CEPP National Audit Focus on Antibiotic Prescribing

March 2013 (updated June 2015)

This report has been prepared by a multiprofessional collaborative group, with support from the All Wales Prescribing Advisory Group (AWPAG) and the All Wales Therapeutics and Toxicology Centre (AWTTC), and has subsequently been endorsed by the All Wales Medicines Strategy Group (AWMSG). Please direct any queries to AWTTC: All Wales Therapeutics and Toxicology Centre University Hospital Llandough Penlan Road Llandough Vale of Glamorgan CF64 2XX awttc@wales.nhs.uk 029 2071 6900 This document should be cited as: All Wales Medicines Strategy Group. CEPP National Audit: Focus on Antibiotic Prescribing. June 2015.

CEPP National Audit – Focus on Antibiotic Prescribing

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CONTENTS AUDIT AIMS................................................................................................................. 2

BACKGROUND ........................................................................................................... 2

Supporting tools .................................................................................................. 4

AUDIT METHOD .......................................................................................................... 4

Sample size ........................................................................................................ 4

Audit data ............................................................................................................ 5

QUANTITY OF PRESCRIBING – PRIMARY CARE ..................................................... 6

1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT ........................................ 6

2. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS .......................10

3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES .....................................12

4. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS...16

QUALITY OF PRESCRIBING – PRIMARY CARE .......................................................19

5. FLUOROQUINOLONE PRESCRIBING ..........................................................19

6. CEPHALOSPORIN PRESCRIBING ...............................................................22

7. CO-AMOXICLAV PRESCRIBING ..................................................................24

START SMART AND FOCUS – HOSPITAL SETTING ...............................................27

8. HOSPITAL PRESCRIBING OF ANTIBIOTICS ...............................................27

PRIMARY CARE PROCESSES ..................................................................................30

9. DELAYED/BACK UP PRESCRIBING.............................................................30

10. READ CODING TO IDENTIFY HCAI ............................................................32

FEEDBACK FORMS ...................................................................................................33

11. REVIEW SHEET ..........................................................................................33

12. CPD SHEET (FOR PERSONAL USE) .........................................................34

ABBREVIATIONS .......................................................................................................35

REFERENCES ............................................................................................................36

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 reviewing

antimicrobial prescribing within their teams. BACKGROUND Where an antibiotic is needed, the choice of agent and its use needs to be considered in order to ensure that infections are treated effectively. Broad-spectrum antibiotics such as fluoroquinolones, cephalosporins and co-amoxiclav should be reserved for the treatment of resistant disease only. This audit is underpinned by agreed PHE guidelines for the management of infection in primary care, and supports the implementation of the All Wales Medicines Strategy Group (AWMSG) National Prescribing Indicators (NPIs) 2014–20161,2. Each audit section will be available as a standalone document on the AWMSG website. The use of antibiotic agents is monitored as an NPI in antibacterial items per 1,000 STAR-PUs. Use is generally high in Wales when compared with other parts of the United Kingdom (see Figure 1).

Total antibacterial items per 1,000 STAR-PUs (13) – Quarter ending September 2014

This audit can be used to support the quality improvement required for appraisal and revalidation as described in the General Medicine Council (GMC) guide to Good Medical Practice3: The European Centre for Disease Prevention and Control (ECDC) gives the following key messages for primary care prescribers4.

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Growing antibiotic resistance threatens the effectiveness of antibiotics now and in the future

• Antibiotic resistance is an increasingly serious public health problem in Europe. • While the number of infections due to antibiotic-resistant bacteria is growing,

the pipeline of new antibiotics is unpromising, thus presenting a bleak outlook on availability of effective antibiotic treatment in the future.

Rising levels of antibiotic-resistant bacteria could be curbed by encouraging limited and appropriate antibiotic use in primary care patients

• Antibiotic exposure is linked to the emergence of antibiotic resistance. The overall uptake of antibiotics in a population, as well as how antibiotics are consumed, has an impact on antibiotic resistance.

• Experience from some countries in Europe shows that reduction in antibiotic prescribing for outpatients has resulted in concomitant decrease in antibiotic resistance.

• Primary care accounts for about 80% to 90% of all antibiotic prescriptions, mainly for respiratory tract infections.

• There is evidence showing that, in many cases of respiratory tract infection, antibiotics are not necessary and that the patient’s immune system is competent enough to fight simple infections.

• There are patients with certain risk factors such as, for example, severe exacerbations of chronic obstructive pulmonary disease (COPD) with increased sputum production, for which prescribing antibiotics is needed.

• Unnecessary antibiotic prescribing in primary care is a complex phenomenon, but it is mainly related to factors such as misinterpretation of symptoms, diagnostic uncertainty and perceived patient’s expectations.

Communicating with patients is key • Studies show that patient satisfaction in primary care settings depends more on

effective communication than on receiving an antibiotic prescription and that prescribing an antibiotic for an upper respiratory tract infection does not decrease the rate of subsequent return visits.

• Professional medical advice impacts patients’ perceptions and attitude towards their illness and perceived need for antibiotics, in particular when they are advised on what to expect in the course of the illness, including the realistic recovery time and self-management strategies.

• Primary care prescribers do not need to allocate more time for consultations that involve offering alternatives to antibiotic prescribing. Studies show that this can be done within the same average consultation time while maintaining a high degree of patient satisfaction.4

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Supporting tools • Royal College of General Practitioners (RCGP) TARGET Antibiotics Toolkit:

- Leaflets to share with patients - Resources for clinical and waiting areas - National antibiotic guidance - Training resources - Audit templates - Self assessment checklist - Resources for commissioners - Useful links - Background information

• PHE (2014) Management of infection guidance for primary care for consultation and local adaptation

• Welsh Medicines Resource Centre (WeMeReC) (2012) Appropriate antibiotic use – whose responsibility?

• WeMeReC (2012) Appropriate antibiotics for respiratory tract infections • STAR Educational Programme • ECDC. Toolkit of briefing materials aimed at primary care prescribers • National Institute for Health and Care Excellence (NICE) (2008) Clinical

Guideline (CG) 69: Respiratory tract infections AUDIT METHOD The audits are enclosed for the use of health boards or individual prescribers. A range of criteria has been provided to enable health boards and clinicians to focus on specific areas of prescribing; it is not envisaged that a practice would undertake all audit options in one year. It is recommended that this work is carried out by clinicians, as this will enhance ownership, leading to more effective change. Prescribing data should be considered and a decision reached as to which elements of the tool are most likely to have a positive impact on prescribing practice. This may mean focusing on antibiotic groups, where specific issues are identified, or looking at prescribing in clinical scenarios where general quantity is more of an issue. The process sections will support the use of delayed/back up prescribing and identification of healthcare-acquired infections (HCAI). Sample size Prescribers should ensure that an adequate number of consultations are analysed to determine compliance with the audit standards and to provide a basis for discussion. Welsh GP practices will be advised on sample size by the health board medicines management team. If further guidance on sample size is required consider the following:

• If undertaking an in-depth review of a single specific audit section, consider assessing ten cases per prescriber within the practice.

• If undertaking several audit sections, a smaller case selection may be appropriate.

• The RCGP TARGET Antibiotics Toolkit advises ‘At least 20 consultations should be analysed to determine overall compliance with NICE and PHE Primary Care guidance’5.

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Audit data It is likely that discussing recent antimicrobial prescribing data with prescribing advisors would help to ensure that any focus delivers maximum effect. Health boards are encouraged to include the audit within their Clinical Effectiveness Prescribing Programme (CEPP). For many, it will be a priority area due to the impact of HCAI and increasing resistance problems (with subsequent treatment failure) placing pressure on unscheduled care. A response date for initial data collection of 31 October 2015 will support national collation and feedback of results, and the option to complete the audit cycle within one year. PHE grading of guidance recommendations The strength of each recommendation in the following sections is qualified by a letter in superscript.

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 Background AWMSG NPI: Antibacterial items per 1,000 STAR-PUs The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform, support and promote the prudent use of antimicrobials. Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Adult dose Duration of treatment

Acute sore throat CKS

Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours2A+ If Centor score 3 or 4: (lymphadenopathy; no cough; fever; tonsillar exudate)3A- consider 2 or 3-day delayed or immediate antibiotics1,A+ or rapid antigen test10B+. Antibiotics to prevent quinsy NNT > 40004B- Antibiotics to prevent otitis media NNT 2002A+

10d penicillin lower relapse versus 7d in RCT in < 18 yrs8

Phenoxymethylpenicillin5B-

500 mg QDS 1 g BD6A+ (QDS when severe7D)

10 days8A-

Penicillin allergy: Clarithromycin

250–500 mg BD 5 days9A+

NICE CG69 – Respiratory tract infections 1.3 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

• acute otitis media • acute sore throat/acute pharyngitis/acute tonsillitis • common cold • acute rhinosinusitis • acute cough/acute bronchitis.

Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic or a delayed antibiotic prescribing strategy):

• bilateral acute otitis media in children younger than 2 years • acute otitis media in children with otorrhoea • acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria* are present6.

* Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough.

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Method There is a choice of two methods for identifying cases in this audit:

• Method 1 searches by Read Code diagnosis; it therefore identifies all patients who presented with a sore throat. The patients may or may not have received an antibiotic and this method will highlight the choice of antibiotic for sore throat. The figure for percentage of patients receiving antibiotics should be interpreted with caution as this will vary considerably depending on the Read Codes audited.

• Method 2 searches by antibiotic (penicillin) and therefore focuses on patients who have received an antibiotic and the criteria used at the point for prescribing

For both methods, only the most recent episode for an individual patient should be considered. Patients with recurrent throat infections should be excluded where another episode has been diagnosed in the previous eight weeks. Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Method 1: Sore throat, search by Read Code diagnosis Assess a reasonable sample of records with a diagnosis of sore throat (see section on Sample size). To identify the sample, perform a search using an appropriate selection of the following Read Codes:

1C9 Sore throat symptom 1C9-1 Throat soreness 1C92 Has a sore throat 1CB3 Throat pain 194 Swallowing symptoms 1692 Swollen glands A340 Streptococcal sore throat H02 Acute pharyngitis H02-1 Sore throat NOS

H02-2 Viral sore throat NOS H02-3 Throat infection – pharyngitis H024 Acute viral pharyngitis H02z Acute pharyngitis NOS H03 Acute tonsillitis H03-1 Throat infection – tonsillitis H03-2 Tonsillitis H031 Acute follicular tonsillitis H036 Acute viral tonsillitis H03z Acute tonsillitis NOS

Centor criteria: Score 1 point for each of: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough6. Following the audit, complete the Review Sheet.

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Data collection sheet (Method 1)

Patient Tonsillar exudate

(Y/N) Lymphadenopathy

(Y/N) Fever (Y/N)

Presence/ absence of cough: not recorded (x) cough

present (P) cough

absent(A)

All criteria for Centor

score recorded?

(Y/N)

Centor score 3 or 4? (Y/N)

Antibiotic given? (Y/N)

Criteria met i.e. No antibiotic

prescribed OR

Immediate/delayed antibiotic + Centor

score = 3 or 4? (Y/N)

Delayed/ back up prescribing? (Y/N)

Phenoxy-methylpenicillin

or clarithromycin?†

(Y/N)

Other (record

name and reason, where given)

Comments

Total

% Yes

Standard 100% 90% 95% of prescriptions

† Where clarithromycin is suggested erythromycin may be used7.

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Method 2: Sore throat, search by antibiotic (penicillin) Search for adults and children issued phenoxymethylpenicillin (Penicillin V) and identify the cohort prescribed for throat infection (see section on Sample size). Following the audit, complete the Review Sheet. Data collection sheet (Method 2)

Patient Tonsillar exudate

(Y/N) Lymphadenopathy

(Y/N) Fever (Y/N)

Presence/absence of cough:

not recorded (x) cough present (P) cough absent (A)

All criteria for Centor

score recorded?

(Y/N)

Delayed/back-up prescription?

Immediate antibiotic given

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

Comments

Total

% Yes

Standard 100% 90%

All Wales Medicines Strategy Group

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2. ANTIBIOTIC PRESCRIBING FOR ACUTE RHINOSINUSITIS

Background AWMSG NPI: Antibacterial items per 1,000 STAR-PUs

The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform, support and promote the prudent use of antimicrobials. Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Adult dose Duration of treatment

Acute rhinosinusitis5C CKS RS

Avoid antibiotics as 80% resolve in 14 days without; they only offer marginal benefit after 7 days, NNT152,3A+ Use adequate analgesia4B+ Consider 7-day delayed or immediate antibiotic when purulent nasal discharge NNT81,2A+ In persistent infection use an agent with anti-anaerobic activity, e.g. co-amoxiclav6B+

Amoxicillin4A+,7A 500 mg TDS 1 g if severe11D 7 days9A+

or doxycycline 200 mg stat then 100 mg OD 7 days

or phenoxymethylpen-icillin8B+ 500 mg QDS 7 days

For persistent symptoms: co-amoxiclav6B+ 625 mg TDS 7 days

NICE CG69 1.3 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

• acute otitis media • acute sore throat/acute pharyngitis/acute tonsillitis • common cold • acute rhinosinusitis • acute cough/acute bronchitis6.

Method Assess a reasonable sample of records with a diagnosis of acute rhinosinusitis (see section on Sample size). Patients with recurrent or chronic sinus infections should be excluded. Search using the following Read Codes:

H01 Acute sinusitis Hyu00 Other acute sinusitis 1BA9 Sinus headache H014 Acute Rhinosinusitis

If insufficient consultations for sinus infection are identified, consider searching using: H05z-1 Upper respiratory tract infection [only include these patients if consultation identifies sinusitis symptoms]

Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Following the audit, complete the Review Sheet.

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Data collection sheet

Patient Symptoms

recorded as present for 7 days

or more? (Y/N)

Purulent nasal discharge

recorded? (Y/N)

Antibiotic given? (Y/N)

If an antibiotic given, was there either a record of purulent

discharge or symptoms being present for 7 days or more? (Y/N)

Delayed/ back up

prescribing? (Y/N)

Amoxicillin or doxycycline or phenoxymethylpenicillin? (Y/N)

Other (record name and reason, where

given)

Total % Yes

Standard 90% 95% of prescriptions

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3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES

Background AWMSG NPI: Antibacterial items per 1,000 STAR-PUs

The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform, support and promote the prudent use of antimicrobials. Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Adult dose Duration of treatment

UTI in adults (no fever or flank pain) PHE URINE SIGN CKS women CKS men RCGP UTI clinical module SAPG UTI

Treat women with severe/or ≥ 3 symptoms1,2A,3C Women mild/or ≤ 2 symptoms AND a) Urine NOT cloudy 97% negative predictive value (NPV), do not treat unless other risk factors for infection b) If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value; nitrite, leucocytes, blood all negative 76% NPV4A- c) Consider a back-up/delayed antibiotic option20A Men: Consider prostatitis and send pre-treatment MSU1,5C OR if symptoms mild/non-specific, use negative dipstick to exclude UTI6C

Always safety net. First line: Nitrofurantoin if GFR over 45 ml/min24-5

GFR 30–45: only use if resistance and no alternative In treatment failure: always perform culture1B

nitrofurantoin8B+ 9C 10B+ 100 mg m/r BD11C Women all ages: 3 days2,12,13A+

Men: 7 days1,5C

trimethoprim7B+ 200 mg BD pivmecillinam 400 mg STAT then 200 mg TDS If organism susceptible amoxicillin14B+ 500 mg TDS Use nitrofurantoin first line as general resistance and community multi-resistant Extended-spectrum Beta-lactamase E. coli are increasing. Trimethoprim (if low risk of resistance) and pivmecillinam are alternative first line agents. Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones19 If increased resistance risk, send culture for susceptibility testing & give safety net advice. If GFR<45 ml/min or elderly consider pivmecillinam21-3, 28 or fosfomycin (3 g stat in women15,16B,17A plus 2nd 3 g dose in men 3 days later18)

Signs and symptoms of a UTI are dysuria, urgency, frequency, polyuria, suprapubic tenderness and haematuria.

SIGN 88 states: • Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters8. • Consider antibiotic prophylaxis in patients for whom infections are of such frequency or severity that they chronically impinge on function and

well-being8. When changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change8.

NICE Quality Standard 90 (QS90) published in June 2015 provides the following quality statements on UTIs in adults: • Statement 2. Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters. • Statement 4. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. • Statement 6. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with long-term indwelling catheters to prevent urinary

tract infection unless there is a history of recurrent or severe urinary tract infection9.

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Method There are two options for this audit section:

• Method 1 identifies women with urinary infection. • Method 2 identifies people with indwelling urinary catheters.

Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Following the audit, complete the Review Sheet and ensure that this includes achievement against the NICE Quality Standards. Method 1: Women with urinary tract infection Assess a reasonable sample of records with a diagnosis of UTI (female only) (see section on Sample size). Exclude pregnant females, men, children and patients with acute pyelonephritis. Please note that the advice to record the cloudiness of urine is new (2014) and may not be recorded in consultations for the first cycle of the audit. Search using the following Read Codes: R081 Dysuria K15 Cystitis K190 Urinary tract infection 1J4 Suspected UTI

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Data collection sheet (Method 1)

Patient

Cloudy urine?

(Y/N/not recorded)

≤ 2 symptoms?

(Y/N)

≥ 3 symptoms? (Y/N)

Antibiotic given? (Y/N)

Where antibiotic given,

were there either 3 or more symptoms or a positive urine dip recorded?

(Y/N)

Trimethoprim or

nitrofurantoin? (Y/N)

Other antibiotic

(record name and reason, where given)

Antibiotic course length

(number of days)

No fever or flank

pain, course

length = 3 days

(Y/N/Not applicabl

e)

If second course of antibiotics for same episode of infection,

was a midstream specimen of urine

(MSU) sent? (Y/N)

If single course of antibiotics given, leave

blank

Total

% Yes

Standard 90% 95% Locally defined

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Method 2: People with indwelling urinary catheters Identify a reasonable sample of patients who use indwelling urinary catheters (see section on Sample size). In primary care, methods to identify patients using catheters will vary between practices. Consider: (i) Electronic identification. Search for patients who have had an acute/repeat prescription for catheter items issued in the last 3

months. This report will include catheters issued for intermittent self-catheterisation. Before undertaking the audit, confirm that the patient has an indwelling urinary catheter. These are issued in small numbers unlike intermittent catheters which are normally issued in larger quantities e.g. over 28/month. (ii) Informal enquiry of nursing home and care homes or the district nursing team.

Following the audit, complete the Review Sheet. Data collection sheet (Method 2)

Patient

Antibiotics for urinary infection in the last 12

months: None, Acute (A), Prophylaxis (P)?

(A) + (P)?

Acute infection Was the latest suspected

infection investigated with dipstick testing? (Y/N/no

suspected infections)

Other reasons given for prescribing (urinary

tract) antibiotics Prophylaxis? (Y/N)

Prophylaxis History of frequent & severe

urinary infections? Catheter change prophylaxis:

history of UTI following catheter change? (Y/N/uncertain)

Total Number patients reviewed = None = A = P =

Number y/number of patients with suspected acute infections

Are these reasonable indications?

Number y/number of patients reviewed

Number y/number of patients on prophylaxis

% Yes A + P/number reviewed x 100

Standard 0% To be agreed locally. Suggest less than 10% 100%

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4. ANTIBIOTIC PRESCRIBING FOR ACUTE COUGH/ACUTE BRONCHITIS Background AWMSG NPI: Antibacterial items per 1,000 STAR-PUs The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform, support and promote the prudent use of antimicrobials. Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Dose Duration of treatment Note: Low doses of penicillins are more likely to select out resistance, we recommend 500 mg of amoxicillin. Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity.2B- Reserve all quinolones (including levofloxacin) for proven resistant organisms.

Acute cough, bronchitis CKS6

NICE 69

Antibiotic little benefit if no co-morbidity1–4A+ Consider 7 day delayed‡ antibiotic with advice1,5A Symptom resolution can take 3 weeks. Consider immediate antibiotics if > 80 years and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR > 65 years with 2 of above.

amoxicillin 500 mg TDS 5 days

or doxycycline 200 mg stat then 100 mg OD

NICE CG69: Respiratory tract infections, states that a “no antibiotic prescribing strategy” or a “delayed antibiotic prescribing strategy” should be agreed for patients with acute cough/acute bronchitis6. An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:

• if the patient is systemically very unwell; • if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar

abscess, peritonsillar cellulitis, intraorbital and intracranial complications); • if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung,

renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely; • if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one

or more of the following criteria: - hospitalisation in previous year - type 1 or type 2 diabetes - history of congestive heart failure - current use of oral glucocorticoids6.

For these patients, the no antibiotic prescribing strategy and the delayed antibiotic prescribing strategy should not be considered6.

‡Anecdotal advice suggests that the period of delay used is often less than 7 days

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NICE CG191 states that when a clinical diagnosis of community-acquired pneumonia is made in primary care, determine whether patients are at low, intermediate or high risk using the CRB65 score10. [Confusion, raised respiratory rate (30 breaths per minute or more), low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg), age 65 years or more] Delayed prescriptions When the delayed antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash;

• advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs;

• advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription6. A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date6. It has been suggested that asking the patient to return to the practice reception or a nominated pharmacy is more effective than handing the delayed/back up prescription to the patient. An agreement with the pharmacist to return uncollected prescriptions can be informative for the prescriber. Information for the patient can be issued during a consultation to support no prescribing or delayed/back up prescribing (No antibiotic/delayed prescribing patient information leaflet). Method Assess a reasonable sample of records both adults and children (between 5 years and 65 years), with a diagnosis of acute cough/acute bronchitis (see section on Sample size). Exclude from the audit patients with asthma or COPD or those who are allergic to all four agents (amoxicillin, clarithromycin, erythromycin and doxycycline). To identify the sample, perform a search using an appropriate selection of the following Read Codes:

171 Cough, Subset 1713 – 1716 productive cough, 1719 chesty cough R062 Cough Symptom NOS H051 Acute Upper Respiratory Infection; H05z-1 Upper Respiratory Tract Infection H060 Acute Bronchitis H06z0 Chest Infection NOS

Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Following the audit, complete the Review Sheet.

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Data collection sheet

Patient

Documented clinical features, both

temperature, and chest examination?

(Y/N)

Additional clinical features of severity/systemic upset

recorded? (pulse, respiratory rate or

oximetry) (2 or more = Y)

Antibiotic prescribed?

(Y/N/delayed/back up)

Amoxicillin, clarithromycin, erythromycin or

doxycycline? (Y/N)

If antibiotic supplied, does patient fit NICE guidance (systemically very unwell, symptoms

and signs of serious illness or of serious complications, or pre-existing comorbidity)

(Y/N) (provide reason)

NICE criteria6 met?

(Y/N/Other)

Total % Yes

Standard 100% No standard set 95% 90% 90%

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QUALITY OF PRESCRIBING – PRIMARY CARE 5. FLUOROQUINOLONE PRESCRIBING Background AWMSG NPI: Fluoroquinolone items as a percentage of total antibacterial items

Fluoroquinolone items per 1,000 patients Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Dose Duration of treatment

Lower respiratory tract infections

Low doses of penicillins are more likely to select out resistance1, we recommend 500 mg of amoxicillin. Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity2B-. Reserve all quinolones (including levofloxacin) for proven resistant organisms.

Acute pyelonephritis CKS

If admission not needed, send MSU for culture and susceptibility, and start antibiotics1C If no response within 24 hours, admit2C

If ESBL risk and with microbiology advice consider IV antibiotic via outpatients (OPAT)6C

Ciprofloxacin3A- 500 mg BD 7 days5A+

or co-amoxiclav4C

if lab report shows sensitive: trimethoprim3A

500/125 mg TDS 200 mg BD

7 days5A+ 14 days5A

Pelvic inflammatory disease BASHH CKS

Refer woman and contacts to GUM service1,2B+. Always culture for gonorrhoea & chlamydia2B+. 28% of gonorrhoea isolates now resistant to quinolones3B+. If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM.

Metronidazole PLUS Ofloxacin1,2,4,6B+

400 mg BD 400 mg BD

14 days 14 days

If high risk of gonorrhoea: Ceftriaxone3,5C PLUS Metronidazole6 PLUS Doxycycline1,2,4B+

500 mg IM 400 mg BD 100 mg BD

Stat 14 days 14 days

Acute prostatitis BASHH CKS

Send MSU for culture and start antibioticsC 4-week course may prevent chronic prostatitisC Quinolones achieve higher prostate levels

ciprofloxacin1C 500 mg BD 28 days1C or ofloxacin1C 200 mg BD

2nd line: trimethoprim1C 200 mg BD

Chlamydia trachomatis/urethritis SIGN BASHH PHE CKS

Opportunistically screen all aged 15-25 years1 Treat partners and refer to GUM service2,3 B+ Pregnancy2C or breastfeeding: azithromycin is the most effective option5A+ Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment 3C For suspected epididymitis in men over 35 years with low risk of STI15C (High risk, refer GUM)15C

azithromycin 4A+

or doxycycline 4A+ Pregnant or breastfeeding: azithromycin 5A+

or erythromycin 5A+ or amoxicillin 5A+

Epididymitis: low STI risk: ofloxacin or doxycycline

1g 100mg BD 1g (off-label use) 500mg QDS 500mg TDS 200mg BD 100mg BD

stat 4A+ 7 days 4A+

stat 5A+ 7 days 5A+ 7 days 5A+ 14 days 14 days

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Fluoroquinolones may also be required in response to sensitivity results where a preferred agent is not suitable due to resistance. Method Assess a reasonable sample of records per prescriber with prescription of a fluoroquinolone (see section on Sample size). Exclude prescriptions given for traveller’s diarrhoea or Helicobacter pylori eradication. Identify prescriptions for the following oral medicines:

• Ciprofloxacin • Ofloxacin

Start the searches using a 3-month window and extend it if necessary to reach the required number of cases.

Following the audit, complete the Review Sheet.

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Data collection sheet

Patient Fluoroquinolone

prescribed (name)

Pyelonephritis? (Y/N)

Pelvic inflammatory

disease? (Y/N)

Acute prostatitis?

(Y/N)

Laboratory sensitivity?

(Y/N) Other indication (Please list)

Indicated? (According to national/local guidance or lab

sensitivity) (Y/N)

Total

% Yes

Standard 90%

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6. CEPHALOSPORIN PRESCRIBING Background AWMSG NPI: Cephalosporin items as a percentage of total antibacterial items.

Cephalosporin items per 1,000 patients Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Dose Duration of treatment

UTI in pregnancy PHE URINE CKS

Send MSU for culture and start antibiotics1A Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus2C Avoid trimethoprim if low folate status3 or on folate antagonist (e.g. antiepileptic or proguanil)2

First line: nitrofurantoin if susceptible, amoxicillin

100 mg m/r BD 500 mg TDS

All for 7 days6C Second line: trimethoprim Give folate if 1st trimester

200 mg BD (off-label)

Third line: cefalexin4C,5B- 500 mg BD

UTI in children PHE URINE CKS NICE

Child < 3 months: refer urgently for assessment1C Child ≥ 3 months: use positive nitrite to guide Start antibiotics1A+ also send pre-treatment MSU Imaging: only refer if child < 6 months, or recurrent or atypical UTI1C

Lower UTI: trimethoprim1A or nitrofurantoin1A If susceptible, amoxicillin1A Second line: cefalexin1C See BNF for dosage

3 days1A+

Upper UTI: co-amoxiclav1A Second line: cefixime2A

7-10 days1A+

Pelvic inflammatory disease BASHH CKS

Refer woman & contacts to GUM service1,2B+. Always culture for gonorrhoea & chlamydia2B+. 28% of gonorrhoea isolates now resistant to quinolones3B+ If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM.

Metronidazole PLUS Ofloxacin1,2,4,6B

400 mg BD 400 mg BD

14 days 14 days

If high risk of gonorrhoea: Ceftriaxone3,5C PLUS Metronidazole6 PLUS Doxycycline1,2,4B+

500 mg IM 400 mg BD 100 mg BD

Stat 14 days 14 days

Suspected meningococcal disease PHE Meningo

Transfer all patients to hospital immediately. IF time before hospital admission, and non-blanching rash, give IV benzylpenicillin or cefotaxime1-3B+ unless definite history of hypersensitivity

IV or IM benzylpenicillin OR IV or IM cefotaxime

Age 10+ years: 1200 mg Children 1–9 yr: 600 mg Children <1 yr: 300 mg Age 12+ years: 1 gram Child < 12 yrs: 50 mg/kg

(give IM if vein cannot be found)

Cephalosporins are not recommended by PHE for the treatment of acute cough, bronchitis or exacerbation of COPD; please see PHE guidance or acute cough/acute bronchitis section of the audit.

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BNF Long-term low dose therapy may be required in selected patients [with recurrent UTI] to prevent recurrence of infection; indications include frequent relapses and significant kidney damage. Trimethoprim, nitrofurantoin and cefalexin have been recommended for long-term therapy7. Method Assess a reasonable sample of records per prescriber with prescription of a cephalosporin against national guidelines (see section on Sample size). Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Following the audit, complete the Review Sheet. Data collection sheet

Patient Cephalosporin prescribed (name)

UTI in children? (Y/N)

UTI in pregnancy? (Y/N)

Pelvic inflammatory disease? (Y/N)

Laboratory sensitive (Y/N)

Other (Please list)

Indicated? (According to national/local guidance or lab sensitivity) (Y/N)

Total % Yes

Standard 95%

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7. CO-AMOXICLAV PRESCRIBING Background AWMSG NPI: Co-amoxiclav items as a percentage of total antibacterial items

Co-amoxiclav items per 1,000 patients

Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation2:

Illness Comments Medicine Dose Duration of treatment

Acute rhinosinusitis5C CKS RS

Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days NNT152,3A+ Use adequate analgesia4B+ Consider 7-day delayed or immediate antibiotic when purulent nasal discharge NNT81,2A+ In persistent infection, use an agent with anti-anaerobic activity e.g. co-amoxiclav6B+

Amoxicillin4A+,7A 500 mg TDS 1 g if severe11D

7 days9A+

7 days 7 days 7 days

or doxycycline 200 mg stat then 100 mg OD

or phenoxymethylpenicillin8B+ 500mg QDS

For persistent symptoms: co-amoxiclav6B+ 625 mg TDS

Acute exacerbation of COPD NICE 12 GOLD

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume1-3B+. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months2.

Amoxicillin 500 mg TDS 5 days4C 5 days4C 5 days4A 5 days4A

or doxycycline 200 mg stat/ 100 mg OD

Clarithromycin 500 mg BD

If resistance: co-amoxiclav 625 mg TDS

UTI in children PHE URINE CKS NICE

Child < 3 months: refer urgently for assessment1C Child ≥ 3 months: use positive nitrite to guide Start antibiotics1A+ also send pre-treatment MSU. Imaging: only refer if child < 6 months, or recurrent or atypical UTI1C

Lower UTI: Trimethoprim1A or nitrofurantoinA-

See BNF for dosage

3 days1A+ If susceptible, amoxicillin1A

Second line: cefalexin1C

Upper UTI: co-amoxiclavA 7-10 days1A+ Second line: cefiximeA

Acute pyelonephritis CKS

If admission not needed, send MSU for culture & susceptibility and start antibiotics1C Ciprofloxacin3A- 500 mg BD 7 days5A+

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Illness Comments Medicine Dose Duration of treatment

If no response within 24 hours, admit2C If ESBL risk and with microbiology advice consider IV antibiotic via outpatients (OPAT)6C

or co-amoxiclav4C

if lab report shows sensitive: trimethoprim3A

500/125 mg TDS 200 mg BD

7days5A+ 14 days5A

Cellulitis CKS

If patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone1,2,5C. If river or sea water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment1C Stop clindamycin if diarrhoea occurs.

Flucloxacillin1,2,3,5C 500 mg QDS All for 7 days If slow response continue for a further 7 days1C

If penicillin allergic: Clarithromycin1,2,3,5C 500 mg BD

or clindamycin1,2C 300–450 mg QDS If facial: co-amoxiclav4C 500/125 mg TDS

Bites (human or animal) CKS

Thorough irrigation is important Prophylaxis or treatment: co-amoxiclav 375–625 mg TDS3C

All for 7 days3,4,5C

Human: Assess risk of tetanus, HIV, hepatitis B&C Antibiotic prophylaxis is advised2B-

If penicillin allergic: Metronidazole plus doxycycline (cat/dog/man) or metronidazole plus clarithromycin (human bite) AND review at 24 & 48hrs6C

400 mg TDS 100 mg BD4C 200–400 mg TDS 250–500 mg BD5C

Cat or dog: Assess risk of tetanus and rabies1C Give prophylaxis if2 cat bite/puncture wound; bite to hand, foot, face, joint, tendon, ligament; immunocompromised/diabetic/asplenic/cirrhotic/presence of prosthetic valve or prosthetic joint

Co-amoxiclav is also recommended for diverticulitis:

• Suitable choices include co-amoxiclav or a combination of ciprofloxacin and metronidazole (if allergic to penicillin). • Treatment should last for at least 7 day11

Method Assess a reasonable sample of records per prescriber with prescription of co-amoxiclav against national guidelines (see section on Sample size). Start the searches using a 3-month window and extend it if necessary to reach the required number of cases. Following the audit, complete the Review Sheet.

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Data collection sheet

Patient Co-amoxiclav? (Y/N)

Persistent sinusitis

(Y/N)

COPD with resistance factors?

(Y/N)

Upper UTI in children? Acute pyelonephritis?

(Y/N)

Human bite? (Y/N)

Facial cellulitis?

(Y/N) Sensitive?

(Y/N) Other (Please list) Indicated? (According

to national/local guidance or lab sensitivity) (Y/N)

Total

% Yes

Standard 95%

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START SMART AND FOCUS – HOSPITAL SETTING 8. HOSPITAL PRESCRIBING OF ANTIBIOTICS Aims To review a team’s prescribing of antibiotics with respect to:

• Documentation • Choice of antibiotic/formulary compliance • Induction guidance for new team members

Method Review approximately 15 sets of notes where an antibiotic was prescribed by a member of your team and complete the following Data Collection Sheet. Following the audit, complete the Review Sheet. Background Antimicrobial Stewardship – Treatment algorithm (taken from Antimicrobial stewardship: Start smart – then focus12

Start Smart Do not start antibiotics in the absence of clinical evidence of bacterial infection If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with life-threatening infections such as severe sepsis. Avoid inappropriate use of broad-spectrum antibiotics.

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For antibiotic(s) prescribed, document each of the following on the drug chart and in the clinical notes: clinical indication (including disease severity if appropriate), dose, route and duration or review date. Antibiotics in hospitals are often continued unnecessarily because clinicians caring for the patient do not have information indicating why the antibiotics were initially commenced and how long they were planned to be continued. This problem is compounded where primary responsibility for patient care is frequently transferred from one clinician to another. Ensuring that all antibiotic prescriptions are always accompanied by an indication and a clear duration or review date will help clinicians change or stop therapy when appropriate. In children the dose of antimicrobials should be prescribed according to the individuals weight/age – refer to local formulary or BNFc. Obtain cultures first where possible Knowing the antibiotic susceptibility of an infecting organism can help clinicians to prescribe the most appropriate antibiotic. This is useful for narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens and stopping antibiotics when cultures suggest an infection is unlikely. Cultures are also important for epidemiological surveillance. Do not delay treatment for patients with life-threatening infections e.g. severe sepsis. Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have been shown to be effective. Critical to this advice is that the single dose is administered within the 60 minutes prior to surgical incision or tourniquet inflation to enable peak blood levels to be present at the start of the surgical procedure. Intraoperative redosing is needed to ensure adequate serum and tissue concentrations of the antimicrobial if the duration of the procedure exceeds two half-lives of the antimicrobial or there is excessive blood loss (e.g. > 1500 ml in adults, > 25 ml/kg in children). A treatment course of antibiotics may also need to be given (in addition to appropriate prophylaxis) in cases of dirty surgery or infected wounds. The appropriate use and choice of antibiotics should be discussed with infection specialists for each case (see Figure 2 – Surgical Prophylaxis Algorithm12). Then Focus Review the clinical diagnosis and the continuing need for antibiotics by 48–72 hours and make a clear plan of action – the ‘antimicrobial prescribing decision’ Antibiotics are generally started before a patient's full clinical picture is known. By 48–72 hours, when additional information is available, including microbiology, radiographic and clinical information, it is important for clinicians to re-evaluate why the therapy was initiated in the first place and to gather evidence on whether there should be changes to the therapy. The five ‘antimicrobial prescribing decision’ options are Stop, Switch, Change, Continue and OPAT: 1. Stop antibiotics if there is no evidence of infection 2. Switch antibiotics from IV to oral 3. Change antibiotics – ideally to a narrower spectrum – or broader if required. Prescribers should seek expert advice when necessary 4. Continue and document next review date or stop date for IV and oral antibiotics 5. Outpatient Parenteral Antibiotic Therapy (OPAT). For paediatric patients in particular, the choice of oral antibiotic should account for factors potentially affecting adherence such as dosing frequency and palatability/taste of formulation. Palatable oral drugs in a sensible regimen (up to 3 times per day) should be used where possible and middle of the night dosing of oral antibiotics should be avoided whenever possible, especially following discharge. It is essential that the review and subsequent decision be clearly documented in the clinical notes. The decision should also be documented clearly on the drug chart12.

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Data collection sheet (adapted from Department of Health document ‘Antimicrobial stewardship: Start smart – then focus’12) Site/hospital: Ward: Specialty: Date:

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

Complete one line below for each antibiotic Documented indication or provisional diagnosis

(please specify)? (Y/N)

Guideline prescribing or justified off-guideline

prescribing IV

duration on audit

day

Total duration (IV

and oral) on audit

day for this indication

Date Hospital number

Allergy box filled? (Y/N)

Antibiotic given Route Review or stop date

on chart? (Y/N) Consultant

team Guideline for

indication Valid reason

provided

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PRIMARY CARE PROCESSES 9. DELAYED/BACK UP PRESCRIBING No antibiotic/delayed prescribing patient information leaflet When the delayed antibiotic prescribing strategy is adopted, patients should be offered:

• reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash;

• advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs;

• advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription6.

A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date6. It has been suggested that asking the patient to return to the practice reception or a nominated pharmacy is more effective than handing the delayed/back up prescription to the patient. An agreement with the pharmacist to return uncollected prescriptions can be informative for the prescriber. A delayed/back up prescription should include the time period for which it is valid. Delayed/back up prescriptions in one locality are endorsed with the following wording, which is completed by the prescriber: To the pharmacist This prescription should only be dispensed if requested by the patient. Please do not dispense until: . Please do not dispense after: . Please return this prescription to the practice, marked ‘not dispensed’, if it is not requested by the patient.

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1. Does the practice have a protocol or process for delayed/back up prescriptions? 2. What methods are employed within the practice when issuing delayed/back up prescriptions? (Tick all that apply.)

None Given directly to patient For collection at reception For collection at a named pharmacy

3. Does the practice monitor numbers of unused delayed/back up prescriptions that have been given to the patient? 4. Does the practice monitor numbers of uncollected delayed/back up prescriptions left at the reception? Are these returned to the prescriber for their information? 5. Does the practice have an agreement with the local pharmacist to return uncollected prescriptions to the prescriber? 6. How many delayed/back up 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/back up prescription during the consultation to enable appropriate use (including clear descriptions of time and reasons to initiate treatment)? 8. Describe the outcome of clinical discussion with colleagues regarding use of delayed/back up prescriptions. 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, such as post-operative infections: SP25 Post operative infection SP250 Post-op stitch abscess SP251 Post-op wound abscess SP252 Post-op intra-abdominal abscess SP253 Post-op subphrenic abscess SP254 Post-op septicaemia SP256 Post-op wound infection deep SP257 Post-op wound infection superficial L3945 Infection of obstetric surgical wound XaCl0 [X] Infection of C-Section wound following delivery Lyu6A Infection of C-Section wound following delivery What will the practice do to promote the use of these Read Codes for the identification of HCAI?

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FEEDBACK FORMS 11. REVIEW SHEET Include the following summary sheet and Data Collection Sheets. 1. How do the results of the data collection compare with the standards set? 2. What discussion/activities were undertaken as a result of the audit? 3. Provide a summary of the discussion and of the changes it has been agreed to

implement as a result of this audit. Audit cycle Prescribers are reminded that a second data collection in comparison with the standards set will support the identification of quality improvement. (See next page for document to support revalidation for your own records.) Is a second data collection of selected criteria planned, if so which? This audit was completed by: Name(s): Signature(s): Location (name and address): Please send the Data Collection Sheets and the Review Sheet to your local Head of Pharmacy and Medicines Management who will compile the local information. Please forward the response sheet to awttc@wales.nhs.uk if you would like to share your findings with the All Wales Therapeutics and Toxicology Centre. Responses will be treated anonymously and used to enable the identification of key learning points, and inform the ongoing development of the audit pack.

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12. CPD SHEET (FOR PERSONAL USE) Title: AWMSG CEPP National Audit 2013–2016: Focus on antibiotic prescribing The audits can be used to support the quality improvement required for appraisal and revalidation. They are particularly relevant to the following components of the GMC guide to Good Medical Practice:

Good Medical Practice 15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs3.

19 Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards. 20 You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection requirements. 21 Clinical records should include:

a relevant clinical findings b the decisions made and actions agreed, and who is making the decisions and agreeing the actions c the information given to patients d any drugs prescribed or other investigation or treatment e who is making the record and when3.

51 You must support patients in caring for themselves to empower them to improve and maintain their health. This may, for example, include:

a advising patients on the effects of their life choices and lifestyle on their health and well-being b supporting patients to make lifestyle changes where appropriate3.

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ABBREVIATIONS AWMSG: All Wales Medicines Strategy Group BASHH: British Association for Sexual Health and HIV BD: Twice-daily; BMJ: British Medical Journal BNF: British National Formulary CEPP: Clinical Effectiveness Prescribing Programme CKS: Clinical Knowledge Summary COPD: Chronic obstructive pulmonary disease CPD: Continued Professional Development ECDC: European Centre for Disease Prevention and Control GMC: General Medical Council GOLD: Global Initiative for Chronic Obstructive Lung Disease GUM: Genitourinary medicine HCAI: Healthcare-acquired infection HPA: Health Protection Agency MSU: Midstream specimen of urine NICE: National Institute for Health and Care Excellence NNT: Number needed to treat NPV: Negative predictive value OD: Once-daily PPV: Positive predictive value QDS: Four times a day QRG: Quick reference guide RCOG: Royal College of Obstetricians and Gynaecologists RCT: Randomised controlled trial SIGN: Scottish Intercollegiate Guidelines Network STAR-PU: Specific therapeutic group age–sex related prescribing units TDS: Three times a day UTI: Urinary tract infection

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REFERENCES 1 All Wales Medicines Strategy Group. National Prescribing Indicators 2014-2015.

2014. Available at: http://www.awmsg.org/docs/awmsg/medman/National_Prescribing_Indicators_2014-2015.pdf. Accessed Feb 2015.

2 Public Health England. Management of infection guidance for primary care for consultation and local adaptation. 2014. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377509/PHE_Primary_Care_guidance_14_11_14.pdf. Accessed Feb 2015.

3 General Medical Council. Good Medical Practice. 2013. Available at: http://www.gmc-uk.org/guidance/good_medical_practice.asp. Accessed Feb 2015.

4 European Centre for Disease Prevention and Control. ECDC key messages for primary care prescribers. 2013. Available at: http://ecdc.europa.eu/en/eaad/antibiotics/pages/messagesforprescribers.aspx. Accessed Feb 2015.

5 Royal College of General Practitioners. TARGET Antibiotics Toolkit. 2014. Available at: http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx. Accessed May 2015.

6 National Institute for Health and Care Excellence. Clinical Guideline 69. Respiratory tract infections - antibiotic prescribing: Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care (CG69). Jul 2008. Available at: http://www.nice.org.uk/guidance/cg69. Accessed Feb 2015.

7 British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary. No. 68. 2014.

8 Scottish Intercollegiate Guidelines Network. SIGN 88 Management of suspected bacterial urinary tract infection in adults. 2012. Available at: http://www.sign.ac.uk/pdf/sign88.pdf. Accessed Mar 2015.

9 National Institute for Health and Care Excellence. Quality Standard 90. Urinary tract infections in adults. Jun 2015. Available at: https://www.nice.org.uk/guidance/qs90/resources/guidance-urinary-tract-infections-in-adults-pdf. Accessed Jun 2015.

10 National Institute for Health and Care Excellence. Clincal Guideline 191. Pneumonia: Diagnosis and management of community- and hospital aquired pneumonia in adults. Dec 2014. Available at: https://www.nice.org.uk/guidance/cg191/resources/guidance-pneumonia-pdf. Accessed Jun 2015.

11 National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Diverticular disease. 2013. Available at: http://cks.nice.org.uk/diverticular-disease#!scenario:2. Accessed May 2015.

12 Department of Health. Antimicrobial stewardship: Start smart - then focus. 2015. Available at: https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus. Accessed May 2015.