CEPP National Audit: Focus on Antibiotic Prescribing

March 2013

CEPP National Audit: Focus on Antibiotic Prescribing

CONTENTS
AUDIT AIMS BACKGROUND AUDIT METHOD 4 4 6

QUANTITY OF PRESCRIBING PRIMARY CARE 8 1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT 8 2. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS 10 3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES 12 4. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS 14 QUALITY OF PRESCRIBING PRIMARY CARE 5. QUINOLONE PRESCRIBING 6. CEPHALOSPORIN PRESCRIBING 7. CO-AMOXICLAV PRESCRIBING START SMART AND FOCUS HOSPITAL SETTING 8. HOSPITAL PRESCRIBING OF ANTIBIOTICS PRIMARY CARE PROCESSES 9. DELAYED PRESCRIPTIONS 10. READ CODING TO IDENTIFY HCAI FEEDBACK FORMS 11. PRACTICE REVIEW SHEET 12. CPD SHEET (FOR PERSONAL USE) ABBREVIATIONS REFERENCES 17 17 20 22 25 25 27 27 29 30 30 31 32 33

This document should be cited as: All Wales Medicines Strategy Group. Prescribing. March 2013.

CEPP National Audit: Focus on Antibiotic

All Wales Medicines Strategy Group

AUDIT AIMS To promote antibiotic prescribing in accordance with existing guidelines. To support clinicians in promoting quality improvement by reviewing antimicrobial prescribing within their teams.

BACKGROUND
Where an antibiotic is needed, the choice of agent and its use needs to be considered in order to ensure that infections are treated effectively. Broad-spectrum antibiotics such as quinolones, cephalosporins and co-amoxiclav should be reserved for the treatment of resistant disease only. This audit is underpinned by agreed Health Protection Agency (HPA) guidelines for the management of infection in primary care, and supports the implementation of the All Wales Medicines Strategy Group (AWMSG) National Prescribing Indicators 201320141,2. Each audit section will be available as a standalone document on the AWMSG website. The use of antibiotic agents is monitored as a National Prescribing Indicator in antibacterial items per 1,000 STAR-PU. Use is generally high in Wales when compared with other parts of the United Kingdom (see Figure 1). Figure 1. Antibacterial usage in each health board and primary care trust (quarter ending September 2012).
400
ABMU Betsi Cadwaladr Hywel Dda Aneurin Bevan

Cardiff & Vale

Cwm Taf

300 Items per 1000 STAR-PUs

200

100

0 PCTs/HBs

This audit can be used to support the quality improvement required for appraisal and revalidation as described in the General Medicine Council (GMC) guide to Good Medical Practice3:

Powys

CEPP National Audit: Focus on Antibiotic Prescribing

European Centre for Disease Prevention and Control (ECDC) key messages for primary care prescribers4 Growing antibiotic resistance threatens the effectiveness of antibiotics now and in the future Antibiotic resistance is an increasingly serious public health problem in Europe [1, 2]. While the number of infections due to antibiotic-resistant bacteria is growing, the pipeline of new antibiotics is unpromising, thus presenting a bleak outlook on availability of effective antibiotic treatment in the future [3, 4]. Rising levels of antibiotic-resistant bacteria could be curbed by encouraging limited and appropriate antibiotic use in primary care patients Antibiotic exposure is linked to the emergence of antibiotic resistance [58]. The overall uptake of antibiotics in a population, as well as how antibiotics are consumed, has an impact on antibiotic resistance [9, 10]. Experience from some countries in Europe shows that reduction in antibiotic prescribing for outpatients has resulted in concomitant decrease in antibiotic resistance [1012]. Primary care accounts for about 80% to 90% of all antibiotic prescriptions, mainly for respiratory tract infections [9, 14, 15]. There is evidence showing that, in many cases of respiratory tract infection, antibiotics are not necessary [1618] and that the patients immune system is competent enough to fight simple infections. There are patients with certain risk factors such as, for example, severe exacerbations of chronic obstructive pulmonary disease (COPD) with increased sputum production, for which prescribing antibiotics is needed [19, 20]. Unnecessary antibiotic prescribing in primary care is a complex phenomenon, but it is mainly related to factors such as misinterpretation of symptoms, diagnostic uncertainty and perceived patients expectations [14, 21]. Communicating with patients is key Studies show that patient satisfaction in primary care settings depends more on effective communication than on receiving an antibiotic prescription [2224] and that prescribing an antibiotic for an upper respiratory tract infection does not decrease the rate of subsequent return visits [25]. Professional medical advice impacts patients perceptions and attitude towards their illness and perceived need for antibiotics, in particular when they are advised on what to expect in the course of the illness, including the realistic recovery time and self-management strategies [26]. Primary care prescribers do not need to allocate more time for consultations that involve offering alternatives to antibiotic prescribing. Studies show that this can be done within the same average consultation time while maintaining a high degree of patient satisfaction [14, 27, 28].

All Wales Medicines Strategy Group

Supporting tools The Royal College of General Practitioners website hosts the TARGET antibiotics toolkit (http://www.rcgp.org.uk/clinical-and-research/target-antibioticstoolkit.aspx): - Clinical resources - Patient resources - Self-assessment checklist and audit - Antibiotic management guidance - External clinical resources HPA guidelines for the management of infection in primary care (http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801) Welsh Medicines Resource Centre (WeMeReC) bulletin 2012. Appropriate antibiotic use whose responsibility? (http://www.wemerec.org/Documents/Bulletins/AntibioBulletin2012Online.pdf and http://www.wemerec.org/Documents/Bulletins/AntibioSupp2012.pdf) STAR educational programme (http://www.stemmingthetide.org/) ECDC. Toolkit of briefing materials aimed at primary care prescribers5 (http://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspx) National Institute for Health and Clinical Excellence. CG69: Respiratory tract infections (http://www.nice.org.uk/cg69)

AUDIT METHOD
The audits are enclosed for the use of health boards or individual prescribers. A range of criteria has been provided to enable health boards and clinicians to focus on specific areas of prescribing; it is not envisaged that a practice would undertake all audit options in one year. It is recommended that this work is carried out by clinicians, as this will enhance ownership, leading to more effective change. Prescribing data should be considered and a decision reached as to which elements of the tool are most likely to have a positive impact on prescribing practice. This may mean focusing on antibiotic groups, where specific issues are identified, or looking at prescribing in clinical scenarios where general quantity is more of an issue. The process sections will support the use of delayed prescriptions and identification of healthcare-acquired infections (HCAI). Practices may choose to undertake an in-depth review using a single specific tool, e.g. ten cases per prescriber within the practice, or choose a smaller case selection of several criteria, depending on their priorities (prescribers should ensure that an adequate number of consultations are analysed to determine compliance with the audit standards and to provide a basis for discussion). It is likely that discussing recent antimicrobial prescribing data with prescribing advisors would help to ensure that any focus delivers maximum effect. Health boards are encouraged to include the audit within their Clinical Effectiveness Prescribing Programme (CEPP). For many, it will be a priority area due to the impact of HCAI and increasing resistance problems (with subsequent treatment failure) placing pressure on unscheduled care. A response date for initial data collection of 31 October 2013 will support national collation and feedback of results, and the option to complete the audit cycle within one year.

CEPP National Audit: Focus on Antibiotic Prescribing

HPA grading of guidance recommendations The strength of each recommendation in the following sections is qualified by a letter in supercript.
Study design Good recent systematic review of studies One or more rigorous studies, not combined One or more prospective studies One or more retrospective studies Formal combination of expert opinion Informal opinion, other information Recommendation grade A+ AB+ BC D

All Wales Medicines Strategy Group

QUANTITY OF PRESCRIBING PRIMARY CARE

1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT Background AWMSG indicator: Antibacterial items per 1,000 STAR-PU The development of antibiotic prescribing indicators supports the core aims of the Antimicrobial Resistance Programme in Wales to inform, support and promote the prudent use of antimicrobials. Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced A+ by 16 hours If Centor score 3 or 4: (lymphadenopathy; no cough; fever; tonsillar exudate)A- consider 2 or 3 day delayed or immediate antibioticsA+ or rapid antigen test. RCT in < 18 year olds shows 10d had lower relapse Antibiotics to prevent quinsy NNT > 4000BAntibiotics to prevent otitis media NNT 200A+ Penicillin allergy: Clarithromycin 250500 mg BD 5 daysA+ Phenoxymethylp enicillinBMedicine Adult dose Duration of treatment

500 mg QDS 1 g BDA+ (QDS when severeD)

10 daysA-

Acute sore throat CKS

Method Assess a reasonable sample of records with a diagnosis of sore throat. Patients with recurrent throat infections should be excluded where another episode has been diagnosed within eight weeks. Search using the following codes: 1C9 1C92 1CB3 194 1692 A75 M04 H02 H02-1 H02-2 H02-3 H024 Sore throat symptom/ throat soreness Has a sore throat Throat pain Dysphagia Swollen glands Infectious mononucleosis Acute lymphadenitis Acute pharyngitis Sore throat NOS Viral sore throat NOS Throat infection pharyngitis Acute viral pharyngitis H02z H03 H03-1 H031 H036 H03z H04 H05z H05z-1 Acute pharyngitis NOS Acute tonsillitis Throat infection tonsillitis Acute follicular tonsillitis Acute viral tonsillitis Acute tonsillitis NOS Acute laryngitis/tracheitis Upper respiratory tract infection Upper respiratory tract infection NOS

Centor criteria: Score 1 point for each of: temperature > 38C; absence of cough; tender anterior cervical adenopathy; tonsillar swelling or exudate; age < 15 years.

CEPP National Audit: Focus on Antibiotic Prescribing

Data collection sheet

All criteria for Centor score recorded?
(lymphadenopathy no cough; fever; tonsillar exudate)

Patient

Centor score

Centor score 3 or 4? (Y/N)

Antibiotic given? (Y/N)

(Y/N)

No antibiotic prescribed OR Immediate/delayed antibiotic given and Centor score = 3 or 4? (Y/N)

Delayed script? (Y/N)

Phenoxymethylpe Other (record nicillin or name and clarithromycin? reason, where (Y/N) given)

Total % Yes Standard

100%

90%

95%

All Wales Medicines Strategy Group

2. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS Background AWMSG indicator: Antibacterial items per 1,000 STAR-PU The development of antibiotic prescribing indicators supports the core aims of the Antimicrobial Resistance Programme in Wales to inform, support and promote the prudent use of antimicrobials. Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 A+ days, NNT15 Use analgesiaB+ adequate Medicine Adult dose 500 mg TDS 1 g if severeD Duration of treatment

AmoxicillinA+,A

or doxycycline

200 mg stat/ 100 mg OD 7 days 500 mg QDS

Acute rhinosinusitisC CKS

Consider 7 day delayed* or immediate antibiotic when purulent nasal discharge NNT8A+ In persistent infection use an agent with antianaerobic activity, e.g. coamoxiclavB+

or phenoxymethylpenicillinB+ For persistent symptoms: co-amoxiclavB+

625 mg TDS

* The period of delay is often less than 7 days

Method Assess a reasonable sample of records with a diagnosis of acute rhinosinusitis. Patients with recurrent or chronic sinus infections should be excluded. Search using the following codes H05z-1 H01 Hyu00 1BA9 1B1G0 Upper respiratory tract infection Acute sinusitis Other acute sinusitis Sinus headache Sinus headache

10

CEPP National Audit: Focus on Antibiotic Prescribing

Data collection sheet

Symptoms recorded as present for 7 days or more? (Y/N) If an antibiotic given, was there either a record of purulent Antibiotic given? discharge or symptoms (Y/N) being present for 7 days or more? (Y/N) Amoxicillin or doxycycline or phenoxymethyl penicillin? (Y/N)

Patient

Purulent nasal discharge recorded? (Y/N)

Delayed script? (Y/N)

Other (record name and reason, where given)

Total % Yes Standard

90%

95%

11

All Wales Medicines Strategy Group

3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES Background AWMSG indicator: Antibacterial items per 1,000 STAR-PU The development of antibiotic prescribing indicators supports the core aims of the Antimicrobial Resistance Programme in Wales to inform, support and promote the prudent use of antimicrobials. Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Women: Severe/or 3 symptoms: A,C treat UTI in adults (no fever or flank pain) HPA QRG, SIGN, CKS, CKS Women: Mild/or 2 symptoms: use dipstick and presence of cloudy urine to guide treatment. Nitrite and blood/leucocytes has 92% PPV; negative nitrite, leucocytes and blood has a 76% ANPV Men: Consider prostatitis and send C OR if pre-treatment MSU symptoms mild/non-specific, use negative dipstick to exclude UTIC Medicine TrimethoprimB+ or nitrofurantoinB,C Adult dose 200 mg BD 100 mg m/r BDC Duration of treatment Women ages: daysA+ Men: C days all 3 7

Second line: perform culture in all treatment failuresB Amoxicillin resistance is common; only use if susceptibleB+ Community multi-resistant extended-spectrum Betalactamase E. coli are increasing: consider nitrofurantoin

Signs and symptoms of a urinary tract infection (UTI) are dysuria, urgency, frequency, polyuria, suprapubic tenderness and haematuria. Method Assess a reasonable sample of records with a diagnosis of UTI (female only). Exclude pregnant females, men, children and patients with acute pyelonephritis. Search using the following codes: R081 K15 K190 K197 K5 Kz Dysuria Cystitis Urinary tract infection Haematuria Other female tract disorder Genitourinary disease NOS

12

CEPP National Audit: Focus on Antibiotic Prescribing

Data collection sheet

Where an antibiotic was given, were there either 3 or more symptoms or a positive urine dip recorded? (Y/N)

Patient

2 symptoms and positive dip? (Y/N)

3 symptoms? (Y/N)

Antibiotic given? (Y/N)

Trimethoprim or nitrofurantoin? (Y/N)

Other (record name and reason, where given)

Total % Yes Standard 90% 95%

13

All Wales Medicines Strategy Group

4. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS Background AWMSG indicator: Antibacterial items per 1,000 STAR-PU The development of antibiotic prescribing indicators supports the core aims of the Antimicrobial Resistance Programme in Wales to inform, support and promote the prudent use of antimicrobials. Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Antibiotic little benefit if no co-morbidity Acute cough/ bronchitis CKS, NICE 69
A+

Medicine

Dose

Duration of treatment

Consider 7 day* delayed antibiotic with A advice Symptom resolution can take 3 weeks Consider immediate antibiotics if > 80 years and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure, OR > 65 years with 2 of above

Amoxicillin

500 mg TDS 5 days

or doxycycline

200 mg stat/ 100 mg OD

* The period of delay is often less than 7 days

National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 69: Respiratory tract infections, states that a no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with acute cough/acute bronchitis6. An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations: if the patient is systemically very unwell; if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications); if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely; if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: - hospitalisation in previous year - type 1 or type 2 diabetes - history of congestive heart failure - current use of oral glucocorticoids.6 For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered6.

14

CEPP National Audit: Focus on Antibiotic Prescribing

Delayed prescriptions When the delayed antibiotic prescribing strategy is adopted, patients should be offered: reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash; advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs; advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.6 A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date6. It has been suggested that asking the patient to return to the practice reception or a nominated pharmacy is more effective than handing the delayed prescription to the patient. An agreement with the pharmacist to return uncollected prescriptions can be informative for the prescriber. Information for the patient can be issued during a consultation to support no prescribing or delayed prescribing (delayed prescribing pad/patient information leaflet). Method Assess a reasonable sample of records both adults and children (between 5 years and 65 years), with a diagnosis of acute cough/acute bronchitis. Exclude patients with asthma or COPD. Search using the following codes: 171 and subset R062 H05z-1 Cough Cough Symptom NOS Upper Respiratory Tract Infection

(Exclude patients who are allergic to all four agents (amoxicillin, clarithromycin, erythromycin and doxycycline) from the audit.

15

All Wales Medicines Strategy Group

Data collection sheet

Documented clinical features, both temperature, and chest examination? (Y/N) Additional clinical features of severity/systemic upset recorded? (pulse, respiratory rate or oximetry) (2 or more = Y) If antibiotic supplied, does patient fit NICE guidance (systemically very unwell, symptoms and signs of serious illness or of serious complications, or pre-existing comorbidity) (Y/N) (provide reason)

Patient

Antibiotic prescribed? (Y/N/delayed)

Amoxicillin, clarithromycin, erythromycin or doxycycline? (Y/N)

NICE criteria6 met? (Y/N/Other)

Total % Yes Standard

100%

No standard set

95 %

90%

90%

16

CEPP National Audit: Focus on Antibiotic Prescribing

QUALITY OF PRESCRIBING PRIMARY CARE

5. QUINOLONE PRESCRIBING Background AWMSG indicator: Quinolones as a percentage of total antibacterial items Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Low doses of penicillins are more likely to select out resistance. Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. If admission not needed, send MSU for culture and sensitivities, and start antibioticsC If no response within 24 hours, admit
C

Medicine

Dose

Duration of treatment

Lower respiratory tract infections

Acute pyelonephritis CKS

CiprofloxacinAor co-amoxiclavC

500 mg BD 500 mg/ 125 mg TDS

7 daysA14 daysC

Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers diarrhoeaC Travellers diarrhoea CKS If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private prescription)C,B+ If quinolone resistance high (e.g. south Asia): consider bismuth subsalicylate (PeptoBismol) 2 tablets QDS as B+ B+ prophylaxis or for 2 days treatment Refer woman and contacts to GUM B+ Always culture for service . gonorrhoea & chlamydiaB+. 28% of gonorrhoea isolates now resistant to B+ quinolones . If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM. Send MSU antibioticsC Acute prostatitis BASHH, CKS for culture and start Ciprofloxacin Bismuth subsalicylate (PeptoBismol ) Metronidazole PLUS B+ ofloxacin If high risk of GC: C ceftriaxone PLUS metronidazole PLUS doxycyclineB+ Ciprofloxacin or ofloxacinC 2nd line: trimethoprimC
C

500 mg BD

3 days (private prescription) As prophylaxis or for two days 14 days 14 days

2 tablets QDS 400 mg BD 400 mg BD

Pelvic inflammatory disease RCOG, BASHH, CKS

500 mg IM 400 mg BD 100 mg BD 500 mg BD 200 mg BD 200 mg BD

Stat 14 days 14 days

4-week course may prevent chronic C prostatitis Quinolones achieve higher prostate levels

28 days

Quinolones may also be required in response to sensitivity results where a preferred agent is not suitable due to resistance.

17

All Wales Medicines Strategy Group

Method Assess a reasonable sample of records per prescriber with prescription of a quinolone. Exclude prescriptions given for travellers diarrhoea. Identify prescriptions for the following oral medicines: Ciprofloxacin Ofloxacin

18

CEPP National Audit: Focus on Antibiotic Prescribing

Data collection sheet

Pelvic inflammatory disease? (Y/N) Indicated? Acute prostatitis? (Y/N) Laboratory sensitivity? (Y/N) Other indication (Please list)
(According to national/local guidance or lab sensitivity)

Patient

Quinolone prescribed (name)

Pyelonephritis? (Y/N)

(Y/N)

Total % Yes Standard 90%

19

All Wales Medicines Strategy Group

6. CEPHALOSPORIN PRESCRIBING Background AWMSG indicator: Cephalosporins as a percentage of total antibacterial items. Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Send MSU for culture and start A antibiotics UTI in pregnancy HPA QRG, CKS Short-term use of nitrofurantoin in pregnancy is unlikely to C cause problems to the foetus Avoid trimethoprim if low folate status or on folate antagonist (e.g. antiepileptic or proguanil) Child < 3 months: refer urgently C for assessment UTI in children HPA QRG, CKS, NICE Child 3 months: use positive nitrite to start antibioticsA+ Send pre-treatment MSU for all. Imaging: only refer if child < 6 months, recurrent or atypical C UTI Medicine First line: nitrofurantoin if susceptible, amoxicillin Second line: trimethoprim Third cefalexin line: Dose 100 mg m/r BD 500 mg TDS 200 mg BD (offlabel) Give folic acid if first trimester 500 mg BD 7 days Duration of treatment

Lower UTI: A trimethoprim or nitrofurantoinA If susceptible, amoxicillinA Second C cefalexin line: See BNF dosage for

3 days

A+

Upper UTI: co-amoxiclavA 7-10 days Second A cefixime line:

A+

Pelvic inflammatory disease RCOG, BASHH, CKS

Refer woman & contacts to GUM serviceB+. Always culture for gonorrhoea & chlamydiaB+. 28% of gonorrhoea isolates now resistant to quinolonesB+ If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM.

Metronidazole PLUS ofloxacinB+ If high risk of GC: C ceftriaxone PLUS metronidazole PLUS doxycyclineB+

400 mg BD 400 mg BD

14 days 14 days

500 mg IM 400 mg BD 100 mg BD

Stat 14 days 14 days

Method Assess a reasonable sample of records per prescriber with prescription of a cephalosporin against national guidelines.

20

CEPP National Audit: Focus on Antibiotic Prescribing

Data collection sheet

Pelvic inflammatory disease? (Y/N) Indicated? Laboratory sensitive (Y/N) Other (Please list)
(According to national/local guidance or lab sensitivity)

Patient

Cephalosporin prescribed (name)

UTI in children? (Y/N)

UTI in pregnancy? (Y/N)

(Y/N)

Total % Yes Standard 95%

21

All Wales Medicines Strategy Group

7. CO-AMOXICLAV PRESCRIBING Background AWMSG indicator: Co-amoxiclav as a percentage of total antibacterial items Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days NNT15A+ Acute rhinosinusitisC CKS Use adequate analgesia
B+

Medicine

Dose 500 mg TDS 1 g if severeD 200 stat/100 OD mg mg

Duration of treatment

AmoxicillinA+,A

or doxycycline or phenoxymethylpenicilli B+ n For persistent symptoms: co-amoxiclavB+ Amoxicillin or doxycycline Clarithromycin If resistance factors: co-amoxiclav Lower UTI: trimethoprimA ornitrofurantoinAIf susceptible, A amoxicillin Second C cefalexin Upper UTI: A co-amoxiclav Second line: cefixime CiprofloxacinAC A

Consider 7 day* delayed or immediate antibiotic when purulent nasal discharge NNT8A+ In persistent infection, use an agent with anti-anaerobic activity e.g. co-amoxiclavB+ Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or B+ increased sputum volume . Risk factors for antibiotic resistant organisms include comorbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months. Child < 3 months: refer urgently for assessmentC

7 days

A+

500mg QDS

625 mg TDS 500 mg TDS 200 mg stat/ 100 mg OD 500 mg BD 5 days

Acute exacerbation of COPD NICE 12, GOLD, BMJ

risk 625 mg TDS

UTI in children HPA QRG CKS NICE

Child 3 months: use positive A+ nitrite to start antibiotics Send pre-treatment MSU for all. Imaging: only refer if child < 6 months, recurrent or atypical C UTI

3 daysA+ See BNF for dosage 7-10 A+ days 500 mg BD 500/125 TDS mg 7 daysA14 daysC 7 days If slow response continue for a further 7 C days

line:

Acute pyelonephritis CKS

If admission not needed, send MSU for culture & sensitivities C and start antibiotics If no response within 24 hours, C admit If patient afebrile and healthy other than cellulitis, use oral C flucloxacillinalone . If river or sea water exposure, discuss with microbiologist. If febrile C and ill, admit for IV treatment Stop clindamycin if diarrhoea occurs.

or co-amoxiclav FlucloxacillinC

500 mg QDS 500 mg BD 300450 mg QDS 500/125 TDS mg

Cellulitis CKS

If penicillin allergic: C clarithromycin or clindamycinC Facial: co-amoxiclavC

22

CEPP National Audit: Focus on Antibiotic Prescribing Duration of treatment

Illness

Comments Thorough importantC irrigation is

Medicine Prophylaxis treatment: co-amoxiclav or

Dose 375625 mg TDSC

Bites CKS

Human: Assess risk of tetanus, HIV, C hepatitis B&C Antibiotic prophylaxis is advisedBCat or dog: Assess risk of tetanus and C rabies Give prophylaxis if cat bite/puncture wound; bite to hand, foot, face, joint, tendon, ligament; immunocompromised/ diabetic/asplenic/cirrhotic

If penicillin allergic: Metronidazole plus doxycycline (cat/dog/man) or metronidazole plus clarithromycin (human bite) AND review at 24 & 48hrsC

200400 mg TDS C 100 mg BD 200400 mg TDS 250500 mg BDC

7 days

* The period of delay is often less than 7 days

Method Assess a reasonable sample of records per prescriber with prescription of coamoxiclav against national guidelines.

23

All Wales Medicines Strategy Group

Data collection sheet

COPD with resistance factors? (Y/N) Upper UTI in children? Acute pyelonephritis? (Y/N) Indicated? Human bite? (Y/N) Facial cellulitis? (Y/N) Sensitive? (Y/N) Other (Please list)
(According to national/local guidance or lab sensitivity)

Patient

Coamoxiclav? (Y/N)

Persistent sinusitis (Y/N)

(Y/N)

Total % Yes Standard 95%

24

CEPP National Audit: Focus on Antibiotic Prescribing

START SMART AND FOCUS HOSPITAL SETTING

8. HOSPITAL PRESCRIBING OF ANTIBIOTICS Aims To review a teams prescribing of antibiotics with respect to: Documentation Choice of antibiotic/formulary compliance Induction guidance for new team members Method Review approximately 15 sets of notes where an antibiotic was prescribed by a member of your team and complete the following data collection sheet.

25

All Wales Medicines Strategy Group

Data collection sheet (adapted from Department of Health Antimicrobial stewardship: Start smart - then focus7) Site/hospital: Total number of patients on ward: Ward: Specialty: Date:

Number of patients prescribed antimicrobials:

Guideline prescribing or justified off-guideline prescribing Documented indication or provisional diagnosis (please specify)? (Y/N) IV duration on audit day Total duration (IV and oral) on audit day for this indication

Complete one line below for each antibiotic

Date

Hospital number

Allergy box filled? (Y/N)

Antibiotic given

Route

Review or stop date on chart? (Y/N)

Consultant team

Guideline for indication

Valid reason provided

26

CEPP National Audit: Focus on Antibiotic Prescribing

PRIMARY CARE PROCESSES

9. DELAYED PRESCRIPTIONS Delayed prescribing pad/patient information leaflet When the delayed antibiotic prescribing strategy is adopted, patients should be offered: reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash; advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs; advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.6 A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date6. It has been suggested that asking the patient to return to the practice reception or a nominated pharmacy is more effective than handing the delayed prescription to the patient. An agreement with the pharmacist to return uncollected prescriptions can be informative for the prescriber. A delayed prescription should include the time period for which it is valid. Delayed prescriptions in one locality are endorsed with the following wording which is completed by the prescriber: To the pharmacist This prescription should only be dispensed if requested by the patient. Please do not dispense until: Please do not dispense after: . .

Please return this prescription to the practice, marked not dispensed, if it is not requested by the patient.

27

All Wales Medicines Strategy Group

1. Does the practice have a protocol or process for addressing delayed prescriptions?

2. What methods are employed within the practice for delayed prescriptions (tick all that apply): None Given directly to patient For collection at reception For collection at a named pharmacy 3. Does the practice monitor unused delayed prescriptions that have been given to the patient?

4. Does the practice monitor uncollected delayed prescriptions left at the reception?

5. Does the practice have an agreement with the local pharmacist to return uncollected prescriptions to the prescriber?

6. How many delayed prescriptions have been unused ? State time frame e.g. 6 weeks = Uncollected from reception = Returned from named pharmacy = 7. Is clear guidance given with a delayed script during the consultation to enable appropriate use (including clear descriptions of time and reasons)?

8. Outcome of clinical discussion with colleagues regarding use of delayed prescriptions

9. Describe any changes to process that have occurred following this review.

28

CEPP National Audit: Focus on Antibiotic Prescribing

10. READ CODING TO IDENTIFY HCAI The following Read Codes are recommended to support the surveillance of HCAI, such as post-operative infections: SP25 SP250 SP251 SP252 SP253 SP254 SP256 SP257 L3945 XaCl0 Lyu6A Post operative infection Post-op stitch abscess Post-op wound abscess Post-op intra-abdominal abscess Post-op subphrenic abscess Post-op septicaemia Post-op wound infection deep Post-op wound infection superficial Infection of obstetric surgical wound [X] Infection of C-Section wound following delivery Infection of C-Section wound following delivery

What will the practice do to promote the use of these Read Codes for the identification of HCAI?

29

All Wales Medicines Strategy Group

FEEDBACK FORMS
11. PRACTICE REVIEW SHEET Include the following summary sheet and data collection summary sheets. 1. How do the results of the first data collection compare with the standards set?

2.

What discussion/activities did the practice undertake as a result of the audit?

3.

Provide a summary of the discussion and of the changes the practice has agreed to implement as a result of this audit.

Audit cycle Prescribers are reminded that a second data collection in comparison with the standards set will support the identification of quality improvement. (See next page for document to support revalidation for your own records) Is a second data collection of selected criteria planned, if so which?

This audit was completed by: Name(s): Signature(s): Practice (name and address):

Please send the data collection sheets and the practice review sheet to your local Head of Pharmacy and Medicines Management who will compile the local information.

30

CEPP National Audit: Focus on Antibiotic Prescribing

12. CPD SHEET (FOR PERSONAL USE) Title: AWMSG National Audit 20132014: Focus on antibiotic prescribing The audits can be used to support the quality improvement required for appraisal and revalidation. They are particularly relevant to the following components of the GMC guide to Good Medical Practice: Good Medical Practice: Providing good clinical care 2. Good clinical care must include: a) Adequately assessing the patient's conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient's views, and where necessary examining the patient. b) Providing or arranging advice, investigations or treatment where necessary. 3. In providing care you must: f) Keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment. Good Medical Practice: Supporting self care 4. You should encourage patients and the public to take an interest in their health and to take action to improve and maintain it. This may include advising patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatments.

31

All Wales Medicines Strategy Group

ABBREVIATIONS
AWMSG: All Wales Medicines Strategy Group BASHH: British Association for Sexual Health and HIV BD: twice-daily; BMJ: British Medical Journal BNF: British National Formulary CEPP: Clinical Effectiveness Prescribing Programme CKS: Clinical Knowledge Summary COPD: chronic obstructive pulmonary disease CPD: Continued Professional Development ECDC: European Centre for Disease Prevention and Control GMC: General Medical Council GOLD: Global Initiative for Chronic Obstructive Lung Disease GUM: genitourinary medicine HCAI: healthcare-acquired infection HPA: Health Protection Agency MSU: midstream specimen of urine NICE: National Institute for Health and Clinical Excellence NNT: number needed to treat NPV: negative predictive value OD: once-daily PPV: positive predictive value QDS: four times a day QRG: quick reference guide RCOG: Royal College of Obstetricians and Gynaecologists RCT: randomised controlled trial SIGN: Scottish Intercollegiate Guidelines Network STAR-PU: specific therapeutic group agesex related prescribing units TDS: three times a day UTI: urinary tract infection

32

CEPP National Audit: Focus on Antibiotic Prescribing

REFERENCES
1 Health Protection Agency, British Infection Association. Management of infection guidance for primary care. Oct 2012. Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801. Accessed Dec 2012. 2 All Wales Medicines Strategy Group. National Prescribing Indicators 2013-2014. 2013. Available at: http://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%2 02013-2014.pdf. Accessed Mar 2013. 3 General Medical Council. Good Medical Practice: Supporting self care. 2012. Available at: http://www.gmcuk.org/guidance/good_medical_practice/good_clinical_care.asp . Accessed Dec 2012. 4 European Centre for Disease Prevention and Control. ECDC key messages for primary care prescribers. 2013. Available at: http://ecdc.europa.eu/en/eaad/antibiotics/pages/messagesforprescribers.aspx. Accessed Feb 2013. 5 European Centre for Disease Prevention and Control. European Antibiotic Awareness Day. Toolkit of briefing materials aimed at primary care prescribers. 2012. Available at: http://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspx. Accessed Dec 2012. 6 National Institute for Health and Clinical Excellence. Clinical Guideline 69. Respiratory tract infections - antibiotic prescribing: Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. Jul 2008. Available at: http://guidance.nice.org.uk/CG69. Accessed Dec 2012. 7 Department of Health. Antimicrobial stewardship: Start smart - then focus. 2011. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_131062. Accessed Feb 2013.

33