cepp national audit - focus on antibiotic prescribing

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CEPP NationalAudit:Focus on AntibioticPrescribing

March 2013


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CEPP National Audit: Focus on Antibiotic Prescribing

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CONTENTS

AUDIT AIMS 4BACKGROUND 4AUDIT METHOD 6

QUANTITY OF PRESCRIBING PRIMARY CARE 8

1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT 82. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS 103. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES 124. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS 14

QUALITY OF PRESCRIBING PRIMARY CARE 175. QUINOLONE PRESCRIBING 176. CEPHALOSPORIN PRESCRIBING 207. CO-AMOXICLAV PRESCRIBING 22

START SMART AND FOCUS HOSPITAL SETTING 258. HOSPITAL PRESCRIBING OF ANTIBIOTICS 25

PRIMARY CARE PROCESSES 279. DELAYED PRESCRIPTIONS 2710. READ CODING TO IDENTIFY HCAI 29

FEEDBACK FORMS 3011. PRACTICE REVIEW SHEET 3012. CPD SHEET (FOR PERSONAL USE) 31

ABBREVIATIONS 32REFERENCES 33

This document should be cited as:All Wales Medicines Strategy Group. CEPP National Audit: Focus on AntibioticPrescribing. March 2013.


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All Wales Medicines Strategy Group

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AUDIT AIMS

To promote antibiotic prescribing in accordance with existing guidelines.

To support clinicians in promoting quality improvement by reviewingantimicrobial prescribing within their teams.

BACKGROUND

Where an antibiotic is needed, the choice of agent and its use needs to be consideredin order to ensure that infections are treated effectively. Broad-spectrum antibioticssuch as quinolones, cephalosporins and co-amoxiclav should be reserved for thetreatment of resistant disease only.

This audit is underpinned by agreed Health Protection Agency (HPA) guidelines for themanagement of infection in primary care, and supports the implementation of the AllWales Medicines Strategy Group (AWMSG) National Prescribing Indicators

20132014

1,2

. Each audit section will be available as a standalone document on theAWMSG website.

The use of antibiotic agents is monitored as a National Prescribing Indicator inantibacterial items per 1,000 STAR-PU. Use is generally high in Wales whencompared 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).

PowysC

ardiff

&Vale

Cwm

Taf

HywelDda

ABMU

Bets

iCadwaladr

Ane

urinBevan

0

100

200

300

400

PCTs/HBs

Itemsper1000STAR-PUs

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


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5

European Centre for Disease Prevention and Control (ECDC) key messages forprimary care prescribers4

Growing antibiotic resistance threatens the effectiveness of antibioticsnow and in the future

Antibiotic resistance is an increasingly serious public health problem inEurope [1, 2].

While the number of infections due to antibiotic-resistant bacteria isgrowing, the pipeline of new antibiotics is unpromising, thus presentinga bleak outlook on availability of effective antibiotic treatment in thefuture [3, 4].

Rising levels of antibiotic-resistant bacteria could be curbed byencouraging limited and appropriate antibiotic use in primary carepatients

Antibiotic exposure is linked to the emergence of antibiotic resistance[58]. The overall uptake of antibiotics in a population, as well as howantibiotics are consumed, has an impact on antibiotic resistance [9, 10].

Experience from some countries in Europe shows that reduction inantibiotic prescribing for outpatients has resulted in concomitantdecrease in antibiotic resistance [1012].

Primary care accounts for about 80% to 90% of all antibioticprescriptions, mainly for respiratory tract infections [9, 14, 15].

There is evidence showing that, in many cases of respiratory tractinfection, antibiotics are not necessary [1618] and that the patientsimmune system is competent enough to fight simple infections.

There are patients with certain risk factors such as, for example, severeexacerbations of chronic obstructive pulmonary disease (COPD) withincreased sputum production, for which prescribing antibiotics isneeded [19, 20].

Unnecessary antibiotic prescribing in primary care is a complexphenomenon, but it is mainly related to factors such asmisinterpretation of symptoms, diagnostic uncertainty and perceivedpatients expectations [14, 21].

Communicating with patients is key

Studies show that patient satisfaction in primary care settings dependsmore on effective communication than on receiving an antibioticprescription [2224] and that prescribing an antibiotic for an upperrespiratory tract infection does not decrease the rate of subsequentreturn visits [25].

Professional medical advice impacts patients perceptions and attitudetowards their illness and perceived need for antibiotics, in particularwhen 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 forconsultations that involve offering alternatives to antibiotic prescribing.Studies show that this can be done within the same averageconsultation time while maintaining a high degree of patient satisfaction[14, 27, 28].


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Supporting tools

The Royal College of General Practitioners website hosts the TARGETantibiotics toolkit (http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.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. Appropriateantibiotic use whose responsibility?(http://www.wemerec.org/Documents/Bulletins/AntibioBulletin2012Online.pdfand 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 tractinfections (http://www.nice.org.uk/cg69)

AUDIT METHOD

The audits are enclosed for the use of health boards or individual prescribers. A rangeof criteria has been provided to enable health boards and clinicians to focus on specificareas of prescribing; it is not envisaged that a practice would undertake all auditoptions in one year. It is recommended that this work is carried out by clinicians, asthis will enhance ownership, leading to more effective change.

Prescribing data should be considered and a decision reached as to which elements ofthe tool are most likely to have a positive impact on prescribing practice. This maymean focusing on antibiotic groups, where specific issues are identified, or looking atprescribing in clinical scenarios where general quantity is more of an issue. Theprocess sections will support the use of delayed prescriptions and identification ofhealthcare-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 ofseveral criteria, depending on their priorities (prescribers should ensure that anadequate number of consultations are analysed to determine compliance with the audit

standards and to provide a basis for discussion). It is likely that discussing recentantimicrobial prescribing data with prescribing advisors would help to ensure that anyfocus delivers maximum effect.

Health boards are encouraged to include the audit within their Clinical EffectivenessPrescribing Programme (CEPP). For many, it will be a priority area due to the impactof HCAI and increasing resistance problems (with subsequent treatment failure) placingpressure on unscheduled care.

A response date for initial data collection of 31 October 2013 will support nationalcollation and feedback of results, and the option to complete the audit cycle within oneyear.
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspxhttp://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspxhttp://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801http://www.wemerec.org/Documents/Bulletins/AntibioBulletin2012Online.pdfhttp://www.wemerec.org/Documents/Bulletins/AntibioSupp2012.pdfhttp://www.stemmingthetide.org/http://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspxhttp://www.nice.org.uk/cg69http://www.nice.org.uk/cg69http://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspxhttp://www.stemmingthetide.org/http://www.wemerec.org/Documents/Bulletins/AntibioSupp2012.pdfhttp://www.wemerec.org/Documents/Bulletins/AntibioBulletin2012Online.pdfhttp://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspxhttp://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx


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HPA grading of guidance recommendationsThe strength of each recommendation in the following sections is qualified by a letter insupercript.

Study design Recommendation grade

Good recent systematic review of studies A+

One or more rigorous studies, not combined A-One or more prospective studies B+

One or more retrospective studies B-

Formal combination of expert opinion C

Informal opinion, other information D


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QUANTITY OF PRESCRIBING PRIMARY CARE

1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT

BackgroundAWMSG indicator: Antibacterial items per 1,000 STAR-PU

The development of antibiotic prescribing indicators supports the core aims of theAntimicrobial Resistance Programme in Wales to inform, support and promote theprudent use of antimicrobials.

Information from HPA Management of Infection Guidance for Primary Care1:

Illness Comments Medicine Adult doseDuration oftreatment

Phenoxymethylpenicillin

B-

500 mg QDS

1 g BDA+(QDS whensevere

D)

10 daysA-

AcutesorethroatCKS

Avoid antibiotics as 90% resolve in7 days without, and pain only reducedby 16 hours

A+

If Centor score 3 or 4:(lymphadenopathy; no cough; fever;tonsillar exudate)

A-consider 2 or 3

day delayed or immediateantibiotics

A+or rapid antigen test.

RCT in < 18 year olds shows 10d hadlower relapse

Antibiotics to prevent quinsy NNT >4000

B-

Antibiotics to prevent otitis mediaNNT 200

A+

Penicillin allergy:Clarithromycin

250500 mg BD 5 daysA+

MethodAssess a reasonable sample of records with a diagnosis of sore throat. Patients withrecurrent throat infections should be excluded where another episode has beendiagnosed within eight weeks. Search using the following codes:

1C9 Sore throat symptom/throat soreness

1C92 Has a sore throat1CB3 Throat pain194 Dysphagia

1692 Swollen glandsA75 Infectiousmononucleosis

M04 Acute lymphadenitisH02 Acute pharyngitisH02-1 Sore throat NOSH02-2 Viral sore throat NOSH02-3 Throat infection -

pharyngitisH024 Acute viral pharyngitis

H02z Acute pharyngitis NOSH03 Acute tonsillitisH03-1 Throat infection -

tonsillitisH031 Acute follicular tonsillitis

H036 Acute viral tonsillitisH03z Acute tonsillitis NOS

H04 Acute laryngitis/tracheitisH05z Upper respiratory tract

infectionH05z-1 Upper respiratory tract

infection NOS

Centor criteria:

Score 1 point for each of: temperature > 38C; absence of cough; tenderanterior cervical adenopathy; tonsillar swelling or exudate; age < 15 years.
http://www.prodigy.nhs.uk/guidance.asp?gt=Otitis%20media%20-%20acutehttp://www.prodigy.nhs.uk/guidance.asp?gt=Otitis%20media%20-%20acute


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CEPP

Data collection sheet

Patient

All criteria forCentor score

recorded?(lymphadenopathy no

cough; fever;

tonsillar exudate)(Y/N)

Centorscore

Centorscore

3 or 4?

(Y/N)

Antibioticgiven?(Y/N)

No antibiotic prescribedOR

Immediate/delayed antibioticgiven and

Centor score = 3 or 4?(Y/N)

Delayescript(Y/N)

Total% Yes

Standard 100% 90%


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2. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS


The development of antibiotic prescribing indicators supports the core aims of theAntimicrobial Resistance Programme in Wales to inform, support and promote the

prudent use of antimicrobials.



AmoxicillinA+,A

500 mg TDS1 g if severe

D

or doxycycline200 mg stat/

100 mg OD

orphenoxymethylpen-icillin

B+

500 mg QDS

Acuterhinosinusitis

C

CKS

Avoid antibiotics as 80%resolve in 14 days without,and they only offermarginal benefit after 7days, NNT15

A+

Use adequateanalgesiaB+

Consider 7 day delayed*or immediate antibioticwhen purulent nasaldischarge NNT8

A+

In persistent infection usean agent with anti-anaerobic activity, e.g. co-amoxiclav

B+

For persistentsymptoms:co-amoxiclav

B+

625 mg TDS

7 days

* The period of delay is often less than 7 days

MethodAssess a reasonable sample of records with a diagnosis of acute rhinosinusitis.Patients with recurrent or chronic sinus infections should be excluded. Search usingthe following codes

H05z-1 Upper respiratory tract infectionH01 Acute sinusitisHyu00 Other acute sinusitis1BA9 Sinus headache1B1G0 Sinus headache
http://www.cks.library.nhs.uk/sinusitishttp://www.cks.library.nhs.uk/sinusitis


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CEPP


Patient

Symptomsrecorded as

present for 7 daysor more?

(Y/N)

Purulent nasaldischargerecorded?

(Y/N)

Antibiotic given?(Y/N)

If an antibiotic given,was there either arecord of purulent

discharge or symptomsbeing present for 7 days

or more?(Y/N)

Delayedscript?(Y/N)

Total

% Yes

Standard 90%


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3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES






TrimethoprimB+

200 mg BD

ornitrofurantoin

B,C

100 mg m/r BDC

Women allages: 3days

A+

Men: 7days

C

UTI inadults(no feveror flank

pain)HPAQRG,SIGN,CKS,CKS

Women: Severe/or 3 symptoms:treat

A,C

Women: Mild/or 2 symptoms:use dipstick and presence ofcloudy urine to guide treatment.Nitrite and blood/leucocytes has92% PPV; negative nitrite,leucocytes and blood has a 76%NPV

A-

Men: Consider prostatitis and sendpre-treatment MSU

COR if

symptoms mild/non-specific, usenegative dipstick to exclude UTI

C

Second line: perform culture in all treatment failures

B

Amoxicillin resistance is common; only use ifsusceptible

B+

Community multi-resistant extended-spectrum Beta-lactamase E. coli are increasing: considernitrofurantoin

Signs and symptoms of a urinary tract infection (UTI) are dysuria, urgency, frequency,polyuria, suprapubic tenderness and haematuria.

MethodAssess a reasonable sample of records with a diagnosis of UTI (female only). Excludepregnant females, men, children and patients with acute pyelonephritis. Search usingthe following codes:

R081 DysuriaK15 CystitisK190 Urinary tract infectionK197 HaematuriaK5 Other female tract disorderKz Genitourinary disease NOS
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.sign.ac.uk/guidelines/fulltext/88/index.htmlhttp://www.cks.nhs.uk/urinary_tract_infection_lower_womenhttp://www.cks.nhs.uk/uti_lower_menhttp://www.cks.nhs.uk/uti_lower_menhttp://www.cks.nhs.uk/urinary_tract_infection_lower_womenhttp://www.sign.ac.uk/guidelines/fulltext/88/index.htmlhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720


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CEPP


Patient 2 symptoms and

positive dip?(Y/N)

3 symptoms?(Y/N)

Antibiotic given?(Y/N)

Where an antibioticwas given, werethere either 3 or

more symptoms ora positive urine dip

recorded?(Y/N)

T

Total

% Yes

Standard 90%


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4. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS





Illness Comments Medicine DoseDuration oftreatment

Amoxicillin 500 mg TDSAcutecough/bronchitisCKS, NICE

69

Antibiotic little benefit if no co-morbidityA+

Consider 7 day* delayed antibiotic withadvice

A

Symptom resolution can take 3 weeks

Consider immediate antibiotics if > 80 yearsand ONE of: hospitalisation in past year,oral steroids, diabetic, congestive heartfailure, OR > 65 years with 2 of above

ordoxycycline

200 mg stat/100 mg OD

5 days


National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 69:Respiratory tract infections, states that a no antibiotic prescribing strategy or adelayed antibiotic prescribing strategy should be agreed for patients with acutecough/acute bronchitis6.

An immediate antibiotic prescription and/or further appropriate investigation and

management should only be offered to patients (both adults and children) in thefollowing situations:

if the patient is systemically very unwell;

if the patient has symptoms and signs suggestive of serious illness and/orcomplications (particularly pneumonia, mastoiditis, peritonsillar abscess,peritonsillar cellulitis, intraorbital and intracranial complications);

if the patient is at high risk of serious complications because of pre-existingcomorbidity. This includes patients with significant heart, lung, renal, liver orneuromuscular disease, immunosuppression, cystic fibrosis, and young childrenwho 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 ofthe 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 antibioticprescribing strategy should not be considered6.
http://www.cks.nhs.uk/cough/background_information/causeshttp://www.nice.org.uk/cg69http://www.nice.org.uk/cg69http://www.nice.org.uk/cg69http://www.nice.org.uk/cg69http://www.cks.nhs.uk/cough/background_information/causes


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Delayed prescriptionsWhen the delayed antibiotic prescribing strategy is adopted, patients should be offered:

reassurance that antibiotics are not needed immediately because they are likelyto 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 tosettle in accordance with the expected course of the illness or if a significantworsening of symptoms occurs;

advice about re-consulting if there is a significant worsening of symptomsdespite using the delayed prescription.6

A delayed prescription with instructions can either be given to the patient or left at anagreed location to be collected at a later date6.

It has been suggested that asking the patient to return to the practice reception or anominated pharmacy is more effective than handing the delayed prescription to thepatient. An agreement with the pharmacist to return uncollected prescriptions can beinformative for the prescriber.

Information for the patient can be issued during a consultation to support no prescribingor delayed prescribing (delayed prescribing pad/patient information leaflet).

MethodAssess a reasonable sample of records both adults and children (between 5 years and65 years), with a diagnosis of acute cough/acute bronchitis. Exclude patients withasthma or COPD. Search using the following codes:

171 and subset CoughR062 Cough Symptom NOSH05z-1 Upper Respiratory Tract Infection

(Exclude patients who are allergic to all four agents (amoxicillin, clarithromycin,erythromycin and doxycycline) from the audit.
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/Patient-Antibiotic-leaflet.ashxhttp://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/Patient-Antibiotic-leaflet.ashx


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Patient

Documentedclinical features,

both temperature,and chest

examination?(Y/N)

Additional clinicalfeatures of

severity/systemicupset recorded?

(pulse, respiratoryrate or oximetry)(2 or more = Y)

Antibioticprescribed?

(Y/N/delayed)

Amoxicillin,clarithromycin,erythromycin or

doxycycline?(Y/N)

If antpatie(syst

symptoill

compli

(Y/

Total

% Yes

Standard 100% No standard set 95 %


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QUALITY OF PRESCRIBING PRIMARY CARE

5. QUINOLONE PRESCRIBING

BackgroundAWMSG indicator: Quinolones as a percentage of total antibacterial items



Lowerrespiratorytractinfections

Low doses of penicillins are more likelyto select out resistance. Do not usequinolone (ciprofloxacin, ofloxacin) firstline due to poor pneumococcal activity.Reserve all quinolones (includinglevofloxacin) for proven resistantorganisms.

CiprofloxacinA-

500 mg BD 7 daysA-

AcutepyelonephritisCKS

If admission not needed, send MSU for

culture and sensitivities, and startantibiotics

C

If no response within 24 hours, admitC

orco-amoxiclav

C

500 mg/125 mgTDS

14 daysC

Only consider standby antibioticsfor remote areas or people at high-riskof severe illness with travellersdiarrhoea

C

If standby treatment appropriate give:ciprofloxacin 500 mg twice a day for3 days (private prescription)

C,B+

Ciprofloxacin 500 mg BD3 days(privateprescription)

TravellersdiarrhoeaCKS

If quinolone resistance high (e.g. southAsia): consider bismuth subsalicylate

(PeptoBismol

) 2 tablets QDS asprophylaxis

B+or for 2 days treatment

B+

Bismuthsubsalicylate(PeptoBismol)

2 tablets

QDS

Asprophylaxis

or for twodays

MetronidazolePLUSofloxacin

B+

400 mg BD

400 mg BD

14 days

14 daysPelvicinflammatorydiseaseRCOG,BASHH, CKS

Refer woman and contacts to GUMservice

B+. Always culture for

gonorrhoea & chlamydiaB+

. 28% ofgonorrhoea isolates now resistant toquinolones

B+. If gonorrhoea likely

(partner has it, severe symptoms, sexabroad) use ceftriaxone regimen orrefer to GUM.

If high risk ofGC:ceftriaxone

C

PLUSmetronidazolePLUSdoxycycline

B+

500 mg IM

400 mg BD

100 mg BD

Stat

14 days

14 days

Ciprofloxacin

C

500 mg BD

or ofloxacinC

200 mg BDAcuteprostatitisBASHH, CKS

Send MSU for culture and startantibioticsC

4-week course may prevent chronicprostatitis

C

Quinolones achieve higher prostatelevels

2nd line:trimethoprim

C

200 mg BD

28 daysC

Quinolones may also be required in response to sensitivity results where a preferredagent is not suitable due to resistance.
http://www.cks.nhs.uk/pyelonephritis_acutehttp://www.cks.nhs.uk/diarrhoea_prevention_and_advice_for_travellershttp://www.rcog.org.uk/womens-health/guidelineshttp://www.bashh.org/guidelineshttp://www.cks.nhs.uk/pelvic_inflammatory_diseasehttp://www.bashh.org/guidelineshttp://www.cks.nhs.uk/prostatitis_acutehttp://www.cks.nhs.uk/prostatitis_acutehttp://www.bashh.org/guidelineshttp://www.cks.nhs.uk/pelvic_inflammatory_diseasehttp://www.bashh.org/guidelineshttp://www.rcog.org.uk/womens-health/guidelineshttp://www.cks.nhs.uk/diarrhoea_prevention_and_advice_for_travellershttp://www.cks.nhs.uk/pyelonephritis_acute


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MethodAssess 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


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CEPP


PatientQuinoloneprescribed

(name)

Pyelonephritis?(Y/N)

Pelvicinflammatory

disease?(Y/N)

Acuteprostatitis?

(Y/N)

Laboratorysensitivity?

(Y/N)

Total

% Yes

Standard


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6. CEPHALOSPORIN PRESCRIBING

BackgroundAWMSG indicator: Cephalosporins as a percentage of total antibacterial items.



First line:nitrofurantoinif susceptible,amoxicillin

100 mg m/r BD

500 mg TDS

Second line:trimethoprim

200 mg BD (off-label)

UTI inpregnancyHPA QRG, CKS

Send MSU for culture and startantibiotics

A

Short-term use ofnitrofurantoinin pregnancy is unlikely tocause problems to the foetus

C

Avoid trimethoprim if low folatestatus or on folate antagonist(e.g. antiepileptic or proguanil)

Third line:cefalexin

Give folic acid iffirst trimester500 mg BD

7 days

Lower UTI:

trimethoprimA ornitrofurantoin

A

If susceptible,amoxicillin

A

Second line:cefalexin

C

3 daysA+

UTI in childrenHPA QRG,CKS, NICE

Child < 3 months: refer urgentlyfor assessment

C

Child 3 months: use positivenitrite to start antibiotics

A+

Send pre-treatment MSU for all.

Imaging: only refer if child < 6months, recurrent or atypicalUTI

C

Upper UTI:co-amoxiclav

A

Second line:cefixime

A

See BNF fordosage

7-10 daysA+

MetronidazolePLUSofloxacin

B+

400 mg BD

400 mg BD

14 days

14 daysPelvicinflammatorydiseaseRCOG, BASHH,CKS

Refer woman & contacts toGUM serviceB+

. Always culturefor gonorrhoea & chlamydia

B+.

28% of gonorrhoea isolatesnow resistant to quinolones

B+

If gonorrhoea likely (partner hasit, severe symptoms, sexabroad) use ceftriaxoneregimen or refer to GUM.

If high risk ofGC:ceftriaxone

C

PLUSmetronidazolePLUSdoxycycline

B+

500 mg IM

400 mg BD

100 mg BD

Stat

14 days

14 days

MethodAssess a reasonable sample of records per prescriber with prescription of acephalosporin against national guidelines.
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.cks.nhs.uk/urinary_tract_infection_lower_womenhttp://www.uktis.org/docs/Nitrofurantoin.pdfhttp://www.uktis.org/docs/antibiotics.pdfhttp://www.uktis.org/docs/trimethoprim.pdfhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.cks.nhs.uk/urinary_tract_infection_childrenhttp://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdfhttp://www.rcog.org.uk/womens-health/guidelineshttp://www.bashh.org/guidelineshttp://www.cks.nhs.uk/pelvic_inflammatory_diseasehttp://www.cks.nhs.uk/pelvic_inflammatory_diseasehttp://www.bashh.org/guidelineshttp://www.rcog.org.uk/womens-health/guidelineshttp://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdfhttp://www.cks.nhs.uk/urinary_tract_infection_childrenhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.uktis.org/docs/trimethoprim.pdfhttp://www.uktis.org/docs/antibiotics.pdfhttp://www.uktis.org/docs/Nitrofurantoin.pdfhttp://www.cks.nhs.uk/urinary_tract_infection_lower_womenhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720


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CEPP


PatientCephalosporin

prescribed(name)

UTI in children?(Y/N)

UTI inpregnancy?

(Y/N)

Pelvicinflammatory

disease?(Y/N)

Laboratorysensitive

(Y/N)

Total

% Yes

Standard


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7. CO-AMOXICLAV PRESCRIBING

BackgroundAWMSG indicator: Co-amoxiclav as a percentage of total antibacterial items


Illness Comments Medicine DoseDuration

oftreatment

AmoxicillinA+,A

500 mg TDS1 g if severe

D

or doxycycline200 mgstat/100 mgOD

orphenoxymethylpenicillin

B+

500mg QDS

Acuterhinosinusitis

C

CKS

Avoid antibiotics as 80%resolve in 14 days without, andthey only offer marginal benefitafter 7 days NNT15

A+

Use adequate analgesiaB+

Consider 7 day* delayed orimmediate antibiotic whenpurulent nasal dischargeNNT8

A+

In persistent infection, use anagent with anti-anaerobicactivity e.g. co-amoxiclav

B+

For persistentsymptoms:co-amoxiclav

B+

625 mg TDS

7 daysA+

Amoxicillin 500 mg TDS

or doxycycline200 mg stat/100 mg OD

Clarithromycin 500 mg BD

Acuteexacerbation ofCOPDNICE 12,GOLD, BMJ

Treat exacerbations promptlywith antibiotics if purulentsputum and increasedshortness of breath and/orincreased sputum volume

B+.

Risk factors for antibioticresistant organisms include co-morbid disease, severe COPD,frequent exacerbations,antibiotics in last 3 months.

If resistance riskfactors:

co-amoxiclav

625 mg TDS

5 days

Lower UTI:trimethoprimAornitrofurantoin

A-

If susceptible,amoxicillin

A

Second line:cefalexin

C

3 daysA+

Upper UTI:co-amoxiclav

A

UTI in childrenHPA QRGCKSNICE

Child < 3 months: refer urgentlyfor assessment

C

Child 3 months: use positivenitrite to start antibiotics

A+

Send pre-treatment MSU for all.

Imaging: only refer if child < 6months, recurrent or atypicalUTI

C Second line: cefixime

A

See BNF fordosage

7-10days

A+

CiprofloxacinA-

500 mg BD 7 daysA-

AcutepyelonephritisCKS

If admission not needed, send

MSU for culture & sensitivitiesand start antibiotics

C

If no response within 24 hours,admit

C

or co-amoxiclavC

500/125 mgTDS

14 daysC

FlucloxacillinC

500 mg QDS

If penicillin allergic:clarithromycin

C

500 mg BD

or clindamycinC

300450 mgQDS

CellulitisCKS

If patient afebrile and healthyother than cellulitis, use oralflucloxacillinalone

C. If river or

sea water exposure, discusswith microbiologist. If febrileand ill, admit for IV treatment

C

Stop clindamycin if diarrhoeaoccurs.

Facial:co-amoxiclav

C

500/125 mgTDS

7 days

If slowresponsecontinuefor afurther 7days

C
http://www.cks.library.nhs.uk/sinusitishttp://guidance.nice.org.uk/CG12http://www.goldcopd.org/Guidelines/guidelines-resources.htmlhttp://thorax.bmj.com/content/59/suppl_1/i131.full.pdf+htmlhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://www.cks.nhs.uk/urinary_tract_infection_childrenhttp://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdfhttp://www.cks.nhs.uk/pyelonephritis_acutehttp://www.cks.nhs.uk/cellulitis_acutehttp://www.cks.nhs.uk/cellulitis_acutehttp://www.cks.nhs.uk/pyelonephritis_acutehttp://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdfhttp://www.cks.nhs.uk/urinary_tract_infection_childrenhttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720http://thorax.bmj.com/content/59/suppl_1/i131.full.pdf+htmlhttp://www.goldcopd.org/Guidelines/guidelines-resources.htmlhttp://guidance.nice.org.uk/CG12http://www.cks.library.nhs.uk/sinusitis


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Illness Comments Medicine DoseDuration

oftreatment

Thorough irrigation isimportant

C

Prophylaxis ortreatment:co-amoxiclav

375625 mgTDS

C

Human:Assess risk of tetanus, HIV,hepatitis B&CCAntibiotic prophylaxis isadvised

B-Bites

CKS Cat or dog:Assess risk of tetanus andrabies

C

Give prophylaxis if catbite/puncture wound; bite tohand, foot, face, joint, tendon,ligament;immunocompromised/diabetic/asplenic/cirrhotic

If penicillin allergic:Metronidazole plusdoxycycline(cat/dog/man)

or metronidazole plusclarithromycin (humanbite) AND review at 24& 48hrs

C

200400 mgTDS100 mg BD

C

200400 mgTDS250500 mgBD

C

7 daysC


MethodAssess a reasonable sample of records per prescriber with prescription of co-amoxiclav against national guidelines.
http://www.cks.nhs.uk/bites_human_and_animalhttp://www.cks.nhs.uk/bites_human_and_animal


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PatientCo-

amoxiclav?(Y/N)

Persistentsinusitis

(Y/N)

COPDwith

resistancefactors?

(Y/N)

Upper UTI inchildren?

Acutepyelonephritis?

(Y/N)

Humanbite?(Y/N)

Facialcellulitis?

(Y/N)

Sen(

Total

% YesStandard


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25

START SMART AND FOCUS HOSPITAL SETTING

8. HOSPITAL PRESCRIBING OF ANTIBIOTICS

AimsTo review a teams prescribing of antibiotics with respect to:

Documentation Choice of antibiotic/formulary compliance

Induction guidance for new team members

MethodReview approximately 15 sets of notes where an antibiotic was prescribed by amember of your team and complete the following data collection sheet.


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Data collection sheet (adapted from Department of Health Antimicrobial stewardship: Start smart - then

Site/hospital: Ward: Specialty:

Total number of patients on ward: Number of patients prescribed antimicrobials:

Complete one line below for each antibioticGuideline pjustified o

pres

DateHospitalnumber

Allergybox

filled?(Y/N)

Antibioticgiven

Route

Reviewor stopdate onchart?(Y/N)

Consultantteam

Documentedindication orprovisionaldiagnosis

(pleasespecify)?

(Y/N)

Guidelinefor

indication


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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 tosettle in accordance with the expected course of the illness or if a significantworsening of symptoms occurs;

advice about re-consulting if there is a significant worsening of symptomsdespite using the delayed prescription.6

A delayed prescription with instructions can either be given to the patient or left at anagreed location to be collected at a later date6.

It has been suggested that asking the patient to return to the practice reception or anominated pharmacy is more effective than handing the delayed prescription to thepatient. An agreement with the pharmacist to return uncollected prescriptions can beinformative for the prescriber. A delayed prescription should include the time period forwhich it is valid. Delayed prescriptions in one locality are endorsed with the followingwording 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 notrequested by the patient.
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/Patient-Antibiotic-leaflet.ashxhttp://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/Patient-Antibiotic-leaflet.ashx


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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 allthat apply):

NoneGiven directly to patientFor collection at receptionFor collection at a named pharmacy

3. Does the practice monitor unused delayed prescriptions that have been given tothe 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 returnuncollected 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 enableappropriate use (including clear descriptions of time and reasons)?

8. Outcome of clinical discussion with colleagues regarding use of delayedprescriptions

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


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10. READ CODING TO IDENTIFY HCAI

The following Read Codes are recommended to support the surveillance of HCAI, suchas post-operative infections:

SP25 Post operative infectionSP250 Post-op stitch abscess

SP251 Post-op wound abscessSP252 Post-op intra-abdominal abscessSP253 Post-op subphrenic abscessSP254 Post-op septicaemiaSP256 Post-op wound infection deepSP257 Post-op wound infection superficialL3945 Infection of obstetric surgical woundXaCl0 [X] Infection of C-Section wound following deliveryLyu6A Infection of C-Section wound following delivery

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


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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 agreedto implement as a result of this audit.

Audit cyclePrescribers are reminded that a second data collection in comparison with thestandards set will support the identification of quality improvement. (See next page fordocument 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 localHead of Pharmacy and Medicines Management who will compile the local information.


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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 andrevalidation. They are particularly relevant to the following components of the GMCguide to Good Medical Practice:

Good Medical Practice: Providing good clinical care2. Good clinical care must include:

a) Adequately assessing the patient's conditions, taking account of thehistory (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 wherenecessary.

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 anydrugs prescribed or other investigation or treatment.

Good Medical Practice: Supporting self care4. You should encourage patients and the public to take an interest in their healthand to take action to improve and maintain it. This may include advising patientson the effects of their life choices on their health and well-being and the possibleoutcomes of their treatments.


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ABBREVIATIONS

AWMSG: All Wales Medicines Strategy GroupBASHH: British Association for Sexual Health and HIVBD: twice-daily;BMJ: British Medical JournalBNF: British National FormularyCEPP: Clinical Effectiveness Prescribing ProgrammeCKS: Clinical Knowledge SummaryCOPD: chronic obstructive pulmonary diseaseCPD: Continued Professional DevelopmentECDC: European Centre for Disease Prevention and ControlGMC: General Medical CouncilGOLD: Global Initiative for Chronic Obstructive Lung DiseaseGUM: genitourinary medicineHCAI: healthcare-acquired infectionHPA: Health Protection AgencyMSU: midstream specimen of urine

NICE: National Institute for Health and Clinical ExcellenceNNT: number needed to treatNPV: negative predictive valueOD: once-dailyPPV: positive predictive valueQDS: four times a dayQRG: quick reference guideRCOG: Royal College of Obstetricians and GynaecologistsRCT: randomised controlled trialSIGN: Scottish Intercollegiate Guidelines NetworkSTAR-PU: specific therapeutic group agesex related prescribing unitsTDS: three times a day

UTI: urinary tract infection


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REFERENCES

1 Health Protection Agency, British Infection Association. Management of infectionguidance for primary care. Oct 2012. Available at:http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801. AccessedDec 2012.

2 All Wales Medicines Strategy Group. National Prescribing Indicators 2013-2014.2013. Available at:http://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdf. Accessed Mar 2013.

3 General Medical Council. Good Medical Practice: Supporting self care. 2012.Available at: http://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care.asp . Accessed Dec2012.

4 European Centre for Disease Prevention and Control. ECDC key messages forprimary 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 AntibioticAwareness 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 forself-limiting respiratory tract infections in adults and children in primary care. Jul2008. 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.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801http://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdfhttp://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdfhttp://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care.asphttp://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care.asphttp://ecdc.europa.eu/en/eaad/antibiotics/pages/messagesforprescribers.aspxhttp://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspxhttp://guidance.nice.org.uk/CG69http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131062http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131062http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131062http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131062http://guidance.nice.org.uk/CG69http://ecdc.europa.eu/en/eaad/Pages/ToolkitsPrimaryCarePrescribers.aspxhttp://ecdc.europa.eu/en/eaad/antibiotics/pages/messagesforprescribers.aspxhttp://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care.asphttp://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care.asphttp://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdfhttp://awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdfhttp://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947333801