Research and analysis

ESPAUR report 2023 to 2024: lay summary

Updated 14 November 2024

Chapter 1. Introduction: Why surveillance is important to tackling antimicrobial resistance

ESPAUR is an acronym for the English Surveillance Programme for Antimicrobial Utilisation and Resistance.

It aims to collect data on the use of, and resistance to, antimicrobial medicines which are designed to treat infections that are caused by germs (microorganisms) such as:

• bacteria
• viruses
• fungi
• parasites

Those antimicrobial medicine types include antibacterials or antibiotics, antivirals, antifungals and antiparasitics (Figure 1). The most widely recognised type of antimicrobial medicine is antibiotics which are used to treat bacterial infections. When bacteria, or other germs, become resistant, it means that these antimicrobial medicines no longer work against the infection as well as they did before.

Figure 1. An overview of the different types of antimicrobials and the type of microorganisms they are used to treat

Accessible text for Figure 1:

Figure 1 shows various types of antimicrobial medicines used to prevent and treat infections caused by microorganisms in humans, animals and plants. Antibiotics (antibacterials) prevent and treat bacterial infections such as respiratory or urinary tract infections and sexually transmitted infections such as gonorrhoea and cellulitis. Antivirals can prevent and treat viral infections such as colds, flu, chickenpox, COVID-19 and HIV. Antiparasitics prevent and treat parasites such as malaria, threadworm and headlice. Antifungals prevent and treat fungal infections such as thrush, ringworm, athlete’s foot and fungal respiratory infections such as aspergillosis.

End of accessible text

Antimicrobial resistance (AMR) occurs when microorganisms responsible for these infections develop mechanisms to evade and survive these medicines. By collecting data about these microorganisms, ESPAUR supports the aim of reducing AMR and inappropriate antimicrobial use which is one of the main drivers of AMR. It is important to know that AMR can result in harder to treat or even untreatable infections, which is why it has been acknowledged as an urgent global threat.

This report comprises chapters covering AMR, antimicrobial consumption, antimicrobial stewardship (that is educating and supporting healthcare professionals to follow evidence-based guidelines for prescribing and administering antimicrobials), improvement and assurance schemes that NHS England implement, as well as research initiatives and activities that members of the ESPAUR oversight group are undertaking to contribute toward tackling AMR.

Chapter 2. The rise of antimicrobial resistance

The UK Health Security Agency (UKHSA) collects, analyses and disseminates information about infections in England that are resistant to antimicrobials, focusing on bloodstream infections. This includes information on how many infections there are, where they are happening, who is being affected and how medicines are being prescribed. This chapter presents findings from this work and looks at how different factors affect the distribution of infections.

Figures from 2023 show that there has been an increase in the number of bloodstream infections from 2022. The reported number of these infections had reduced during 2020 and 2021, coinciding with the COVID-19 pandemic, but rose in 2022 and now again in 2023, and they are now at the level seen before the COVID-19 pandemic in 2019. Some of the drop seen during the pandemic was likely caused by changes in how infections were reported.

The number of reported resistant infections had decreased during the pandemic, due to various factors such as reduced socialising, improved hand and respiratory hygiene (for example handwashing, covering coughs and sneezes, and wearing masks) and changes in healthcare-seeking behaviours (the actions people take to find medical care when they are unwell or require advice). The decrease in reported numbers may also have been caused, in part, by decreased detection of infections. The increases in the last 2 years were expected following removal of restrictions on socialising seen during the pandemic, but the extent of the rise is notable, with there now being more resistant infections than at any point on record.

When looking at antibiotic-resistant bloodstream infections, there has been a 3.5% increase between 2019 and 2023. These infections include those caused by a defined set of important bacteria resistant to at least one key antibiotic. The most common causative microorganisms were Escherichia coli (E. coli) and Staphylococcus aureus. In 2023, as in previous years, E. coli was responsible for most cases of antibiotic-resistant bloodstream infections, making up over 65% of the total.

This chapter also looks at Carbapenemase-producing organisms (CPOs), a group of antibiotic resistant microorganisms that are of particular concern and have been included as part of mandatory surveillance since 2020. The rate of reported CPOs has more than doubled between 2021 and 2023, although this is due in part to an increase in screening and reporting.

As in recent years, the report also takes a closer look at health inequalities in the context of AMR burden, including factors such as ethnicity and deprivation.

The highest number and rate (cases per 100,000 people) of bloodstream infection episodes were observed among individuals of the white ethnic group. This group accounted for 88.4% of total bloodstream infections, of which 20.1% were resistant to at least one key antibiotic.

However, the highest resistance percentage was noted in the Asian or Asian British ethnic group, with nearly 2 in every 5 of these infections showing resistance, an increase since 2022.

Additionally, deprivation levels were looked at using something called the Indices of Multiple Deprivation (IMD), which is used to measure levels of deprivation across various domains including income, employment, health and education, within different geographical areas in the UK.

It was reported that areas with higher levels of deprivation had a greater burden of antibiotic-resistant bloodstream infections. The rate of these resistant infections has increased by 9.5% in the most deprived group since 2019.

The report also presents infection data by age group. It finds that the overall rate of bloodstream infections in children has increased by 25.4% since 2019. The risk is highest for young babies in their first year of life.

By calculating the total burden of AMR, it is possible to track progress to reduce antimicrobial-resistant infections by 10% by 2025 from the 2018 baseline as set out in the UK government’s 5-year action plan for antimicrobial resistance 2019 to 2024 target. This target includes other severe resistant infections in addition to the bloodstream infections discussed above. There has been an increase in estimated severe resistant infections in England since 2018, totalling 66,720 in 2023.

A new action plan has now been published, with an updated target aimed at preventing any increase in resistant infections in 2029 compared to the 2019 level.

But the fact that AMR is still a problem shows that we have work to do in terms of using antibiotics and other antimicrobial medicines more responsibly. The next chapter on antimicrobial consumption provides additional information.

Chapter 3. Curbing the consumption of antimicrobials

Antimicrobial medicines are necessary for many health conditions, as well as medical procedures, such as, C-section, hip replacement and some forms of cancer treatment. But every time an antimicrobial is prescribed, there is a risk that AMR could develop or worsen. This is why it is so important that antimicrobial medicines like antibiotics are used appropriately. In short, they should be prescribed at the right times and for the right reasons, because each type of antimicrobial should only be reserved for the specific type of dangerous, or otherwise deadly type of microorganism that may be causing an infection.

In the latest National Action Plan for AMR, the UK ambition is to reduce human antimicrobial consumption by 5% by 2029 compared to the baseline of 2019. This goal should help to keep prescribers working hard to reduce the amount of inappropriate antimicrobial medicines being used. UKHSA supports this work by providing the data needed to closely monitor how often antimicrobial medicines are being prescribed, as well as the conditions and infections for which they are being used.

In 2023, the total antibiotic consumption was 17.6 daily defined doses (DDD) per 1,000 inhabitants per day (DID), meaning that, on average, every 1,000 people used 17.6 doses of antibiotics each day. This represented a 2.4% increase compared to the previous year, though the overall consumption remained 1.9% below 2019 levels. These increases were seen across primary (including GP practices and other community settings) and secondary care settings (such as hospitals where specialist care is provided after a primary care referral), where consumption was below 2019 levels. Dental practices, which observed a 6.7% decrease in DIDs compared to 2022, were an exception to this trend.

The out-of-season increases in invasive group A streptococcal (iGAS) infections from September 2022 and re-emergence of Mycoplasma pneumoniae (M. pneumoniae) in 2023, which were seen globally post-pandemic, were both linked with an increase in prescribing.

Most antibiotics in England are prescribed in GP settings, which continued in 2023, accounting for 80% of all prescriptions. Because of this, GPs are important places to study to make sure that antibiotics are being prescribed appropriately. This was followed by 13% in hospital inpatients, 7% in hospital outpatients, as well as other community settings and dental practices comprising 4% each. Prescriptions in GPs increased by 2.6% in 2023 and are now slightly higher than they were in 2019, before the COVID-19 pandemic. North East and North West regions continue to have the highest DIDs compared to the lowest observed in London and South East.

A breakdown by antibiotic group revealed that penicillins remained the most commonly used antibiotic group in England, accounting for 39% of total consumption, primarily related to increased use of amoxicillin and flucloxacillin, which had a greater increase in 2022 due to the iGAS surge. Consumption across most antibiotic groups remained lower than 2019 levels, with the greatest increase in 2023 compared to 2022 levels seen in anti-C. difficile agents, which increased by 15% compared to 2022 – likely due to recent increases in C. difficile infections.

There have been significant efforts to reduce treatment durations for particular antibiotics in order to reduce total antimicrobial prescribing. Updates to national guidelines, which recommend shortened regimens where appropriate for certain antibiotics and medical conditions, have also been shown to have a positive impact on reducing total consumption.

Antifungal consumption was at a similar level in 2023 compared to 2019: 0.04%. The large decrease in 2020 was due to the pandemic, after which usage increased year-on-year. Between 2020 and 2023, systemic antifungal usage in primary and NHS acute trusts increased by 30.8% and 11.4 respectively. Terbinafine usage, an antifungal medicine commonly used in the community to treat fungal skin infections such as athlete’s foot, increased by 44% from 0.6 to 0.87 DID, which is now higher than pre-pandemic levels. Another antifungal called posaconazole, which is used to treat invasive Aspergillus and Candida infections, saw increased secondary care prescribing increased by 46% to 41.8 DDDs per 1,000 admissions in 2020 compared to the previous year and remains at this increased level in 2023 (44.9 DDDs per 1,000 admissions).

Usage of COVID-19 antivirals reduced by 45% in 2023 compared to 2022, reflecting the reduction in COVID-19 cases and changes in testing and guidance.

In antiparasitics, quinine – an antiparasitic used mainly to treat malaria – use has been decreasing since 2019. Mebendazole, used for threadworm infections, was most frequently used in 2023 but has been declining from 2019. Albendazole use increased by 75% in 2023 compared to 2021, reflecting increasing echinococcosis. The majority of systemic antifungals, which can be found in various forms such as oral tablets, oral suspensions, cream and gels, were used in the community setting, comprising 89% in 2023. But as there are several antifungals supplied over the counter (OTC), which are not captured here, it is difficult to know if this a true presentation.

Chapter 4. Point Prevalence Survey

This year’s report presents results from the 2023 Point Prevalence Survey (PPS) on healthcare-associated infections (HCAIs), antimicrobial use and antimicrobial stewardship in England. This was a large study looking to provide a snapshot of the burden of infections and antimicrobial use. The survey collected data from over 44,000 patients in 113 NHS and private sector organisations.

A total of 3,359 patients (7.6%) had an HCAI, of which 29.6% were respiratory infections and 17.5% were urinary tract infections. A total of 15,134 patients (34.1%) received antimicrobial treatment on the day of the survey. While 20.7% of antimicrobials were prescribed for HCAIs, most antimicrobials (58.5%) were prescribed for community-acquired infections. Most of the remaining antimicrobials (16%) were prescribed prophylactically, meaning that there was no infection at the time, but that doctors were trying to prevent an infection occurring, often in patients who were at increased risk, for example after surgery.

Chapter 5. Protecting antimicrobials: the importance of antimicrobial stewardship

To tackle AMR, it is important to act on several fronts so that we use these medicines wisely and reduce the spread of resistant infections. One aspect of this effort is antimicrobial stewardship. This supports healthcare workers in carefully selecting the most appropriate antimicrobial medicine, accurate dose and treatment length. These strategies also contribute toward another UK National Action Plan target of reducing antimicrobial use in humans by 5% by 2029 against the 2019 baseline. In the efforts to use antimicrobials wisely and effectively, several helpful tools and resources have been developed. This chapter provides a summary of the main national primary and secondary care antimicrobial stewardship interventions.

One example is the TARGET toolkit, which is an acronym for ‘Treat Antibiotics Responsibly, Guidance, Education and Tools’, aimed at use in the primary care setting, providing the tools and resources to improve use of antimicrobials and champion antimicrobial stewardship activities.

Included in TARGET, there is now a table summarising antimicrobial prescribing guidance for common infections, as well as 2 new slide sets to support the review of long-term or repeated antibiotic prescriptions for conditions such as acne vulgaris and various respiratory diseases, including chronic obstructive pulmonary disease (COPD). Additionally, quick reference tools for abnormal vaginal discharge and Chlamydia have been updated which provide clinicians with diagnostic guidance reference sheets to support adherence of national prescribing guidelines. These tools can guide doctors in making the right decisions about when and how to prescribe these life-saving antibiotics to ensure they are used appropriately.

In GP settings, an effective initiative has been using SMS (text) messaging to send patients online leaflets featuring a range of topics that are related to infection risks and which can have a serious impact on different patient or disease groups before, during and after a consultation. Between April 2023 and March 2024, over 12,000 leaflets were shared nationally using these templates, with the most widely shared being the urinary tract infection (UTI) leaflet for women under 65 years of age which represented 39% of leaflets shared.

Additionally, resources have been developed to support community pharmacies to implement antimicrobial stewardship principles. Pharmacy healthcare professionals play a crucial role in this effort, particularly due to their expertise in medications and direct patient interactions. These tools are designed to help pharmacists and other professionals understand and communicate about antibiotics effectively.

During 2023 to 2024, there was a particular focus on enhancing knowledge mobilisation within the Start smart then focus (SSTF): antimicrobial stewardship toolkit for inpatient care settings toolkit which was developed based on feedback from healthcare professionals. A national training workshop was conducted to raise awareness of the updates to the SSTF toolkit, with pre- and post-workshop webinars and a feedback survey providing useful information on the barriers and facilitators for implementation of the toolkit, which could also be used to inform improvements to the toolkit. While AMS have mostly focused on antibiotic use, due to the wider use of antibiotics, there are ongoing efforts to develop antiviral and antifungal stewardship activities, including development of similar SSTF toolkits for antiviral use focused on the key principles of virological diagnosis, antiviral drugs and doses, administration routes and discontinuation when not clinically required. Additionally, in 2023, an antifungal stewardship survey (AFS) was conducted among UK secondary care providers to gather information on the current challenges of implementing AFS in hospitals.

By following these guidelines, we can preserve the effectiveness of antimicrobial medicines like antibiotics, ultimately benefiting patient-centred care and public health. Additionally, it’s important to consider factors like deprivation and specific clinical conditions when managing infections to address health inequalities and improve outcomes for everyone.

Chapter 6. NHS England: improvement and assurance schemes

NHS England works on different programmes to improve healthcare to ensure antimicrobials are used wisely. They have schemes to encourage healthcare providers to use these medicines carefully to benefit patients and prevent AMR. These include the:

• NHS Oversight Framework for Primary Care Networks
• National Medicines Optimisation Opportunities
• Pharmacy Quality Scheme for community pharmacies
• NHS Standard Contract for acute hospitals
• Commissioning for Quality and Innovation framework for acute hospitals

To take the NHS Oversight Framework as an example, it sets targets for antibiotic prescribing in primary care and monitors how well different areas are meeting these targets. It uses 2 main metrics:

• number of antibiotics being prescribed in primary care
• the percentage of broad-spectrum antibiotics being prescribed in primary care

Broad-spectrum antibiotics, for example amoxicillin, can treat a wide range of bacteria. They are useful when doctors are unsure which bacteria is causing the infection but must be used with caution as they can also harm good bacteria in the body and increase risk of antibiotic resistance. In the past year, some areas met these targets, while others did not. Overall, there was an improvement in performance compared with the previous year.

In the Pharmacy Quality Scheme, community pharmacies collect data about patients with infections like urinary tract or respiratory infections to help improve care. In the NHS Standard Contract, they aim to reduce the use of certain antibiotics, but some hospitals are still using them more than they should.

The NHS England Medicines Optimisation Executive Group identified 16 opportunities for improved medicine use, including reducing course length for antimicrobial prescribing. One of the key measures of this is increasing the proportion of amoxicillin prescriptions that are 5-day courses, as opposed to longer courses. This proportion increased from 42% in March 2023 to 57% in March 2024.

All these efforts are part of a bigger plan to make sure antibiotics are used properly and that patients get the antibiotic best suited for the bacterial infection they have. This will help to improve patient outcomes while also tackling resistance.

Chapter 7. Professional education, training and public engagement

In the UK, healthcare professionals are actively working to educate and train other stakeholders, such as patients and the public, about the responsible use of antibiotics.

UKHSA worked with the Royal College of GPs (RCGP) aiming to promote awareness of AMR and engagement with TARGET among prescribers in general practice. This included 3 webinars, on topics such as antibiotic prescribing for respiratory and urinary tract infections, and over 900 people attended. These resources were also later hosted on the TARGET website for future use. The joint campaign by UKHSA and RCGP for World AMR Awareness Week (WAA) to promote awareness of the TARGET toolkit led to a 61% increase in views during the campaign period compared to 2022 to 2023.

Additionally, a free eLearning course was developed in collaboration with the British Society for Antimicrobial Chemotherapy (BSAC) for the FutureLearn platform, to help improve prescribing of antibiotics in primary care. One hundred and thirty-seven people participated in the course during the year from March 2023 to March 2024.

In addition, there is also a campaign called Antibiotic Guardian, which encourages healthcare organisations, GP practices, hospitals, community pharmacies, farmers, patients and the public to pledge responsible use of antibiotics. In 2023, over 80 organisations, including some from abroad, registered their efforts on the Antibiotic Guardian website. There was a total of 19,321 pledges, bringing the cumulative number of pledges since the inception of the campaign in 2014 to 178,303.

The influence of the pledge can involve trainee pharmacists and even reach young people in schools to raise awareness. For instance, the Antibiotic Guardian Schools Ambassadors Programme has seen many colleagues registering to become ambassadors, including some from other countries. These ambassadors are working hard to make sure that everyone, from healthcare professionals to students, understand the importance of responsible antibiotic use.

Interactive programmes such as Antibiotic Guardian raise the level of professional, patient and public understanding around antibiotic use, and will help us address some of the main problems at the heart of AMR.  

Chapter 8. Recent research initiatives

While progress has been made in recent years to reduce inappropriate antibiotic use in the UK, it is important that this continues so we can make sure the best outcomes are provided for patients in future. This can be achieved partly by implementing what we already understand about healthcare-associated infections and AMR, but it is also vital that scientists and healthcare professionals continue to improve their understanding of these areas through scientific research. The publication of the UK national action plan (NAP) for 2024 to 2029 also identified some key research priorities, with many of the projects highlighted in the chapter aligning closely with the upcoming NAP commitments.

Healthcare-associated infections and AMR have been the subject of many important UK research projects over the last year and have resulted in over 100 scientific papers from UKHSA, each one reviewed and approved by experts in the field. Several research projects conducted from April 2023 to March 2024 were highlighted in the chapter, comprising:

• prescribing and antimicrobial consumption (5 projects)
• infection prevention and control (4 projects)
• inequalities and risk factors (3 projects)
• surveillance (9 projects)
• primary care (4 projects)
• new vaccines and treatments (9 projects)

This commitment to improving scientific knowledge is reflected in the funding of 2 specialist research units dedicated to studying healthcare-associated infections and AMR, one at the University of Oxford and the other at Imperial College London. The research conducted at these units aims to improve public health policies and practices and is essential for keeping patients and the public safe and healthy.

Importantly, this research has also started to focus more on how we can address inequalities in health. Understanding how different groups of people are affected by healthcare-associated infections and AMR can help us to improve outcomes for everyone in future.

Chapter 9. Support from stakeholders

The production of the ESPAUR report benefits greatly from the input of experts from various organisations, each bringing diverse perspectives to the table. In total, 13 different organisations contributed to this year’s report:

• British Dental Association (BDA)
• British Infection Association (BIA)
• British Society for Antimicrobial Chemotherapy (BSAC)
• Care Quality Commission (CQC)
• College of General Dentistry (CGDent)
• National Institute for Health and Care Excellence (NICE)
• Royal Pharmaceutical Society (RPS)
• Specialist Pharmacy Service (SPS)
• Veterinary Medicines Directorate (VMD) and Department for Environment, Food and Rural Affairs (DEFRA)
• Scottish One Health Antimicrobial Use and Antimicrobial Resistance (SONAAR)
• Public Health Agency Northern Ireland
• Public Health Wales (PHW)
• NHS England (NHSE)

As well as contributing information to the report, these stakeholders are part of the ESPAUR Oversight Group, which consists of over 30 stakeholder members. They also engage in various other activities that support the national effort to tackle healthcare-associated infections and AMR. These activities include:

• running programmes to help improve the effective use of antimicrobial medicines
• publishing guidance and providing tools for healthcare professionals
• engaging with the public and patients to help improve understanding of the issues related to preventing and managing AMR
• organising conferences, workshops and other events

Writing the ESPAUR report with the input of stakeholders from various organisations with their own unique experiences of performing activities aiming to tackle AMR is helping us all to build a more strategic agenda and plan to improve outcomes in future.

Chapter 10. Feedback from stakeholders and report users

Over the past 10 years, the ESPAUR report has broadened and diversified its content to extend beyond AMR. To accompany the report, UKHSA hosts a webinar to present key insights to stakeholders, and feedback surveys are used to gather information on the report’s usage.

The majority of feedback received from users of the report have been positive, with 76% (out of 393 respondents) in 2021 to 2022 and 97% (out of 404 respondents in 2022 to 2023) endorsing the ESPAUR report to other stakeholders. Some of the key findings included:

• the most common job role of respondents was reported as pharmacist, accounting for 37% of responses in 2021 to 2022 and 29% in 2022 to 2023, followed by doctors and nurses
• infographics were reported to be useful by most respondents (84% in 2021 to 2022 and 86% in 2022 to 2023)
• the AMR (20% in 2021 to 2022 and 30% in 2022 to 2023), antimicrobial stewardship (20% in 2021 to 2022 and 23% in 2022 to 2023), and antimicrobial consumption (18% in 2021 to 2022 and 22% in 2022 to 2023) were among the most frequently used chapters
• gathering information and sharing with others were among the commonest reasons from accessing the report
• some users suggested areas for improvement, including shortening the report, developing a more accessible colour scheme and addressing the high reading level of the content

In response to previous feedback, several changes have been made to the ESPAUR report, including:

• adding main messages to the start of each chapter to provide a concise summary of the content
• including infographics for improve interpretation
• hosting a webinar to present the findings

What can we do to tackle AMR together?

As we have seen in this latest ESPAUR report, levels of infections and antimicrobial resistance have been increasing in England in recent years.

We all have a role to play in tackling these increases. The public can play as important a part as anyone in keeping the level of infections low.

Some actions you can take to help reduce infection levels are:

• regular personal hygiene such as handwashing, dental and oral care, and practicing good respiratory hygiene (for example covering your mouth when coughing or sneezing)
• understanding and practicing good environmental hygiene, such as proper food preparation and damp control
• keeping track of which medicines you take, to help prescribers who may not have your full medical history
• being aware of One Health – an approach that recognises how closely connected the health of humans, animals (including pets), plants, and the environment are – as it relates to you
• staying hydrated

You can find out more about how to protect these vital medicines at Antibiotic Guardian.

Acknowledgements

Fran Husson, Vanessa Carter, Zahin Amin-Chowdhury, Matt Wilson, Tehreem Mohiyuddin, Diane Ashiru-Oredope.