The indicative curriculum for antimicrobial resistance (AMR) has been developed by NHS England – Workforce, Education and Training (WT&E) Directorate, NHS England – Antimicrobial Prescribing and Medicines Optimisation (APMO) team, the national antimicrobial pharmacy education group (NAPEG) and the Pharmacy Schools Council.

The revised General Pharmaceutical Council (GPhC) standards for the Initial Education and Training of Pharmacists (IETP) integrate learning outcomes that demonstrate competency as an Independent Prescriber at the point of registration. They span the entire initial five years of training. Independent prescribing will not be incorporated into foundation training until the 2025/26 training year. The learning outcomes for training years 2021/22 – 2024/25 have been modified by the GPhC to reflect this.

To support the implementation of the IETPs, a number of priority subjects were identified by NHS England WT&E and Pharmacy Schools Council for the development of indicative curricula. Antimicrobial resistance was identified as one of these subjects. Indicative curricula are designed in the interest of an effective continuum of learning and training in practice across the 5 years of initial education and training.

These are additional resources to support the indicative curriculum in AMR to help guide the teaching content in both the MPharm and the Foundation Training Year to support effective initial education and training in England. This will support undergraduate pharmacy students and trainee pharmacists to successfully demonstrate the learning outcomes of the IETPs and RPS Prescribing Competencies that link to AMR. It is not compulsory to use but is there as a guide to support educators.

NHS England Workforce Training and Education – Initial Education and Training Reform Programme.

Development process

The following resources were consolidated and adapted for undergraduate pharmacy training by the NHS England Antimicrobial Pharmacy and Medicines Optimisation (APMO) portfolio leads for education and training and presented to the National AMS Pharmacy Education Group (NAPEG).

• Courtenay M et al 2018. Development of consensus based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.
• Department of Health, Expert Committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI) and Public Health England 2013. Antimicrobial prescribing and stewardship competencies.
• Royal Pharmaceutical Society 2014. Infection and antimicrobial stewardship expert professional practice curriculum. 

This group includes educators of antimicrobial stewardship for undergraduate pharmacy students and trainee pharmacists in the United Kingdom (UK) including representation from:

• Academics at Schools of Pharmacy (SOPs)
• British Pharmaceutical Students Association (BPSA)
• British Society for Antimicrobial Chemotherapy (BSAC)
• NHS England (AMS and Infection Prevention and Control representatives)
• NHS Scotland
• Royal Pharmaceutical Society Expert Advisory Group on AMS (RPSEAG)
• United Kingdom Health Security Agency (UKHSA)
• Specialist antimicrobial pharmacists
• United Kingdom Clinical Pharmacy Association (UKCPA)

The group refined this document and added extra competencies to meet the requirements of undergraduate pharmacy students.

This document was then compared with the following framework for medical students: McMaster D et al, 2020. Consensus-based antimicrobial resistance and stewardship competencies for UK undergraduate medical students and any missing competencies added.

Domains

 
Domain 1: Infection prevention and control (IPC)

Competency statement

All newly qualified pharmacists must understand the core knowledge underpinning infection prevention and control and use this knowledge appropriately to prevent the spread of infection by applying the principles of the national infection prevention and control manual.

Descriptors

1.01. Describe the nature and classification of pathogenic micro-organisms, including the structural differences between Gram-positive, Gram-negative and atypical bacteria and their association with different human anatomical sites of infection.

1.02. Describe how micro-organisms cause infections in humans: the importance of understanding the differences between colonisation (e.g. of venous leg ulceration or urinary catheters) and infection.

1.03. Explain what an antimicrobial resistant organism is.

1.04. Describe the micro-organisms (bacteria, viruses and fungi) that commonly cause infection in the UK and how these micro-organisms are transmitted in both community and hospital settings.

1.05. Define the components required for infection transmission (i.e. presence of an organism, route of transmission of the organism from one person to another, a host who is susceptible to infection).

1.06. Describe the routes of transmission of infectious organisms (i.e. contact, droplet, airborne routes).

1.07. Present and recognise the characteristics of a susceptible host (e.g. immunocompromise).

1.08. Demonstrate an understanding of the principles of why screening for colonisation (e.g. MRSA or CPE on admission to hospital) is important for reducing nosocomial spread.

1.09. Demonstrate the application of standard precautions in healthcare environments.

1.10. Apply appropriate policies/procedures and guidelines when collecting and handling specimens.

1.11. Apply appropriate policies, procedures and guidelines relevant to infection control when presented with infection control cases and situations.

1.12. Implement work practices that reduce risk of infection (such as taking appropriate immunisation or not coming to work when sick to ensure patient and other healthcare worker protection).

1.13. Appreciate that healthcare workers have the accountability and obligation to follow infection control protocols as part of their contract of employment recognise barriers to IPC protocols and demonstrate awareness of how to raise concerns.

1.14. Act as a role model to healthcare workers and members of the public by adhering to infection prevention and control principles.

1.15. Describe what is meant by contact precautions, droplet precautions and airborne precautions.

1.16. Understand how to use PPE and when to apply to appropriate situation.

1.17.* Demonstrate an understanding of the principles of infectious diseases epidemiology and the importance of surveillance for identifying new and emerging pathogenic microorganisms or changes in the prevalence of existing pathogens that impact on infection prevention and management.

1.18.* Demonstrate awareness of key national and international initiatives to promote effective infection prevention and control and address the threat of antimicrobial resistance.

1.19.* Demonstrate awareness of the important micro-organisms that cause healthcare-associated infections (including MRSA, C. difficile, VRE, ESBL-producers and CPE) and how they are transmitted and monitored.

Domain 2: Antimicrobials and antimicrobial resistance

Competency statement

All newly qualified pharmacists need to understand the core knowledge underpinning the action of antibiotics and the concept of antimicrobial resistance; and use this knowledge to help prevent antimicrobial resistance.

Descriptors

2.01. Demonstrate an understanding of the major classes of antimicrobials, their mechanisms of action and their spectrum of antimicrobial activity in terms of Gram-positive, Gram-negative, anaerobic and atypical bacteria and viruses, fungi and parasites.

2.02. Describe the spectrum of activity for commonly prescribed antimicrobials within each major class.

2.03. Describe broad-spectrum and narrow-spectrum antimicrobials, the contribution of broad-spectrum antimicrobials to antimicrobial resistance, the AWaRe categories from the WHO Essential Medicines List; and outline situations when broad-spectrum antimicrobials are warranted instead of narrow-spectrum.

2.04. Describe the major mechanisms of antimicrobial resistance and the implications for treatment of commonly encountered resistance profiles in terms of patient management (e.g. MRSA, VRE, ESBL, CPE).

2.05. Demonstrate understanding of factors contributing to AMR including inappropriate prescribing by healthcare workers and the sale of antimicrobials without prescription (e.g. over the counter in some parts of the world; online sales).

2.06.* Demonstrate an understanding of the challenge of diagnostic uncertainty for infection syndromes due to variation in pathogen epidemiology, unknown pathogen identification and the phenomenon of intrinsic and acquired resistance to antimicrobials.

2.07.* Demonstrate awareness of the burden of antimicrobial resistance to society, the importance of surveillance of epidemiological trends in resistance and the consequences of AMR for individual patient health outcomes.

2.08.* Demonstrate an understanding of the concept of One Health where AMR is concerned and the inter-dependencies between human health, animal health, agriculture, food and the environment.

Domain 3: Antimicrobial prescribing and stewardship

Competency statement

All newly qualified pharmacists need to demonstrate knowledge of how infections are diagnosed and managed and use this knowledge appropriately to manage patients with infections including the appropriate use of antimicrobial agents.

Descriptors

3.01. Demonstrate an appreciation that appropriate use of antimicrobials, including spectrum of activity and treatment duration, reduces the emergence of resistance and reduces adverse effects (e.g. their disruptive effects on host normal flora or microbiota which may lead to, for example, opportunistic infection with C. difficile or Candida species, or inflammatory disorders such as inflammatory bowel disease).

3.02. Demonstrate an understanding of the key elements of prescribing an antimicrobial, including: determining whether or not an antimicrobial is indicated; obtaining microbiological cultures or other relevant tests before commencing treatment as necessary; the choice of agent; the route of administration; its pharmacokinetics and how this affects the choice of dosage regimen; how to monitor levels (therapeutic drug monitoring) and adjust doses (e.g. in obesity, the elderly or renal impairment); where to seek specialist advice; decisions to switch agent (e.g. from intravenous to oral, narrower to broader spectrum [or vice versa]) based on microbiological results; the duration of treatment and when to consider review/stop dates.

3.03. Recognise the importance of initiating prompt effective empirical antimicrobial treatment in patients with life-threatening infections (sepsis) and demonstrate the ability to apply relevant severity scoring tools such as NEWS2 or CRB-65.

3.04. Understand why self-limiting bacterial or viral infections are unlikely to benefit from antimicrobials and demonstrate the ability to apply clinical decision aids (e.g. FeverPAIN) to target treatment to patients most likely to benefit from antimicrobials.

3.05. Describe key features of and diagnostic criteria for specific infections (e.g. UTI, pneumonia, cellulitis).

3.06. Understand how vital signs and inflammatory markers (e.g. C-reactive protein, white cell count and procalcitonin) and other investigations are used to aid diagnosis and monitor the response to treatment of infections and their complications.

3.07. Understand when and how to request and interpret relevant basic diagnostic tests in primary and secondary care that can guide antimicrobial therapy (e.g. microbiology, radiology, immunology, point-of-care tests).

3.08. Describe and demonstrate how to select the appropriate antimicrobial regimen according to site of infection and anticipated pathogen groups, paying due consideration to local and national guidance (e.g. from NICE and UKHSA), including how, and where, to access this.

3.09. Understand the concepts of empirical therapy and pathogen-directed therapy, how local microbial/antimicrobial susceptibility patterns impact on the choice of empirical therapy and the significance of using local or national empirical therapy guidelines.

3.10. Demonstrate an understanding of patient specific factors unique to antimicrobials that need to be considered when choosing an antimicrobial which may influence the choice of antimicrobial (e.g. immune function, infection severity and risk of antimicrobial resistance – including previous exposure to antimicrobials or healthcare environments, relevant travel history or known colonisation or contact with resistant organisms).

3.11. Demonstrate an understanding of how to interpret microbiology results/reports from the laboratory, the significance of preliminary pathogen identification (e.g. Gram stain) for selecting initial treatment and awareness of the common methods of testing for antimicrobial resistance.

3.12. Describe and demonstrate switching to the correct antimicrobial when susceptibility testing indicates resistance, or to a narrower spectrum or more cost-effective antimicrobial that is also compatible with the clinical presentation.

3.13. Describe the common side-effects, including allergy, drug/disease interactions, less common but clinically significant side-effects and contraindications of the main classes of antimicrobials, and the importance of monitoring for these, and what to do when these are suspected

3.14. Demonstrate knowledge of when not to prescribe antimicrobials, including the application of clinical decision aids, and use of alternatives, such as the removal of invasive devices (e.g. intravenous or urinary catheters and incision and drainage of abscesses [source control]).

3.15. Demonstrate an understanding of the rationale and use of perioperative prophylactic antimicrobials to prevent surgical site infection, including the significance of timing of administration and indications for repeat dosing.

3.16. Demonstrate an understanding of why accurately diagnosing and documenting a patient allergy to an antimicrobial and distinguishing between allergy and intolerance is important and describe the principles of penicillin allergy de-labelling.

3.17. Demonstrate an understanding of the importance of documenting on the prescription chart and/or in patients’ clinical records, the clinical indication and degree of diagnostic certainty, route, dosing regimen, duration and review date of antimicrobials

3.18. Demonstrate knowledge of when to use a delayed (back-up) antimicrobial prescription and how to negotiate this with the patient.

3.19. Understand the principles and importance of post-prescription review of antimicrobial therapy for hospital inpatients on all ward rounds, appropriately selecting and documenting the prescribing decision in accordance with ARHAI Guidance – Start Smart – then Focus.

3.20. Demonstrate the ability to educate patients and their carers, nurses and other supporting clinical staff about the natural history of common infections, how to self-care (e.g. with evidence-based interventions including analgesia, rest and fluids), when antibiotics are and are not required, the importance of complying with the duration/frequency of administration of their prescribed antimicrobial and when to seek help.

3.21.* Demonstrate knowledge of clinically significant drug-drug and drug-food interactions that can cause antimicrobial toxicity or treatment failure and recognise antimicrobials that are potent inhibitors or inducers of drug metabolism.

3.22.* Demonstrate awareness of the content of national evidence-based antimicrobial stewardship resources (e.g. NICE guideline NG15, TARGET toolkit and Start Smart – Then Focus).

3.23.* Describe the principles of the pharmacokinetics and pharmacodynamics (PK-PD) of antimicrobials and the application of PK-PD principles for selection of dosing regimens, including for patients with organ dysfunction or at extremes of body weight.

3.24.* Understand the importance of timely intravenous-to-oral switch and demonstrate the application of appropriate criteria to identify patients eligible for switch.

Domain 4: Vaccine uptake

Competency statement

All newly qualified pharmacists need to demonstrate knowledge of the importance of vaccines for reducing antimicrobial resistance and use this knowledge appropriately to promote vaccination.

Descriptors

4.01. Demonstrate the ability to discuss the relevant national and local immunisation programmes and the diseases for which vaccines are currently available. Aware of programmes for specific clinical risk groups, health and care staff and use of vaccination in outbreak situations.

4.02. Demonstrate the ability to explain the general principles of immunisation (e.g. why multiple and/or booster doses are required, why intervals need to be observed between doses and why the influenza vaccine needs to be given annually).

4.03. Demonstrate the ability to clearly and confidently discuss the risks and benefits of vaccination and able to address any concerns patients and/or parents/carers may have.

4.04. Demonstrate awareness of, and ability to discuss, any current issues, controversies or misconceptions surrounding immunisation.

4.05. Demonstrate awareness of the cultural sensitivities around refusal to take vaccines.

Domain 5: Person-centred care

Competency statement

All newly qualified pharmacists must seek out, integrate and value as a partner the input and engagement of the patient /carer in designing and implementing care.

Descriptors

5.01. Support participation of patients/carers as integral partners when planning/delivering their care including where antimicrobials are not recommended, self-care advice, delayed or immediate antibiotic prescribing, adverse effects and risk of antimicrobial resistance.

5.02. Share information with patients/carers in a respectful manner and in such a way that is understandable, encourages discussion, and enhances participation in decision-making. This includes discussing with the patient/carers about what to do if their condition deteriorates (safety-netting advice) and making use of shared decision-making aids (e.g. NICE, TARGET toolkit).

5.03. Ensure that appropriate education and support is provided by learners to patients/carers, and others involved with their care or service using evidence-based resources, such as the Community Pharmacy Antibiotic checklist and TARGET “Managing your infection” leaflets.

5.04. Listen respectfully to the expressed needs of all parties in shaping and delivering care or services.

5.05. Discuss patient/carers expectations or demands of antimicrobials and the need to use antimicrobials appropriately, including the risks and benefits of antimicrobial therapy.

5.06.* Counsel patients/carers about the risks of obtaining antimicrobials without a prescription including the risks of sharing antimicrobials prescribed for others or prescribed for animals.

5.07.* Demonstrate awareness of and support for AMR public health campaigns such as World Antimicrobial Awareness Week, Keep Antibiotics Working, Antibiotic Guardian and e-Bug.

5.08.* Demonstrate awareness of health inequalities associated with antimicrobial exposure and AMR.

Domain 6: Interprofessional collaborative practice

Competency statement

All newly qualified pharmacists need to understand how different professions collaborate in relation to how they contribute to antimicrobial stewardship and quality improvement.

Descriptors

6.01. Demonstrate awareness of the roles, responsibilities, and competencies of other health professionals involved in planning and delivering the care of patients with infection and the stewardship of antimicrobials.

6.02. Explain why it is important that healthcare professionals involved in the delivery of antimicrobial therapy (including the prescription, supply and administration) have a common understanding of antimicrobial treatment policy, the principles of antimicrobial stewardship and diagnostic stewardship; and their impact on safe and effective patient/client outcomes.

6.03. Establish collaborative communication principles and actively listen to other professionals and patients/carers involved in the delivery of safe, effective antimicrobial therapy.

6.04. Communicate effectively to ensure common understanding of care decisions, including diagnostic certainty, treatment plan and risk of AMR or healthcare-associated infection.

6.05. Develop trusting relationships with patients/carer and other health/social care professionals

6.06.* Demonstrate awareness of the common antimicrobial stewardship structures and processes deployed by healthcare organisations (e.g. clinical governance committees, monitoring quantity and quality of antibiotic prescribing; education; audit and feedback; prescribing restrictions; laboratory reporting restrictions; guidelines and digital decision-support).

6.07.* Demonstrate awareness of the important human factors that can influence antimicrobial prescribing, including hierarchy and prescribing etiquette, and understand the implications for antimicrobial stewardship.

6.08.* Understand why regular engagement in team-based measurement of the quality and quantity of antimicrobial use is important and the significance of sharing results with all prescribers, as well as informing future antimicrobial surveillance and infection prevention and control measures.

6.09.* Understand why it is important to use locally agreed process measures of quality (e.g. compliance with guidance), along with outcomes and balancing measures, such as unintended adverse events or complications.

6.10.* Understand the importance of engaging in national antimicrobial stewardship initiatives aimed at supporting national policy and quality improvement e.g. Commissioning for Quality and Innovation (CQUIN) schemes.

Authors

• Kieran Hand, AMR National Clinical Lead for Pharmacy and Prescribing, NHS England
• Naomi Fleming, Regional Antimicrobial Stewardship Lead East of England, NHS England; UKCPA; BSAC
• Gill Damant, Regional Antimicrobial Stewardship Lead, North West NHS England
• Esther Taborn, IPC Improvement Lead, NHS England
• Diane Ashiru-Oredope, Lead Pharmacist, HCAI, Fungal, AMR, AMU and Sepsis Division
  UKHSA
• Conor Jamieson, Regional Antimicrobial Stewardship Lead Midlands, NHS England
• Philip Howard, Regional Antimicrobial Stewardship Lead North East and Yorkshire, NHS England
  BSAC
• Elizabeth Beech, Regional Antimicrobial Stewardship Lead, South West NHS England
• Preety Ramdut, Regional Antimicrobial Stewardship Lead, South East NHS England
• Laura Whitney, Regional Antimicrobial Stewardship Lead, London NHS England
• Sandra Martin, Associate Professor in Pharmacy Practice University of Bradford; UKCPA
• Sally Tipping, Education Officer/Events secretary, British Society of Antimicrobial Chemotherapy (BSAC)
• Katherine Shemilt, Senior Lecturer in Clinical Pharmacy, Liverpool John Moores University
• David Allison, Reader in Pharmacy Education, Division of Pharmacy and Optometry, University of Manchester
• Roger Harrison, Senior Lecturer in Public Health, University of Manchester
• Antonella Tonna, Senior Lecturer in Clinical Pharmacy, School of Pharmacy and Life Sciences, Robert Gordon University
• Kathryn Bullen, MPharm Programme Leader, University of Sunderland.

Publication reference: PRN00969i