Bacteria that cause common infections are becoming increasingly resistant to currently available antibiotics. Antibiotics are essential in modern healthcare but their use drives the development of resistance as bacteria develop ways of surviving their effects. Previous research has found that antibiotics are often used when they are not needed, which increases the development of resistance in bacteria.

Older people living in care homes are prescribed many more antibiotics than average and as a result often get antibiotic resistant infections later, which are then harder to treat. The amount of antibiotics used in different care homes varies a lot but we don't really know why. Most research on finding ways to safely reduce antibiotic use has been carried out in hospitals or GP surgeries rather than care homes.

There is general agreement that antibiotic use in care homes could and should be safely reduced. However, to design effective approaches to reducing antibiotic prescribing for care home residents we need to understand more about how, when and why they get prescribed, from the perspectives of nurses, carers, GPs, and residents and their relatives.

Under the ARCH Study, Researchers with different areas of expertise will work together in a four-stage project:  

1. Measuring patterns of antibiotic use (epidemiology): We will analyse information on antibiotic prescribing and antibiotic resistance for all care home residents in two Scottish health board regions. As well examining the link between antibiotic prescribing and later antibiotic resistance, this will help us better understand how common antibiotic use is, which residents are prescribed, and variation in prescribing between care homes. This information will also be used to invite care homes with different patterns of antibiotic use to participate in the next stages of the project.

2. Understanding how and why antibiotic prescribing happens in different care homes (sociology and social anthropology): We will work with staff, GPs, residents and relatives in eight care homes. We will observe how staff and GPs work together and react to residents being unwell, and how this leads to antibiotic prescribing. We will also interview staff, GPs, residents and relatives to understand how the way the care home and general practices are organised influences the care different residents receive. This will help us identify new approaches to improving antibiotic prescribing decisions.

3. Identifying staff behaviours that could be changed to reduce antibiotic prescribing (health psychology): We will also carry out more focussed interviews and questionnaires to find out specific reasons why carers, nurses and GPs perform certain actions, and investigate what might encourage or discourage these actions. For example, what causes a nurse to phone a GP to request a prescription for a resident? Why might the GP sometimes write a prescription without reviewing the patient first? This will help us identify specific changes in behaviour which could improve antibiotic prescribing decisions.

4. Creating and testing new approaches to changing antibiotic prescribing (intervention development and testing): We will use all the information from the first three phases, and evidence from other situations (e.g. hospital or GP antibiotic studies) to create an intervention that we will try out in a small number of care homes to see if it is acceptable to staff and residents, and whether it is feasible to do alongside normal work. The intervention will include different elements, such as education for care home staff and GPs, and feedback about how many antibiotics are being used in each care home. At the end of the study, we will have created new and useful knowledge about antibiotic prescribing and its consequences in care homes, but we will also have pilot-tested a new intervention. The next stage of our research programme will be testing it in a large-scale trial to see if it 'works'.

Data Usage

All personal information used in this research will be managed in accordance with General Data Protection Regulation (GDPR) and the data handling policies of the Health Informatics Centre (HIC) at the University of Dundee, the National Health Service (NHS) and NHS National Services Scotland:

HIC: https://www.dundee.ac.uk/hic/datasecurityconfidentiality/

NHS inform: https://www.nhsinform.scot/media/2368/how-nhs-handles-your-data-v1-nov_2018-web.pdf

NHS NSS Data protection information: https://nhsnss.org/how-nss-works/data-protection/

NHS data used in the research will be managed by HIC who have more than 20 years’ expertise in the provision of anonymised, linked, patient-level data for research. HIC has ISO27001:2013 certification, the internationally recognised gold standard in information security. Researchers in the ARCH team will only access anonymised data for analysis within the HIC secure data safe haven and all researchers have completed data governance training and signed a data user agreement.

Information collected by the ARCH research team, including observation and interviews, will be with individual informed consent with assurance of anonymity and confidentiality for participating care homes and individuals. The study including our handling of data (use, legal basis and protection) has been approved by the London Camberwell St Giles Research Ethics Committee, by our joint sponsors, NHS Tayside and the University of Dundee, and by Research & Development departments of NHS Tayside and NHS Fife. No identifiable personal information will be shared unless mandated by research regulators. All published results including quotes and names, of care home and/or individuals, will be anonymised.