Background Information
Infectious diseases make headline news and cause a significant threat to public health every few years. New sources of threat are constantly being identified.
The Department of Health report in 2002 “ Getting Ahead of the Curve ” also highlights this.
Such threats occur not only from outbreaks occurring naturally but now also from biological warfare and possibly terrorist activity. We must not underestimate the real threat that infectious diseases presents us with.
Key point: infectious diseases cause a real public health threat
Along with preventative measures, antibiotics are essential to tackle infectious disease.
Whilst new diseases are constantly being identified, the development of antibiotics to tackle the problem appears to have slowed.
Also, lots of new effective antimicrobials are unlikely to be forthcoming to deal with new or existing virulent infectious disease. The key problem is that the financial returns from developing antimicrobials are not worth the investments required by pharmaceutical companies. Much greater returns can be made from drugs to manage chronic diseases or from preventative treatment where vast sections of population may potentially use the product.
This highlights the need to preserve our current antibiotic portfolio and to safeguard against developing resistance patterns.
Key point: new antibiotics are not forthcoming. We need to respect and preserve those that we currently have.
The House of Lords Select Committee Report in 1998 highlighted the problem of antibiotic resistance and set out a range of measures to tackle the issue on both a national and local level. Since 80% of antibiotic prescribing is in primary care, most of these recommendations affect patients and prescribers in the primary care setting. Prudent prescribing can be achieved by carefully identifying only those patients who will really benefit from treatment, and by using infection control measures.
The challenge for preserving the effectiveness of our antibiotics is compounded by the fact that antibiotic resistance is inevitable (House of Lords Report, 1988). Generally the higher the use of specific antibiotics, the higher the resistance (Nasrin et al. BMJ 2002; 324: 28 –31) and so prudent prescribing may help to slow its development.
Key points: resistance to antibiotics is inevitable and overuse contributes to this problem.
Antibiotics should be reserved for use only when their benefits clearly outweigh the harms.
What constitutes a sensible approach to maintaining prudent antibiotic prescribing?
Firstly, it is vital to use signs and symptoms to do the best we can to differentiate between common self-limiting illness, and more serious or more unusual conditions that would be managed differently or more aggressively. For example, we would always attempt to differentiate community acquired pneumonia from a routine acute cough, and treat it more aggressively as it has potentially fatal consequences in some people. Not only must diagnosis be confirmed but the overall severity of disease should be assessed. The patient with more severe systemic features (e.g. fever and rigors) should be distinguished from someone with milder symptoms.

Secondly, the likelihood of any infection having a bacterial cause must be determined.
Many common infections can be viral or bacterial and the former will not respond to antibiotic therapy. The likelihood of a bacterial cause can often be determined by careful patient assessment. A number of clinical prediction tools are available to help with this process.
Finally, once a bacterial cause is considered to be likely, the benefits of antibiotic treatment must be weighed against the harms that may be caused, both in terms of individual patient well-being and also in terms of antibiotic resistance.
Many studies have shown only marginal benefit from giving antibiotics for some conditions and many infections self-resolve without need for intervention. It should be remembered that antibiotics can cause gastrointestinal and other, sometimes more serious, side effects.
Key points: A sensible approach is to assess the patient for:
- differential diagnosis
- likely bacterial cause
- severity or self-limiting nature of disease then weigh up the harms versus benefits of antibiotic treatment
Once the likelihood of bacterial infection has been established, a number of management strategies may be employed to ensure that antibiotic prescribing is minimised and that it is only targeted at patients who are likely to obtain clinical benefit.
There are a number of strategies that can be used to manage the patient.
Symptomatic treatment may be all that is necessary. This would include such measures as pain killer or NSAID for otitis media or a sore throat, or a decongestant for a cold (Prodigy guidance, Common Cold, June 2004).
Using a delayed prescription is another approach and reduces the prescribing of antibiotics whilst encouraging patient autonomy and confidence in management. There is now much evidence to support the use of delayed prescriptions in a number of infections, and there is even a Cochrane review on it (Spurling GKP, et al. The Cochrane Database of Systematic
Reviews, 2004 Issue 4).
In this approach, patients are issued with a prescription but told not to collect it from the surgery or “cash” it in at the pharmacy until several days later, and then only if symptoms still persist or worsen. One of the key advantages of this approach is that it has been shown to reduce the number of patients who returned to the surgery for subsequent self-limiting infections and increases their belief that antibiotics are of limited benefit (Little P, et al. 1997;
315: 350 –52).
Selectively targeting prescribing may also form a part of the patient management strategy.
In this strategy, prescribing is targeted at those whose symptoms are most severe.
Prescribing a shorter course of antibiotics may also be used where this is appropriate, e.g. 3 days for UTIs (see www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm
accessed Nov 06).
Patient Information Leaflets (PILs) may also help and examples are available from Prodigy
(Prodigy guidance, Antibiotics – why no antibiotic, June 2006. Available from: http://www.prodigy.nhs.uk/patient_information/pils/antibiotics_why_no_antibiotic.pdf
).
They advise patients what to do to gain symptom relief, when antibiotics are inappropriate, about the likely course of the disease and when to re-consult. PILs have been demonstrated to be successful at reducing patient return rate (MacFarlane JT, et al. BJGP 1997; 47: 719 –
22)
The aims of this audit are to:

Review the safe and effective prescribing of antibiotics in line with NLTPCT
Treatment of Primary Care Infections Guidelines and agreed audit criteria

Ensure that patients receiving cephalosporins or quinolones do so in line with recommended indications in NLTPCT Treatment of Primary Care Infections
Guidelines


Ensure that patients prescribed an antibiotic have a documented indication recorded
There is a range of additional resources available from the National Prescribing
Centre (NPC) to support NSAID prescribing in practices. These materials can be accessed through the NPC website www.npc.co.uk
. In addition, www.npci.org.uk
contains detailed resources for the prescribing of NSAIDs in clinical situations.
Your PCT or PBC cluster may also have materials that could be helpful to you.
Planning the audit

Discuss the example audit criteria at a practice team meeting. You may decide to change these according to your own local guidelines.
You will also need to discuss the audit standards that are appropriate to you.

Decide who should be involved in carrying out the audit ( e.g all partners, practice nurses, reception staff, practice-based pharmacy teams) and agree what they will be doing as part of the audit protocol.

Agree timescales and draw up a brief plan.

Prepare the appropriate data collection and audit forms in advance.

Make sure everyone understands how to collect and collate the data that you will produce.

Make sure everyone knows when the audit will start and finish.
Audit Criteria and standards
Criteria Standard % of patients achieving standard
General
All patients prescribed an antibiotic have a clear indication recorded in their records and this is read-coded on the clinical system
100%
Choice of drug
Antibiotics prescribed are within NLTPCT
Treatment of Primary
Care Infections
Guidelines
90%
Indication
90%
Use of cephalosporins or quinolones is restricted to indications within
NLTPCT Treatment of
Primary Care Infections
Guidelines or on specific recommendations of microbiology

It is good practice for all medication to be linked to a diagnosis and read-coded on the GP clinical system.
Method
1. Search the practice computer system for all patients with an oral antibiotic prescription within the last 6 months (remember to search for branded products too).
Table 1 - Generic names of antibiotics (brand names in brackets)

Amoxicillin (Amoxil, Amix, Amoram,

Flucloxacillin (Floxapen, Fluclomix,





Cefalexin (Ceporex, Keflex)



Cefuroxime (Zinnat)

Ciprofloxacin ( Ciproxin)

Clarithromycin (Klaricid)

Clindamycin (Dalacin C)

Co-amoxiclav (Augmentin, Augmentin


Amoxident, Galenamox, Rimoxacillin)
Ampicillin
Azithromycin
Cefaclor
Cefadroxil
Cefixime (Suprax)
Cefradine (Velosef)
Duo)
(Penbritin, Rimacillin)
(Zithromax)
(Keftid, Distaclor)
(Baxan)
Co-fluampicil (Magnapen)
Co-trimoxazole (Septrin)

Doxycycline (Vibramycin, Vibramycin D)

Erythromycin (Tiloryth, Erymax)

Erythromycin ethylsuccinate
Ladropen)

Levofloxacin (Tavanic)

Lymecycline (Tetralysal 300)

Metronidazole (Flagyl)

Minocycline (Acamino MR, Minocin MR,




Sebomin MR)
Moxifloxacin
Nitrofurantoin
Macrodantin)
Norfloxacin
Ofloxacin
(Avelox)
(Furadantin, Macrobid,
(Utinor)
(Taravid)

Oxytetracycline (Oxymycin)

Phenoxymethylpenicillin

Telithromycin (Ketek)


Tetracycline
Trimethoprim (Trimopan)
(Erythroped, Erythroped A)

Erythromycin stearate (Erythrocin)
Enter the name and computer number of patients on the audit data collection form.
2. Search drug records for each patient to find antibiotic prescribed. Record name of antibiotic and issue date. Record dose and length of treatment, whether an indication was recorded on that date and, if so, what it was.
3. Confirm if chosen antibiotic appears in NLTPCT formulary and if indication and length of treatment matches one of those listed in Table 2.
Table 2. NLTPCT antibiotic formulary choices, indication and treatment length
Formulary drug Formulary Indication
Amoxicillin Otitis media
Sinusitis
Acute bronchitis
Exacerbation of COPD
Community acquired pneumonia
5
5
5
Length of
Treatment
(days)
5
Up to 10 days

Azithromycin
Cefalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Co-amoxiclav
Doxycycline
Erythromycin
(including stearate, ethylsuccinate)
Flucloxacillin
Metronidazole
Dental infection
Eradication of H. Pylori
Chlamydia
5
7-14
Urinary tract infection
IN PREGNANCY
Acute pyelonephritis
Single dose
7
7
Acute bacterial prostatitis 28
Acute bacterial gastroenteritis 5
Throat infections 7
Otitis media
Sinusitis
Exacerbation of COPD
Community pneumonia
Dental infections
Rosacea acquired
Impetigo
Cellulitis
Eradication of H. Pylori
5
5
5
Up to 10 days
5
Up to 84 days
5-7
7-14
7-14
Human bites (+ metronidazole) 7
Acne 4-6 months
Cellulitis 14
Dental infections
Acute pyelonephritis
Animal and human bites
5
14
7
Sinusitis
Acute bronchitis
Rosacea
Pelvic Inflammatory Disease
(+ metronidazole)
5
5
Acute exacerbation of COPD 5
Chlamydia 7
84
14
Acne
Dental infections
4-6 months
5
Cellulitis
Impetigo
Leg ulcers
Severe dental infections
(+ amoxicillin or erythromycin)
Bacterial vaginosis
Eradication of H. Pylori
Clostridium difficile
Animal and human bites
7-14
7
7
5
7
7-14
10-14
7

(+doxycycline or oxytetracycline or clarithromycin)
Trichomoniasis 5 days or single dose
14
Nitrofurantoin
Ofloxacin
Oxytetracycline
Phenoxymethylpenicillin
Trimethoprim
Pelvic Inflammatory Disease
(+ ofloxacin or oxytetracycline)
Urinary tract infection
Pelvic Inflammatory Disease
(+ metronidazole)
Animal bite
(+ metronidazole)
Throat infections
Urinary tract infections
Acute bacterial prostatitis
3 (7 days in pregnancy)
14
7
7
3
28
4. If cephalosporin or quinolone prescribed, confirm if indication and length of treatment match those in Table 3.
Table 3. Recommended length of treatment and indication for cephalosporins or quinolones
Drug Indication Length of
Treatment
(days)
Cefalexin
Ciprofloxacin
Cefaclor
Urinary tract infection
In pregnancy
Acute pyelonephritis
7
7
Acute bacterial prostatitis 28
Acute bacterial gastroenteritis 5
Non-formulary
Cefadroxil
Cefixime
Cefradine
Cefuroxime
Non-formulary
Non-formulary
Non-formulary
Non-formulary
Levofloxacin
Moxifloxacin
Non-formulary
Non-formulary
Non-formulary Norfloxacin
Ofloxacin Pelvic Inflammatory Disease
(+ metronidazole)
5. Enter the results on the data collection form
14

Results
Share and discuss the results of your baseline audit. Consider these questions:

Are the results what we expected?

Can we make any improvements?

What might be stopping us getting better?
Identify areas for improvement: formulate an action plan to optimise prescribing

Decide what it is that you want to achieve

Think about how you will know if you are improving or not

Generate ideas for the things that you could do differently. Start with small changes to begin with and test out your ideas.

Record your progress.
Notes on antibiotic prescribing o Is an antibiotic necessary? o What alternative strategies cold be used instead of prescribing? o Why was a non-formulary drug chosen or a non-formulary indication? o Why was the length of treatment chosen not in line with formulary guidance?

Patient Details Antibiotic Prescribing
Name and
Computer No.
Antibiotic
Prescribed
(generic name)
Choice of drug Indication for cephalosporins or quinolones
Assess Action required