Antimicrobial resistance and healthcare associated infection improvement goals: 2025 to 2027 (WHC/2025/039)

Status:

Action or information.

Category:

Public health quality and care.

Title:

Anti-microbial resistance and healthcare associated infection improvement goals for 2025 to 2027.

Date of expiry or review:

This Welsh health circular will remain applicable until replaced by the next iteration. This is expected to be in 2027 but may be sooner if required.

For action by:

• Chief executives, health boards or trusts.
• Directors of public health, health boards or trusts.
• Medical directors, health boards or trusts.
• Directors of primary care, health boards or trusts.
• Nurse executive directors, health boards or trusts.
• Directors of therapies and health sciences, health boards or trusts.
• Directors of pharmacy and chief pharmacists, health boards or trusts.
• Executive director of public health, Public Health Wales.
• General practitioners, dental practices and community pharmacies.
• Public Health Wales The Healthcare Associated Infection, Antimicrobial Resistance and Prescribing Programme (HARP) Team, Public Health Wales.

Required by:

Immediate.

For information:

• Director General and Chief Executive, Health, Social Services and Early Years Group (HSCEY).
• NHS Wales Deputy Chief Executive (HSCEY).
• NHS Wales Performance and Improvement.
• Welsh NHS Partnership Forum.
• General Practitioner Committee, Wales.
• Royal College of General Practitioners.
• Royal College of Nursing.
• Royal College of Midwives.
• Royal College of Paediatrics and Child Health.
• British Medical Association.
• British Dental Association.
• Royal Pharmaceutical Society.
• Community Pharmacy Wales.
• Care Inspectorate Wales.
• Healthcare Inspectorate Wales.

Senders:

• Isabel Oliver, Chief Medical Officer.
• Sue Tranka, Chief Nursing Officer.

Co-signatories:

• James Calvert, Deputy Chief Medical Officer, Health Services.
• Keith Reid, Deputy Chief Medical Officer, Population Health.
• Andrew Evans, Chief Pharmaceutical Officer.
• Professor Andrew Dickenson, Chief Dental Officer.

Welsh Government contacts:

Health Protection,
Welsh Government,
Cathays Park,
Cardiff.
CF10 3NQ.
HealthProtection@gov.wales

Quality and Nursing,
Welsh Government,
Cathays Park,
Cardiff.
CF10 3NQ.
QualityAndNursing@gov.wales

Enclosures:

Antimicrobial stewardship and infection prevention and control improvement goals for 2025 to 2027.

HCAIs are an important cause of avoidable morbidity and mortality, with HCAIs being one of the major drivers of antimicrobial resistant infections. As part of the UK 20-year vision to confront and address AMR, Wales alongside the other three UK nations, is committed to taking effective action to control and mitigate the major threat of AMR, directing resources at areas of highest risk. Coordination of this collective effort is through a series of five-year UK National Action Plans (NAPs), of which the current NAP for the period 2024 to 2029 (published on 8 May 2024) is the second.

This Welsh health circular reaffirms the improvement goals previously set out in WHC/2024/038 reflecting on the data from the previous year and the updated targets set out in the new AMR NAP.

The threat posed by AMR, and the importance of the best possible standards of infection, prevention and control, and of antimicrobial stewardship, are indisputable. So too is the need to translate this consensus into meaningful progress in reducing the burden of HCAIs and further improving antimicrobial stewardship. The duty to deliver this progress applies at every level of the healthcare system from the individual to the organisations and professions to which they belong.

HCAIs remain a key patient safety issue that results in a significant burden of disease and financial cost to the NHS in Wales and across the care sector. Current trends, including increases in Clostridioides difficile (C. diff) infections and Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteraemias, emphasise the importance of renewed efforts to control the spread of infection in our healthcare settings.

Whilst some progress was made in 2023 to 2024, we remain a significant way off achieving many of the improvement goals and achieving the UK AMR vision.

Working with colleagues in the NHS Wales Performance and Improvement, the Welsh Government will monitor and support progress through both the AMR Wales Programme and wider NHS Wales governance structures.

Your leadership and support are essential in achieving these goals to reduce the impact of AMR and improve patient safety across Wales. We are very grateful for this support.

Yours sincerely

Isabel Oliver
Chief Medical Officer

Sue Tranka
Chief Nursing Officer

Keith Reid
Deputy Chief Medical Officer – Public Health

James Calvert
Deputy Chief Medical Officer – Health Services

Andrew Evans
Chief Pharmaceutical Officer

Andrew Dickenson
Chief Dental Officer

This Welsh Health Circular reaffirms the improvement goals previously set out in WHC/2024/038. These improvement goals take account of the human health targets included in the current AMR national action plan and remain valid and relevant.

As before, the improvement goals set out for the NHS for 2025 to 2026 are set out under the relevant theme, outcomes and human health targets contained in the five-year national action plan for 2024 to 2029.

The value of these improvement goals depends on the action that they stimulate. Where achieved they should reinforce good practice and encourage further progress where possible. Where missed, they demonstrate the need for timely, positive remedial action and ongoing constructive scrutiny. In either case, they are an opportunity to learn and then share the knowledge gained.

1.1: Clostridioides difficile (C. diff) infection.

The position across Wales in regard to C. diff infections deteriorated during 2024 to 2025 and overall there has been a 22.5% increase in cases, with similar increases seen in both hospital onset and community onset cases. The Improvement Goal for 2025 to 2027 seeks to address this increase and drive a reduction in cases to below last year’s baseline.

Actions for health boards to undertake to support this reduction:

• Engagement required with the CDI (Clostridium Difficile Infections) Collaborative being set up by QSI (Quality, Safety and Improvement) Team of NHS Performance and Improvement.
• Adoption of the new cleaning standards for Wales.
• Effective isolation of cases and review of IPC (Infection Prevention and Control) arrangements to manage C. diff in hospital – consideration of use of cohort wards.
• Adherence with antimicrobial prescribing guidelines – primary and secondary care.
• Ensuring that antimicrobial stewardship teams are in place and appropriately resourced across our health boards and trusts.
• All health boards and acute hospitals required to participate in the annual point prevalence survey of antimicrobial prescribing in November.

1.2: Drug-resistant infections

UK AMR national action plan targets for 2024 to 2029
the UK AMR national action plan sets out two relevant targets. These are shown below.

To support the NHS in Wales to achieve these targets improvement goals relating to gram negative blood stream infections (E. coli, Klebsiella spp. and Pseudomonas aeruginosa) and MRSA blood stream infections were set out in WHC/2024/038 as well as ensuring that the following antimicrobial stewardship objectives are met:

• adherence with antimicrobial prescribing guidelines – primary and secondary care
• ensuring that antimicrobial stewardship teams are in place and appropriately resourced across our health boards and trusts
• ensuring that IPC guidance on drug resistant infections (CSARO (Clinically Significant Antimicrobial Resistant Organisms) guidance) is followed and health boards have appropriate screening and isolation policies in place for drug resistant infections

These targets were translated into annual improvement goals for E. coli, Klebsiella spp. and Pseudomonas aeruginosa BSI (Bloodstream Infection) set out in WHC/2024/038. Following review of performance against these existing targets in 2024 to 2025, the following revised improvement goals are set out for 2025 to 2027.

E. coli bloodstream infections

All health boards to continue work to reduce the cases of community origin. Our expectation is fewer cases of E. coli BSI overall than in 2024 to 2025.

Actions for health boards to undertake to support this reduction:

• develop UTI QI programme across primary and secondary care – engaging with the HARP programme led UTI task and finish group; Urinary Tract Infection (UTI) has been included in the Common Ailment Service (CAS) since 1 October following an initial pilot during summer 2024; the CAS is an important route of access to diagnosis and management and needs to be included in this work
• ensure that IPC guidance on Drug Resistant Infections (CSARO guidance) is followed and health boards have appropriate screening and isolation policies in place for drug resistant infections
• ensure IPC/ANTT (Aseptic Non-Touch Technique) education and training is in place and recorded for all healthcare professionals who are involved in the insertion, care and ongoing management for indwelling devices
• encourage use of NICE guidance (24 December) to utilise antibiotic sparing approaches to managing chronic / recurrent urinary tract infection; (use of methenamine hippurate and vaginal oestrogen) Overview | Urinary tract infection (recurrent): antimicrobial prescribing | Guidance | NICE

Klebsiella spp. bloodstream infections

All health boards must continue to work to reduce the cases of community origin. Our expectation is fewer cases of Klebsiella spp BSI overall than in 2024 to 2025.

Pseudomonas aeruginosa bloodstream infections

All health boards to continue to work to reduce the cases of community origin. Our expectation is fewer cases of Pseudomonas (Ps) aeruginosa BSI overall than in 2024 to 2025.

Actions for health boards to undertake to support this reduction:

• review of water safety programmes particularly within augmented care areas (high dependence, critical care, haematology, renal, neonatal units) to ensure alignment with national guidance recommendations
• review of any outbreaks of Ps aeruginosa BSI to learn lessons and implement any interventions to reduce cases.

Staphylococcus aureus bloodstream infections

All health boards are expected to achieve these improvement goals and to continue to work to reduce the incidence of Staphylococcus aureus bloodstream infections.

Actions for health boards to undertake to support this reduction:

• engage with national surgical site infection surveillance
• ensure high compliance with ANTT training in all relevant staff groups
• ensure IPC/ANTT education and training is in place and recorded for all healthcare professionals who are involved in the insertion, care and ongoing management of invasive devices

1.3: Hospital-Acquired Pneumonia (HAP)

Supporting information

HAP is a common indication leading to the use of IV (Intravenous) and broad-spectrum antibiotics. The use of broad-spectrum antibiotics increases the risk of emerging resistance and healthcare acquired infections such as C. diff, this is in support of the reduction of CDIs in collaboration with NHS executive, CDI forum, PHW and is a tier 1 target.

A recent audit (n=59) in Swansea Bay University Health Board, conducted by clinicians across Morriston hospital, showed that a low proportion of the patients audited met the guideline’s criteria for a severe HAP (14%). Despite this nearly 50% of the patients audited were prescribed broad-spectrum intravenous antibiotics. Interestingly, auditor reported compliance to guidelines was high at 83% but when this was adjusted for the severity assessment, only 53% of prescriptions were as per guidelines. This shows a disconnect between the guideline recommendations and what clinicians perceive to be appropriate antibiotic prescribing in this area. This practice will be driving unnecessary use of broad-spectrum antibiotics.

Evidence of an over diagnosis of HAP was seen in an audit carried out in Betsi Cadwaladr University Health Board where a sample of 192 patients were audited looking at reasons for delayed discharges. Of this 192, 121 were categorised as being unlikely to have HAP, 26 were possible HAP, and 45 were probable HAP giving a total of 71 medically fit for discharge spells in which a possible or probable HAP occurred.

Actions for health boards to undertake to support this reduction:

A clinical audit should be completed in each acute hospital across Wales within the period 2025 to 2026. This audit should be undertaken in collaboration with the local antimicrobial stewardship committee or group. A suitable audit tool used in Swansea Bay University Health Board is available on Sharepoint for adaptation and use by all Welsh health boards.

UK AMR National Action Plan Targets for 2024 to 2029

The UK AMR National Action Plan sets out two antimicrobial stewardship targets. These are shown below.

Welsh antimicrobial usage improvement goals

The antimicrobial usage improvement goals for 2025 to 2027 are set out below. Improvement Goals 11a, 11b, and 12 remain unchanged from WHC/2024/038 but have been relabelled (TAU(PC)/2025, TAU(SC)/2025, and PTUA/2025 respectively).

A new improvement goal relating to duration of course in Primary Care (DOC(PC)2025) is now included.

2.1: Total antimicrobial usage

Separate goals are defined for primary and secondary care with the aim of making the improvement goals for total antimicrobial usage more relevant and meaningful.

Update on performance against improvement goals

Primary care

The 2019 to 2020 baseline rate for primary care in Wales was 10,745.5 DDDs/1000 STAR-PU, and the rate achieved at the end of the 2024 to 2025 financial year is 10,000.6 DDDs/1000 STAR-PU.

In 2024 to 2025, primary care in Wales surpassed the 5% reduction target for the financial year, achieving a 6.9% reduction against the baseline.

Secondary Care (SC)

The 2019 to 2020 baseline rate for SC in Wales was 995.6 DDDs/1000 OBD, and the rate achieved at the end of the 2024 to 2025 financial year is 1,003.4 DDDs/1000 OBD.

In 2024 to 2025, secondary care in Wales failed to meet the 2.5% reduction target for the financial year, achieving a 0.8% increase against the baseline.

Actions for health boards and trusts to undertake to support this reduction

Local epidemiological circumstances vary, and it is for each board and trust to determine and implement the interventions most appropriate to their situation. However, the following actions are advised:

• adherence with antimicrobial guidelines, primary and secondary care
• ensuring that antimicrobial stewardship teams are in place and appropriately resourced across our health boards and trusts to enable suitable interventions including multi-disciplinary microbiology or pharmacy ward rounds in all acute hospitals
• health boards are required to participate in the annual point prevalence study of antimicrobial prescribing in November
• audits of antimicrobial prescribing to be performed at local level on a regular basis and fed back to the clinical teams (Start Smart then Focus)
• regular review of antimicrobial prescribing through the antimicrobial data library produced by PHW to support regular review and consideration of antimicrobial stewardship at local level

2.2: Proportion of total usage from with WHO (World Health Organisation) ‘access’ category

Update on performance against Improvement Goals

Improvement goal 12 was met in neither primary nor secondary care in the financial year 2024 to 2025.

Primary Care (PC)

At the end of the financial year 2024 to 2025, the proportion of total usage from the access category was 65.9% in PC in Wales as measured in DDDs.

Secondary care

At the end of the financial year 2024 to 2025, the proportion of total usage from the access category was 64.2% in SC in Wales as measured in DDDs.

Actions for health boards and trusts to achieve a minimum of 70% from the access category

Local epidemiological circumstances vary, and it is for each board and trust to determine and implement the interventions most appropriate to their situation. However, the following actions are suggested:

• ensure that antimicrobial guidance is followed – primary and secondary care
• encourage the use of narrow spectrum antibiotics
• encourage use of NICE guidance (NG112; Updated 12 December 2024 on the NICE website) to utilise antibiotic sparing approaches to managing chronic or recurrent urinary tract infection; (use of methenamine hippurate and vaginal oestrogen noted on the NICE website)
• ensure that antimicrobial stewardship teams are in place, and appropriately resourced and supported

2.3: Duration of course in primary care

Supporting information

Data from January 2025 show that approximately 65% of prescriptions of these antibiotics by primary care services in Wales were for a 5-day duration. This ranged from 37% - 82% across the 7 health boards in Wales. Reducing the course duration of prescriptions for these antibiotics to 5 days is in accordance with NICE and All-Wales guidelines. National and local guidance has been updated to reflect the evidence base which demonstrates that a reduction in antibiotic exposure can be safely achieved by reducing course duration whilst still providing effective treatment and maintaining clinical effectiveness. This supports the national prescribing indicators 2025 to 2028 from AWTTC (the All-Wales Therapeutics and Toxicology Centre) as noted on their website and will help work towards the reduction target set out in the UK AMR National Action Plan 2024 to 2029 as noted on GOV.UK.

Actions for health boards and trusts to undertake to support 5-day course duration

Health boards should encourage the use of messaging through the using decision support software ‘ScriptSwitch’ and ‘Optimise Rx’ messaging on primary care prescribing systems.

Implement default prescribing quantities on GP prescribing system and utilise the ‘how to’ guide produced by Cwm Taf Morgannwg for practices’ for both Vision and EMIS.

The health boards who have already achieved this target have implemented the actions listed above demonstrating their effectiveness.