A new report conducted by the office of Baroness Bennett of Manor Castle has gone live shedding light on the issue of under delivery of antibiotics when administered via an IV administration set and the role this plays in the global AMR crisis. The findings demonstrate how residual volume of antibiotic that remains in the line of the IV administration set can result in patients receiving an under delivery of up to 30% of the prescribed dose, leading to possible resistance within patients owing to the accumulative effect.
The report, which was launched at The House of Lords on 20th November, summarises the findings from a study of antibiotic “line flushing” and disposal practices in NHS organisations across the UK. The launch was attended by representatives from the sector, industry, NHS and parliament.
The report addresses the issue of under dosing of patients that are administered antibiotics through an IV administration set that isn’t ‘flushed’ through with diluent. When the lines aren’t flushed, the dose received can be up to 30% less than what was prescribed resulting in patients receiving too little of the antibiotic they need to fight infection. This drives antimicrobial resistance and can make the patient more susceptible to drug-resistant infections.
While line flushing is best practice in an NHS setting, it is often only followed on paediatric and oncology wards, where the drugs used are high-cost and underdosing could prove fatal, however the same cannot be said for IV antibiotics. Not only does AMR impact the NHS significantly both in cost and in patients returning to hospital or staying in hospital longer, but this in turn contributes to the ongoing global AMR crisis.
By 2050 it is estimated that AMR will kill 10 million people per year, more than cancer and diabetes combined. Without suitable antimicrobials to treat infections, diseases that previously (before antibiotics) were life threatening, are now manageable. They allow patients to recover without risk of infection - however recently we have seen a rise in treatment-resistant infections, such as chlamydia and gonorrhoea which can have great impact on a person's health and wellbeing.
The impact of AMR is vast, it isn't only a pandemic affecting people and the NHS, its environmental impact is widespread - the disposal of ‘left over’ antibiotics was a focus of the report, understanding how IV administration sets were disposed of and in-turn if the antimicrobials were released into the atmosphere. Antibiotic resistance in the environment spreads existing resistant organisms. This contamination can cause further development of resistance. These drugs and bacteria are often found in the waterways and soil.
Dr Paul-Enguerrand Fady, senior parliamentary researcher from Baroness Bennett’s office conducted research into the phenomenon of residual volume of antibiotics that remain in the IV administration set (pump or gravity) if a post-medication flush is not administered.
The research investigated how many NHS acute organisations in the UK have specific policies in place surrounding flushing patients’ lines when they give adults antibiotics.
This can cause the patient to be under dosed by up to 30% of the prescription resulting in not only considerable wastage, but a hidden cause of AMR. These findings also have the potential to impact the time frame with which a patient could be moved to oral antibiotics, further exacerbating the issue of unnecessary wastage of IV antibiotics.
Talking about the research he commented: “It has been fascinating to work on this report, the issue of underdosing is relatively unknown, and is a simple and easy fix to help us tackle the growing pandemic against AMR.”
The report findings show that:
Approximately 70% of NHS organisations don’t have any administration set flushing policy in place to make sure patients are receiving the complete dose of antibiotics as prescribed.
Approximately 5% of NHS organisations report that they do flush the IV set routinely, in all clinical areas, administering the total prescribed dose.
Of the 30% of NHS organisations that do have a policy, fewer than half are fully compliant with their own policy.
Recommendations following the report:
That all NHS organisations implement line flushing policies by late 2024, with the support of the Department for Health and Social Care
That national regulators integrate adherence to line flushing policies into their assessment of hospitals
That funds be made available to enable research into underdosing’s impact on drug-resistant infections and environmental AMR
That proper training be provided surrounding how to dispose of antibiotics appropriately
That hospitals monitor environmental antibiotics contamination, both in effluent and on wards
Commenting on the findings Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at Barking Havering and Redbridge University Hospitals NHS Trust, said: “As a nurse, it is in my inherent desire to do the right thing when delivering clinical treatments and care to patients. With the launch of this report we - as an industry - have an opportunity to not only keep our patients safe and well, but to contribute to the ongoing fight against AMR that we are facing. The practice is being implemented throughout my hospital Trust and I would encourage anyone working in a hospital setting to do the same moving forward.”
Commenting on the findings Ashleigh Hughes, Senior Sister, Newcastle Hospitals NHS Foundation Trust said: “It was a pleasure to speak at the launch of this report in The House of Lords, losing a parent to an incurable disease is heartbreaking, but to know that underdosing of antibiotics shortened the time she had left and it could have been prevented is devastating. Being a nurse puts me in a unique position to be able to understand the impact that underdosing can have - and having it highlighted in this way shows all the more why this should be a focus for Hospital policy teams as we move forward.”