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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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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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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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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
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 the
prudent use of antimicrobials.
Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Medicine Adult doseDuration oftreatment
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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Data collection sheet
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
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 the
prudent use of antimicrobials.
Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Medicine Adult doseDuration oftreatment
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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Data collection sheet
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
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 the
prudent use of antimicrobials.
Information from HPA Management of Infection Guidance for Primary Care1:
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
* 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 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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Data collection sheet
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
Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Medicine DoseDuration oftreatment
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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Data collection sheet
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.
Information from HPA Management of Infection Guidance for Primary Care1:
Illness Comments Medicine DoseDuration oftreatment
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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Data collection sheet
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
Information from HPA Management of Infection Guidance for Primary Care1:
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
* The period of delay is often less than 7 days
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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Data collection sheet
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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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