change prescribing practice by:

circulating the data they receive about rates and trends of prescribing within their organisation
using data on rates and trends of prescribing in programmes for educating prescribers about antimicrobial stewardship.

Further resources

New Zealand

Antimicrobial resistance prevalence and recent trends:
- Williamson DA, Heffernan H. The changing landscape of antimicrobial resistance in New Zealand. [http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2014/vol-127-no-1403/6315]
- ESR. Antimicrobial resistance surveillance reports. [https://surv.esr.cri.nz/antimicrobial/antimicrobial_resistance.php]
Antimicrobial consumption in the community:
- Norris P, Horsburgh S, Keown S, et al. Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region. J Antimicrob Chemother 2011;66:1921-6. [http://jac.oxfordjournals.org/content/66/8/1921.long]
- Thomas MG, Smith AJ, Tilyard M. Rising antimicrobial resistance: a strong reason to reduce excessive antimicrobial consumption in New Zealand. NZ Med J 2014;127:72-84. [http://journal.nzma.org.nz/journal/127-1394/6136/]
- Williamson DA, Roos RF, Verrall A. Antibiotic consumption in New Zealand, 2006-2014. The Institute of Environmental Science and Research Ltd. Porirua, New Zealand. 2016. [ https://surv.esr.cri.nz/PDF_surveillance/AntibioticConsumption/2014/Antibiotic_Consumption_Report_Final.pdf]
Antimicrobial consumption in hospitals:
- Ticehurst R, Thomas M. Antimicrobial consumption at Auckland City Hospital: 2006-2009. NZ Med J 2011;124(1332):9-20. [http://journal.nzma.org.nz/journal/124-1332/4602/content.pdf]
- Beardsley J, Morar B, Blackmore T. Antimicrobial consumption data from New Zealand hospitals. NZ Med J 2011;124:83-5. [http://www.nzma.org.nz/journal/124-1341/4851/]
- Hopkins C J. Inpatient antibiotic consumption in a regional secondary hospital in New Zealand. Intern Med J 2014;44(2)::185-90. [http://onlinelibrary.wiley.com/wol1/doi/10.1111/imj.12345/full]
- Duffy E, Gardiner S, du Plessis T, et al. A snapshot of antimicrobial use in New Zealand hospitals – a comparison to Australian and English data. NZ Med J 2015;128: 82-4. [https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1421-4-september-2015/6651]
MoH/MPI strategy for antimicrobial resistance (most up to date version of the New Zealand National Action Plan on Antimicrobial Resistance to be added when available in New Year)

United Kingdom

Antimicrobial prescribing and stewardship competencies (Public Health England, 2013).
For primary care, the TARGET antibiotics toolkit designed to support CPD, audit, training and self assessment for the whole primary care team within a GP practice or out of hours setting.
Further resources are available from NICE to support implementation of this guideline.
NICE produces indicators annually for use in the Quality and Outcomes Framework (QOF) for the UK. The process for this and the NICE menu are available.
NICE uptake data about guideline recommendations and quality standard measures are available on the NICE website.

3. Research recommendations

The bpac^nz Guidelines and Review committee have made these recommendations following New Zealand specific research. The NICE Guideline Development Group’s full set of research recommendations is detailed in the full guideline.

3.1 Reducing antimicrobial resistance

What interventions, systems and processes are effective and cost effective in reducing antimicrobial resistance without causing harm to patients?

Recommendation

Consider undertaking randomised controlled trials to determine whether short versus longer courses of antimicrobials, directly administered (or observed) therapy, continuous versus intermittent therapy and inhaled antimicrobials reduce the emergence of antimicrobial resistance and maintain patient outcomes compared with usual care in the NZ setting.

3.2 Decision-making

What interventions, systems and processes are effective and cost effective in changing all healthcare providers’ decision making and ensuring appropriate antimicrobial stewardship.

Recommendation

Consider undertaking randomised controlled trials to determine whether using point of care tests in decision making is clinically and cost effective when prescribing antimicrobials in children, young people and adults presenting with respiratory tract infections.

4. Other information

4.1 Scope and how this guideline was developed

This bpac^nz contextualised version of the NICE clinical guideline has been developed in accordance with a scope (available from www.bpac.org.nz/guidelines/3) The guideline covers the effective use of antimicrobials as part of all publically and privately funded human healthcare provided throughout New Zealand.

How this guideline was developed

The bpac^nz contextualised versions of NICE guidelines provide recommendations about the treatment and care of people with specific diseases and conditions in New Zealand.

The guideline was originally developed by the NICE Internal Clinical Guidelines programme and then contextualised by the bpac^nz Guideline Review and Contextualisation Group. The NICE team worked with a group of healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, who reviewed the evidence and drafted the recommendations. The NICE recommendations were finalised after public consultation within the UK. Similarly the bpac^nz contextualised version of the NICE guideline were finalised after wide consultation within New Zealand.

The methods and processes for the bpac^nz contextualisation of NICE clinical guidelines are described on the bpac^nz guidelines website. The NICE guideline was developed using the NICE shore clinical guideline process.

4.2 Related NICE guidance and quality standards

Details are correct at the time of publication of the guideline (August 2015).

Published

Sepsis: recognitions, diagnosis and early management (2016) NICE guideline NG51
Medicines optimisation (2015) NICE guideline NG5
Antibiotics for neonatal infection (2014) NICE quality standard QS75
Infection prevention and control (2014) NICE quality standard QS61
Pneumonia (2014) NICE guideline CG191
Drug allergy (2014) NICE guideline CG183
Managing medicines in care homes (2014) NICE guideline SC1
Surgical site infection (2013) NICE quality standard QS49
Patient group directions (2013) NICE guideline MPG2
Infection (2012) NICE guideline CG139
Patient experience in adult NHS services (2012) NICE guideline CG138
Developing and updating local formularies (2012) NICE guideline MPG1
Service user experience in adult mental health (2011) NICE guideline CG136
Prevention and control of healthcare-associated infections (2011) NICE guideline PH36.
Medicines adherence (2009) NICE guideline CG76
Surgical site infection (2008) NICE guideline CG74
Respiratory tract infections – antibiotic prescribing (2008) NICE guideline CG69
Antimicrobial stewardship: changing risk-related behaviours (2017) NICE guideline NG63

5. About this guideline

5.1 About this guideline

This bpac^nz contextualised version of a NICE clinical guideline provides recommendations about the treatment and care of people with specific diseases and conditions in New Zealand.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover. The bpac^nz scope (available from www.bpac.or.nz/guidelines/3) outlines what the contextualised guideline will and will not cover.

The guideline was originally developed by the Medicines and Prescribing Centre at NICE. The Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation within the UK.

The methods and processes for the bpac^nz contextualisation of NICE clinical guidelines are described on the bpac^nz website. The NICE guideline was developed using the process described in “Developing NICE guidelines: the manual”. See www.nice.org.uk/article/pmg20.

Further information about the The Guideline Development Group, NICE project team, NICE quality assurance team, New Zealand contextualisation group, and declarations of interest are presented as Appendix A, available from www.bpac.or.nz/guidelines/3

The guideline bpac^nz have contextualised was published August 2015.

5.2 Rationale for contextual changes – Antimicrobial Stewardship (NG15)

5.3 Strength of recommendations

Some recommendations can be made with more certainty than others, depending on the quality of the underpinning evidence. The Guideline Development Group (GDG) makes a recommendation based on the trade off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the person about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision.

Interventions that must (or must not) be used

We usually use ‘must’ or ‘must not’ only if there is a legal duty to apply the recommendation. Occasionally we use ‘must’ (or ‘must not’) if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a ‘strong’ recommendation

We use ‘offer’ (and similar words such as ‘refer’ or ‘advise’) when we are confident that, for the majority of people, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, ‘Do not offer…’) when we are confident that an intervention will not be of benefit for most people.

Interventions that could be used

We use ‘consider’ when we are confident that an intervention will do more good than harm for most people, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation, and so the health professionals should spend more time considering and discussing the options with the person.

UK versions of this guideline

The full guideline, antimicrobial stewardship: systems and processes for effective antimicrobial medicine use contains details of the methods and evidence used to develop the guideline. It is published by the Medicines and Prescribing Centre at NICE.

Also available is information for the public about this guideline and Implementation tools and resources to help you put the guideline into practice.

Your responsibility

This guideline represents the view of bpac^nz in contextualising the NICE clinical guideline Antimicrobial Stewardship: systems and processes for effective antimicrobial medicine use (NG15), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summaries of product characteristics of any medicines.

5.4 Copyright

This guideline is an adaption of Antimicrobial Stewardship: systems and processes for effective antimicrobial medicine use (NG15) ©National Institute for Health and Clinical Excellence 2015. All rights reserved.

NICE Copyright material can be downloaded for private research and study, and maybe reproduced for educational and not-for-profit purposes. No preproduction for commercial organisations, or for commercial purposes is allowed without the written permission of NICE.

Appendix A The Guideline Development Group, NICE project team, NICE quality assurance team, New Zealand contextualisation group, and declarations of interest

A.1 Guideline Development Group

Chris Cefai	Consultant in Clinical Microbiology and Infection Control, Betsi Cadwaladr University Health Board, North Wales
Esmita Charani (until 27 November 2014)	Academic Research Pharmacist, the National Centre for Infection Prevention and Management, Imperial College London and Honorary Clinical Pharmacist, Imperial College Healthcare NHS Trust
Lynne Craven	Lay member
Martin Duerden	Sessional/Locum GP, North Wales and Clinical Senior Lecturer, Centre for Health Economics and Medicines Evaluation, Bangor University
Heather Edmonds	Lead Medicines Optimisation and Antimicrobial Pharmacist, Leeds North Clinical Commissioning Group
Alastair Hay (Chair)	Professor of Primary Care and NIHR Research Professor, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol; and GP, Concord Medical Centre, Bristol
Philip Howard	Consultant Antimicrobial Pharmacist, Leeds Teaching Hospitals NHS Trust
Sanjay Kalra	Consultant in Trauma and Orthopaedics and Clinical Lead for Infection Control, Royal Liverpool University Hospitals NHS Trust
Tessa Lewis (Vice Chair)	GP and Medical Adviser to All Wales Therapeutics and Toxicology Centre
Kym Lowder	Head of Medicines Management, Integrated Care 24 Limited, Kent
Cliodna McNulty	Head of Primary Care Unit, Public Health England
John Morris	Lay member
Sanjay Patel	Consultant in Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust
Wendy Thompson	Associate Dentist, Sedbergh Dental Practice, Clinical Supervisor, Blackpool Teaching Hospitals NHS Foundation Trust, Lecturer in Antimicrobial Prescribing, Health Education NE
Susan Walsh	Lay member

A.2 NICE project team

Emma Aaron	Administrator, Medicines and Prescribing Centre, NICE
Anne Louise Clayton	Editor
Leighton Coombs	Data Analyst, Health Technology Intelligence, NICE (from July to December 2014)
Johanna Hulme	Project Lead and Associate Director, Medicines and Prescribing Centre, NICE
Debra Hunter	Assistant Project Manager, Medicines and Prescribing Centre, NICE (from 29 September 2014)
Dominick Moran	Data Analyst, Costing and Commissioning Implementation, NICE (from July to December 2014)
Greg Moran	Senior Adviser, Medicines and Prescribing Centre, NICE
Roberta Richey	Senior Adviser, Medicines and Prescribing Centre, NICE (from 1 August 2014)
Rebekah Robinson	Assistant Project Manager, Medicines and Prescribing Centre, NICE (until 26 September 2014)
Erin Whittingham	Public Involvement Adviser

A.3 NICE quality assurance team

Mark Baker	Clinical Adviser
Christine Carson	Guideline Lead
Louise Shires	Guideline Commissioning Manager
Judith Thornton	Technical Lead

A.4 NZ Guideline Review and Contextualisation Group

Scott Metcalfe	Public Health Physician, Wellington
Alan Moffitt	General Practitioner, Director, Procare, Auckland
Pauline Norris	Pharmacist, Professor of Social Pharmacy, University of Otago, Dunedin
Mark Thomas (Chair)	Infectious Diseases Physician, University of Auckland, Auckland
Nigel Thompson	General Practitioner, bpac^nz, Dunedin
Arlo Upton	Microbiologist and Medical Director, Labtests, Auckland
Theresa McClenaghan	Project Manager, bpac^nz, Dunedin

A.5 Declarations of interests

The following members of the NICE Guideline Development Group (GDG) made declarations of interests. All other NICE GDG members stated that they had no interests to declare. The conflicts of interest policy (2007) was followed until September 2014, when an updated policy was published.

Member	Interest declared	Type of interest	Decision taken
Alastair Hay (Chair)	Member of Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection.	Personal specific non financial	Project lead will monitor for any potential conflict. Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
	Would like to be aware of evidence gaps and GDG research recommendations that could influence future research programme.
	Has an interest in the Longitude prize, no financial interests, no involvement in any new antimicrobials.
Alastair Hay (Chair)	No financial conflicts of interest to declare. Lead a group at the University of Bristol conducting research into primary care infections and antimicrobial resistance.	Personal non financial non specific	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
Esmita Charani	Published in peer reviewed journals.	Personal non financial non specific	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles. Reminded that opinions expressed that may be relevant to the guideline may lead to a conflict of interest.
Esmita Charani	Published author on research into antimicrobial stewardship interventions and behaviour change in this field including Cochrane reviews (one ongoing at present). Has also published research on use of mobile health technology to deliver antimicrobial stewardship interventions.	Personal non financial non specific	Chair and Project lead will monitor for any potential conflict. Also discussed with the NICE Medicines and Prescribing Centre Programme Director. Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles.
	Salary is funded by the National Institute of Health Research on a grant investigating behaviour change in antimicrobial prescribing.	Non personal financial non specific
	Honorary visiting researcher to Haukeland University in Norway where advice on the implementation of the national implementation of an antimicrobial stewardship programme.	Personal non financial non specific
Esmita Charani	Undertaking research at PhD level into antibiotic prescribing behaviours in secondary care.	Personal non financial non specific	Chair and Project lead will monitor for any potential conflict. Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles.
Esmita Charani	Published author in the field of antibiotic prescribing behaviours and antimicrobial stewardship.	Personal non financial non specific
Martin Duerden	Received personal payment (honoraria) plus reimbursement of expenses from Reckitt Benckiser (RB) to speak at 2 meetings in the last 12 months. The subject of the talks was antibiotic use in respiratory infections at each meeting but there was no promotion of products marketed by Reckitt Benckiser in the content.	Personal financial non specific	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles. Advised not to write for any publication until the guideline has published.
Martin Duerden	In the last 12 months has also received payment from the publishers of Pulse, GP and Prescriber for writing various articles on prescribing and therapeutics, including antibiotic use.	Personal financial non specific
Martin Duerden	Clinical Adviser on Prescribing for the Royal College of General Practitioners but does not receive payment for this.	Personal non specific non financial	None
Martin Duerden	Member of the Global Respiratory Infection Partnership (work declared above with Reckitt Benckiser done in this capacity). Now spoken at 4 meetings in the last 12 months.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles. Advised not to write for any publication until the guideline has published.
	Member of the Paediatric Formulary Committee for the British National Formulary (BNF); payment not received for this.	Personal non specific non financial
	On the editorial board of Prescriber (a Wiley publication) which is an unpaid position. Occasionally writes opinion based editorials and articles for this publication. Receives payments for these.	Personal non-specific non financial
	In the last year was commissioned and co wrote a report on Polypharmacy for the King’s Fund and received payment for this. Also spoke at a King’s Fund seminar on the topic.	Personal non specific non financial
	On the Editorial Board of Drug and Therapeutics Bulletin, a BMJ Group publication, this is a paid position.	Personal financial non specific
	Has received small payments for articles on the Lipid Modification Clinical Guideline from Pulse and from Guidelines in Practice.	Personal financial non specific
	Member of the NICE Guideline Development Group on lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease.	Personal non specific non financial
	On the Medicines Committee for the Royal College of Paediatrics and Child Health – payment not received for this.	Personal non specific non financial
	Member of the NICE technology appraisals Committee until October 2014. This is not a paid position.	Personal non specific non financial
Martin Duerden	Presented at workshops for commissioners introducing the proposed new national Antimicrobial Prescribing Quality Premium and guide commissioners towards resources and best practice – March 2015 in Leeds.	Personal non specific financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles. Chair and Project lead will monitor for any potential conflict.
Martin Duerden	Delivered a session on sharing success and the work that has been done in Leeds. No financial payment was received for presenting.	Personal non specific non financial
Heather Edmonds	Involved in a Royal College of Nursing published position statement which was sponsored by Pfizer.	Personal non specific non financial	None
Rose Gallagher	Paid consultancy work on antibiotics for the pharmaceutical industry: Pfizer (linezolid), Astellas (levofloxacin), AstraZeneca (ceftaroline), Novartis (daptomycin), Gilead (AmBisome).	Personal non specific non financial	Chair and Project lead will monitor for any potential conflict. Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
Philip Howard	Paid consultancy work with Danone on antimicrobial stewardship.	Non specific personal financial	Advised not to undertake any further consultancy work in this area during the development of the guideline through to publication.
	Committee member of UK Clinical Pharmacy Association – Pharmacy Infection Network.
	Council member of British Infection Association (until May 2013).
	Council member of British Society of Antimicrobial Chemotherapy.
	Represented International Pharmaceutical Federation (FIP) at WHO (World Health Organisation) Antimicrobial Resistance Strategic Technical Advisory Group (May 2014).
	Published unpaid articles related to antimicrobial stewardship.
	Spokesman on Antimicrobials for Royal Pharmaceutical Society.
Philip Howard	Involved in Antimicrobial Resistance Summit at the Royal Pharmaceutical Society in November 2014.	Personal non specific non financial	Advised not to undertake any further consultancy work in this area during the development of the guideline through to publication. Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc. Chair and Project lead will monitor for any potential conflict.
Philip Howard	Sponsorship to present work at international conferences (no money received directly): European Association of Hospital Pharmacy (B. Braun 2013 and 2014) European Congress of Clinical Pharmacy and Infectious Diseases (Gilead 2014). Received expenses and conference paid directly to conference	Personal non specific financial	Advised that as the evidence of the NICE guideline will have been presented he will need to ensure that information he has learnt as being on the GDG is not shared. He agreed and understood.
	Lecture on Clostridium difficile multicentre local service evaluation of fidaxomycin. European Advisory Board on pipeline antibiotics (January 2014) funded by Sanofi. Lecturing/consultancy about: role of the pharmacist in antimicrobial stewardship antimicrobial medicine specific topics data warehousing pipeline agents. Carried out in September/October 2014. Fees paid into Leeds Teaching Hospitals NHS Trust Charitable Trustees. Funding from Astellas, Baxter, Pfizer and Cubist.	Non personal non specific financial
	Paid by College of Pharmacy Practice and Education to develop Antimicrobials in Focus (Antimicrobial Stewardship for Community Pharmacists).	Personal non specific financial
	Research funding from Novartis and Astellas paid directly to an independent audit company to undertake audit. Audits not directly related to antimicrobial stewardship topic.	Non personal non specific financial
	Committee member of European Society of Clinical Microbiology and Infectious Diseases, Antimicrobial Stewardship Group (ESGAP). Member of the Department of Health/Public Health England ESPAUR group.	Personal non specific non financial
	Department of Health ARHAI (Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection) Start Smart then Focus guidance for hospitals group.	Personal non specific non financial
	PHE (Public Health England) and RCGP (Royal College of General Practitioners) TARGET AMS for primary care group. PHE (Public Health England)/Department of Health Competencies of Antimicrobial Prescribing and Antimicrobial Stewardship.	Personal non specific non financial
	Lead a research project on surveying antimicrobial stewardship in hospitals across the world.	Personal non specific non financial
	Part of a research group developing an antimicrobial guideline application with a European group “Panacea”.	Personal non specific non financial
	Part of a joint NIHR (National Institute for Health Research) Programme grant AMR themed call on behalf of Leeds and Oxford Universities on antimicrobial allergy.	Personal non specific non financial
	Antimicrobial resistance round table group (unfunded) with AstraZeneca to help pharmaceutical industry discussion with Government.	Personal non specific non financial
	Lecture at Clinical Pharmacy Congress (2013 and 2014). Updates provided on respiratory infections in 2013. Updates provided on C. difficile, ESBL and drug allergy in 2014. Payment received directly.	Personal non specific financial
Philip Howard	Speaker for Royal Pharmaceutical Society at the Royal Colleges Summit on Antimicrobial Resistance. No payment received.	Non specific non personal financial	Project lead reiterated the importance that work from this group is not shared with other work that he is involved with. Chair and Project lead will monitor for any potential conflict.
	Introduction of proposed ESPAUR/NHS England on Quality Premium to reduce antibiotic prescribing.	Specific personal non financial
	Secondment to NHS England as Regional Healthcare Associated Infections Project Lead from November 2014 to March 2015.	Non specific non personal financial
	Speaker at British Society for Antimicrobial Chemotherapy Antimicrobial Stewardship conference in India.	Non specific personal non financial
	British Society of Antimicrobial Chemotherapy (BSAC) workshop on antimicrobial stewardship in India (27–28 November 2014).	Non specific personal non financial
Philip Howard	BSAC workshop on antimicrobial stewardship in Bahrain (24–26 February 2015).	Non specific, personal non financial	Project lead reiterated the importance that work from this group is not shared with other work involved with. Chair and Project lead will monitor for any potential conflict.
	BSAC round table talk on pharmacy’s role in antimicrobial stewardship.	Personal non specific non financial
	Advisory board for new pipeline product, Durata (February 2015). Fees paid into Leeds Teaching Hospitals NHS Trust Charitable Trustees.	Personal non specific financial
Philip Howard	Advisory boards for: Durata (Dalbavancin) (February 2015) Cubist (Tedezolid) (March 2015). Payment to be made to employer (Leeds Teaching Hospitals) for time.	Personal non specific financial	Advised that the GDG discussions remain confidential although the draft guideline contents can be used now they are in the public domain.
	Attendance at European Association of Hospital Pharmacy conference. B. Braun paid for accommodation, travel paid and attendance. No direct payment received.	Personal non specific non financial
	Secondment to NHS England as Regional Healthcare Associated Infections Project Lead from November 2014 to March 2015. Extended to June 2015. NHS England payment to Leeds Teaching Hospital Trust for time.	Personal non specific non financial
	Speaker at 3 antimicrobial resistance study days for NHS commissioners and a single C. difficile day (March 2015) (NHS England role).	Personal non specific non financial
	GP C. difficile event in Hull (NHS England role).	Personal non specific non financial
	Part of a Public Health England project on tailoring antimicrobial programmes.	Personal non specific non financial
	Speaker at British Society of Antimicrobial Chemotherapy Gulf Antimicrobial Stewardship conference in Bahrain.	Personal non specific non financial
	National Sepsis Programme Board (March 2015 onwards).	Personal non specific non financial
	POC CRP testing in Primary Care (Alere) – February 15.	Personal non specific non financial
Philip Howard	Associate for the NICE Medicines and Prescribing Centre.	Non specific personal non financial	Advised that the GDG discussions remain confidential although the draft guideline contents can be used now they are in the public domain.
Kym Lowder	Stated no conflicts to declare. Spoken at antimicrobial resistance symposia sponsored by public bodies and one by bioMeriuex but received no payment. Leads the development of national Public Health England antibiotic and laboratory use guidance for GPs which covers the diagnosis and treatment of urinary tract infections. She has received grants from several publically funded research bodies.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
Cliodna McNulty	Lead for e Bug project across Europe.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
Cliodna McNulty	Member of Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
Cliodna McNulty	Observer on British Society for Antimicrobial Chemotherapy Council.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc.
	Member of English surveillance programme for antimicrobial utilisation and resistance.
	Lead in the development of Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) and promotes the TARGET resources hosted by the Royal College of General Practitioners.
Cliodna McNulty	Involved in judging the Longitude prize.	Personal non specific non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups etc
Cliodna McNulty	Attended advisory board meeting organised by Hayward Medical Communications on 16/05/14 to discuss procalcitonin: event organised on behalf of Thermo Fischer. Honorarium paid to University Hospital Southampton, travel expenses reimbursed.	Personal non specific non financial	None
Sanjay Patel	Has written a paper on antimicrobial stewardship.	Non specific personal non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups, etc
Sanjay Patel	Author of book chapter about antimicrobial stewardship in paediatric care. Manuscript prepared April 2015 for Oxford University Press.	Non specific personal non financial	None
Sanjay Patel	Has had a relevant journal article published.	Personal non specific non financial	None
Wendy Thompson	Lectured to foundation dentists on antimicrobial prescribing in general dental practice. Guidance to Foundation Dentists in Health Education (North East).	Specific personal non financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles
Wendy Thompson	Lecturer on antimicrobial stewardship prescribing at a Local Professional Network event in Chester in in November and sponsored by Colgate.	Specific personal non financial
Wendy Thompson	Offer received from Leeds University re PhD sponsored financially by Leeds University entitled educating patients about dental treatment rather than antibiotic prescriptions for dental pain.	Personal non specific financial	Advice given regarding ensuring that information learnt as part of the NICE guideline process is not shared with other committees/groups or included within any written articles.
Wendy Thompson	Lecturing at British Dental Association Conference on prescribing standards and guidance – May 2016 – no financial gain.	Personal non specific non financial
Wendy Thompson	Represents and works for organisations that support people with faulty immune systems. Antimicrobials are life saving medicines for these patients.	Personal non specific non financial	None
Susan Walsh	Primary Immunodeficiency UK (PID UK) received 2 grants from CSL Behring in the last 12 months. They were unrestricted and were unrelated to antimicrobials.	Non personal non specific financial	None
Susan Walsh	Restricted grant from Biotest UK Ltd to PID UK.	Non personal non specific financial	None
Susan Walsh	Sponsorship from Bio Products Laboratory Ltd to attend a European Society for Immunodeficiencies conference – unrelated to antimicrobial stewardship.	Non personal non specific financial	None
Susan Walsh	Appointment as community member of NICE Public Health Advisory Committee: guideline on ‘Antimicrobial resistance: changing risk related behaviours in the general population’ (confirmed 27 January 2015).	Non personal non specific financial	None

A.5.1 Declarations of interests

A.5.2

The following members of the bpac^nz Guideline Review and Contextualisation Group (GRCG) made declarations of interests.

Member	Interest declared	Type of interest	Decision taken
Mark Thomas (Chair)	Member of the Joint NZ Ministry of Health /Ministry for Primary Industries New Zealand Antimicrobial Resistance Action Plan Development Group. http://www.health.govt.nz/our-work/disease-and-conditions/antimicrobial-resistance	Personal, non-financial, non-specific.	Project lead will monitor for any potential conflict.
Mark Thomas (Chair)	Investigator in a HRC and ADHB funded study of the impact of smart phone app (SCRIPT) on the level of adherence of antimicrobial prescribing to Auckland City Hospital antimicrobial guidelines- since 2015.	Personal, non-financial, non-specific.	Project lead will monitor for any potential conflict.
Scott Metcalfe	Employed by PHARMAC (NZ Pharmaceutical Management Agency), a crown entity directly affected by the contextualised guideline. Dr Metcalfe undertook this contextualisation work explicitly in a private capacity as a public health medicine specialist, without recourse to PHARMAC and his views do not represent PHARMAC.	Personal, non-financial, non-specific.	Chair and Project lead will monitor for any potential conflict.
	Observer(without formal group consensus decision-making role) -Joint NZ Ministry of Health /Ministry for Primary Industries New Zealand Antimicrobial Resistance Action Planning Group
	Member, NZ College of Public Health Medicine (NZPHM) Policy Committee. The NZCPHM is a NZ health professional organisation affected by the contextualised guideline, advocates for public health, and has a formal stance on the control of AMR.
	Board Member, NZ Medical Association (NZMA). The NZMA is a NZ health professional organisation affected by the contextualised guideline, advocates for public health, and has a formal stance on the control of AMR.
	Executive Board Member, OraTaiao: The New Zealand Climate and Health Council
	Led the NZCPHM’s August 2016 AMR policy statement http://www.nzcphm.org.nz/medica/97734/2016_08_24_nzcphm_antimicrobial_resistance_policy_statement.pdf
	Led NZCPHM/NZMA joint editorial in the NZMJ October 2016 on AMR http://www/nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1444-28-october-2016/7042
Alan Moffitt	Clinical Director of ProCare PHO & Management Services Organisation	Personal, non-financial, non-specific	Chair and project lead will monitor for any potential conflict.
	Chair Auckland/Waitemata Diabetes Service Level Alliance Team
	Was Chair now Member – Metropolitan Auckland Clinical Governance Forum. Has input to clinical pathways and guidance for PHOs & DHBs in Auckland
	Member Counties Manukau health Alliance leadership Team. Decision-making forum for PHO & DHB activity
	Member Auckland-Waitemata Alliance Leadership team. Decision-making forum for PHO & DHB activity
	Member Primary Care Expert Advisory Group – NZ Health Quality and Safety Commission
Pauline Norris	Published author of research in the field of antibiotic consumption in the community	Personal, non-financial, non-specific	Chair and project lead will monitor for any potential conflict.
Nigel Thompson	No conflicts to declare
Arlo Upton	Work for Healthscope NZ which is a publicly listed company (private laboratories)	Personal, financial, non-specific.	Chair and project lead will monitor for any potential conflict.
Arlo Upton	Owns shares in BLIS Technologies Limited (produces probiotic for GAS throat infections)	Personal, financial, non-specific.

Antimicrobial stewardship: Systems and processes for effective antimicrobial medicine use within human health and healthcare in New Zealand