Antibiotic Prescribing in

Primary Care

Louise Tweddell/Sandra Martin

Antimicrobials Pharmacist
Calderdale and Huddersfield NHS Trust
 Aims and Objectives
• To raise awareness of antibiotic
prescribing
• To raise awareness of how antibiotic
prescribing is analysed and presented
• To consider strategies to influence
antibiotic prescribing
• To practice use of patient-oriented
strategies
 Plan
• Quick quiz
• Prescribing data interpretation
• Strategies to influence antibiotic
prescribing -Patient, prescriber,
secondary care
• Role play
 Why bother?
 One third of hospital in-patients are prescribed
antibiotics
 Increasing incidence of C.difficile associated
disease (CDAD)
 Continued emergence of resistant organisms
 Increasing concerns about healthcare
associated infections
 Legal requirement for NHS bodies to have an
antimicrobial prescribing policy in place
Antibiotic resistance is a major
threat to public health?
Strongly agree – this is clearly outlined
in Getting Ahead of the Curve 2002.
 Newly identified infectious diseases and
pathogens: some examples
Source: World Health Organisation 1999

2003 SARS 1991 Guanarito virus

1999 Nipah virus
1997 H5N1 (avian flu)
1996 nvCJD
Australian bat lyssavirus
1995 Kaposi’s sarcoma virus
1994 Sabia virus
Hendra virus
1993 Hantavirus pulmonary
syndrome
1992 Vibrio cholerae O139
1989 Hepatitis C
1988 Hepatitis E
Human herpesvirus 6
1983 HIV
1982 Escherichia coli O157: H7
1980 Human T-lymphotropic virus
1977 Campylobacter jejuni
1976 Cryptosporidium parvum
Legionnaires’ disease
Ebola
 There’s a pipeline problem…..
Wenzel RP. N Engl J Med 2004; 351: 523–6

 In the 1930s and 1940s there were four novel classes of

antibiotics approved (sulfonamides, beta-lactams,
aminoglycosides, and chloramphenicol)
 In the 1950s and 1960s six new classes became available
(tetracycline, macrolides, glycopeptides, rifamycins,
quinolones and trimethoprim)
 In the 1970s, 1980s and 1990s no new classes were
licensed
 Since 2000 two new classes have been licensed (the
oxazolidinones and the cyclic lipopeptides (daptomycin)
“… it costs the same to develop an antibiotic as it does other drugs. But these
drugs are given for 1–2 weeks compared to many (other) drugs such as the
lipid lowering agents which are lifelong. Hence the returns are lower…” Nelson
R. Lancet 2003; 362: 1726–7
 Prescribing in primary care
Irene Petersen and Andrew C. Hayward* on behalf of the SACAR Surveillance Subgroup
Journal of Antimicrobial Chemotherapy (2007) 60, Suppl. 1, i43–i47

Top 10 leading indications for antibacterial

prescribing
1. upper respiratory tract infection (RTI)
2. lower RTI
3. sore throat
4. urinary tract infection
5. otitis media
6. conjunctivitis
7. vague skin infections without a clear diagnosis
8. sinusitis
9. otitis externa
10. Impetigo
– General Practice Research Database
Consultation rates for respiratory infections
have increased over recent years…?

False. The standardised consultation

rate for any respiratory infection actually
fell by 35% from 1994 –2004. Laryngitis
consultations fell by 43% and sore
throat consultations by 43%.
Ashworth M et al. Why has antibiotic prescribing for respiratory
illness declined in primary care? J Pub Health 2004:26: 268-
274.
 SMAC identified 4 things that every
GP can do to make a difference:
• No prescribing of antibiotics for simple
coughs and colds.
• No prescribing of antibiotics for viral sore
throats.
• Limit prescribing for uncomplicated cystitis
to three days in otherwise fit women.
• Limit prescribing of antibiotics over the
telephone to exceptional cases.
 Antibiotic prescribing levels are
decreasing in the UK?
Trends in usage of antibacterials in general practice in England
8

5
ADQs per Inhabitant per year

0
Ap r.93- Ap r.94- Ap r.95- Ap r.96- Ap r.97- Ap r.98- Ap r.99- Ap r.00- Ap r.01- Ap r.02- Ap r.03- Ap r.04- Ap r.05- Ap r.06- Ap r.07-
M a r.94 M a r.95 M a r.96 M a r.97 M a r.98 M a r.99 M a r.00 M a r.01 M a r.02 M a r.03 M a r.04 M a r.05 M a r.06 M a r07 M a r08
P e n icillin s T e tra cyclin e s M a cro lid e s
Ce p h a lo sp o rin s e tc S u lp h o n a m id e s & trim e th o p rim Q u in o lo n e s
M e tro n id a z o le & tin id a z o le All o th e r a n tib a cte ria l d ru g s
NB If n o ADQ is a va ila b le , th e DDD w a s u se d in ste a d
Antibacterial Drugs Prescribing in General Practice
in England (April 2007 - March 2008)

Benzylpenicillin &
All Others Phenoxymethylpenicillin
4% 7%
Quinolones
Sulphonamides And 4% Penicillinase-Resistant
Trimethoprim Penicillins
9% 10%

Macrolides
12%

Tetracyclines
8% Broad-Spectrum Penicillin
37%

Cephalosporins and other Beta-

Lactams
9%
High antibiotic prescribing will result
in high antibiotic resistance….?
Strongly agree. There is emerging
evidence such as that in the reference
below that this is the case.
Livermore, D. Minimising antibiotic resistance. Lancet Infectious Disease
2005:5: 450-459.
Reducing antibiotic use will result
in reduced resistance…?
• Neutral – Reducing the prescribing of
antibiotics only sometimes results in a
measurable reduction in resistance.
 Quinolone Prescribing
 SMAC 1998 - concerned about increasing use of
ciprofloxacin in RTIs (40% of prescribing)
 Considered its antibacterial spectrum to be more
appropriate against urinary pathogens.
 HPA advise avoiding broad spectrum antibiotics
(such as co-amoxiclav, quinolones and
cephalosporins) when standard and less
expensive antibiotics remain effective, as they
increase the risk of C. difficile, MRSA and resistant
UTIs.
 Indications for Quinolones in the
Formulary
 Acute pyelonephritis
 Acute prostatitis
 Uncomplicated UTI with positive nitrites or
leucocyte esterase
 Diabetic foot ulcer infections (deep infections
including osteomyelitis)
 Acute exacerbations of COPD - THIRD line
for use in proven pseudomonal infections.
 Use of quinolones has been
25,000,000
increasing in recent years?
Ciproflox a cin O flox a cin Norflox a cin Le voflox a cin Na lidix ic Acid M ox iflox a cin

20,000,000

15,000,000
NIC (£)

10,000,000

5,000,000

0
Apr.93- Apr.94- Apr.95- Apr.96- Apr.97- Apr.98- Apr.99- Apr.00- Apr.01- Apr.02- Apr.03- Apr.04- Apr.05- Apr.06- Apr.07-
M a r.94 M a r.95 M a r.96 M a r.97 M a r.98 M a r.99 M a r.00 M a r.01 M a r.02 M a r.03 M a r.04 M a r.05 M a r.06 M a r.07 M a r.08
 Ciprofloxacin resistance in
Escherichia coli has doubled in the
last 10 years
False. It has actually increased more
than four-fold and ciprofloxacin
resistance is now a real problem.
Ciprofloxacin resistance rose from
about 4% in 1998 to about 22% in
2007.
HPA Antimicrobial Resistance and Prescribing in England, Wales and
Northern Ireland. July 2008.
 What antibiotic do you consider
high risk for Clostridium difficile?
 Penicillin
 Ciprofloxacin
 Gentamicin
 Augmentin
 Tazocin
 Common risk factors for MRSA
and CDAD
 Prior antibiotic usage

 Elderly

 Prior hospitalisation
 The evidence
 Prudent prescribing is important in reducing
C.difficile associated disease(CDAD)
 Reduction in the use of broad-spectrum
antimicrobials can play a part in reducing
MRSA rates (esp quinolones, macrolides, 3rd
G cephs)
 Antimicrobial management is a key
component of infection prevention and control
 Overwhelming evidence that over prescribing
and inappropriate usage is the main driver of
increased resistance to antimicrobials
CDAD and Antibiotic classes
 Antimicrobials to avoid where
possible
 Second and third generation
cephalosporins (cefaclor, cefuroxime,
cefixime and cefpodoxime)
 Clindamycin
 Quinolones (027 strain of C. difficile) eg.
ciprofloxacin, levofloxacin, moxifloxacin,
ofloxacin, norfloxacin
 Long courses of amoxicillin, ampicillin, co-
amoxiclav or co-fluampicil
RR associated with specific classes of antibiotic
and MRSA infection or colonization

Highest risk with Quinolones-RR 3

Glycopeptides-RR 2.9
Cephalosporins-RR 2.2
Other beta-lactams- RR 1.9

Tacconelli, E. et al. J. Antimicrob. Chemother. 2007

MRSA suppression treatment
Mupirocin Nasal ointment 2% to both
nostrils TDS
AND
Chlorhexidine gluconate 4% wash OD
(on the first day used as a shampoo)
for 5 days
 Data Interpretation
1. Using the graphs at PCT level give a brief
explanation of the prescribing picture shown by the
PCT compared to the SHA.
2. Using the graphs at practice level give a brief
explanation of the prescribing picture shown by the
practice compared to other practices.
3. Identify any problems with antibiotic prescribing the
data throws up for the practice.
4. Suggest additional data that you might find useful in
assessing the antibiotic prescribing picture.
MEASURES OF PRESCRIBING

Prescription Item
 A single item on a prescription,
irrespective of quantity. Useful as a
measure of frequency of prescribing.
 Mrs Edith Jones Prescription 1
46 Cemetery Road
23/8/40 Anytown

Atenolol 50mg tab

1 daily x 56

FOR TEACHING PURPOSES

Aspirin 75mg Disp. tabs
1 daily x 112

J Jones 7/10/08 ONLY

Dr J Jones 846230
15 Cecil Street
Grimplace
01234 555444
 Michael Williams Prescription 2
88 Court Road
15/6/76
Anytown

Atenolol 50mg tab

FOR TEACHING PURPOSES

1 daily x 28

Aspirin 75mg Disp. tabs

1 daily x 28

ONLY
K Newlove 7/10/08

Dr Karen Newlove 846230

43 Main Road
Niceplace
01234 555444
 PATIENT DENOMINATORS
 Patient
 Prescribing Unit
 ASTRO-PU (Age Sex Temporary Resident
Originated Prescribing Unit)
 STAR-PU (Specific Therapeutic group
Age-sex Related Prescribing Units)
Prescribing Units (PU)
 No of Pus = (no of patients under 65) +
(no of patients over 65) x3

 Dr Smith has 1500 patients, 600 are over 65

years old. What is the number of
prescribing units?
 Dr Jones has 1500 patients, 400 are over 65
years old. What is the number of
prescribing units?
 Prescribing Units
 Dr Smith has 1500 patients, 600 are over 65
years old.
900 are under 65
(600 x 3) + 900 = 2700 prescribing units
 Dr Jones has 1500 patients, 400 are over 65
years old.
1100 are under 65
400 x 3 + 1100 = 2300 units
Specific Therapeutic Group Age-Sex
Related Prescribing Units (STAR-PU)
Devised from the COST of drugs in
specific therapeutic areas accounting for
85% of prescribing
 FINANCIAL TERMS
Net Ingredient Cost (NIC)
 The basic price of a drug (i.e. list price or
Drug Tariff Price). This will be the same
wherever the drug is prescribed.
Actual Cost
 The actual cost to the NHS i.e. after the
removal of discount taken from pharmacies,
and addition of container allowance, but not
professional fees.
 What strategies can we use to
improve antibiotic prescribing?
1. Identify issues within secondary care that
you might want to address which would
have a positive effect on the prescribing
trends.
2. Explore solutions aimed at Prescribers
which you might consider would have a
positive effect on the prescribing picture.
3. Explore solutions aimed at patients which
you might consider would produce a positive
effect on the prescribing picture.
Primary/secondary care liaison

• Formulary production
• Ensure appropriate laboratory testing
• Key links: Hospital Antibiotic Pharmacist/
Consultant
• Consultant Microbiologist-led Antibiotic
workshops
• Joint audit
 Role of microbiology
Tan TY et al. J Antimicrob Chemother 2003:51:379-84.

• GPs working in an area where the

laboratory routinely reported cephalosporin
susceptibilities were FOUR times more
likely to select an oral cephalosporin as
first line empirical therapy than were GPs
in other areas.
Prescriber solutions?
Factors responsible for inappropriate
antibiotic use
Hooton TM and Levy SB. Am Fam Physician 2001: 63:1087-1096.

Physician – provider Factors:

• Real or perceived patient – parent pressure
• Economic concerns for self eg. Loss of clientele.
• Litigation concerns.
• Physician fallibility
• Inadequate knowledge
• Cognitive dissonance (knowledge but fails to
act on it)
• Provide information
• Monitoring
• Evidence– discount myths!
• Facilitate Change
• Prescribing Information
• Audits
• Facilitation Pack/Resources
• QOF Target/Incentive Schemes
• Communication & Feedback
• Newsletters
• Interactive workshops - Local Opinion
leaders
• Educational Outreach visits
• Re-audit Standards
• Evaluation of Approach – eg critical
incident discussion
 Printed Guidance
Coenen, S et al. J Antimicrob Chemother 2004:54:661-72
• Evidence suggests that guidance ALONE
does not affect prescribing behaviour in
relation to antibacterials among GPs and
dentists

Role of formularies
Little evidence on the use of formularies to
reduce antibacterial prescribing in the primary
care setting
• Carbon C, Bax RP. BMJ 1998:317:663-5.
 Primary Care Antimicrobial
Guidelines
• accessible on line at
http://intranet.cht.nhs.uk/formulary/.
Topics covered
 Upper Respiratory Tract Infections
 Lower Respiratory Tract Infections
 Meningitis
 Urinary Tract Infections
 Genital Infections
 Gastro-intestinal Infections
 Viral Infections
 Skin/Soft Tissue Infections
 Eye Infections
 Parasitic Infections
 Academic Detailing

• Conflicting data on the value of educational

outreach visits -“academic detailing”
• May be of benefit in overuse?
• In increasing use of first line agents?? (2 of 4)
• Not clear whether it is better by one profession than
another

• Coenen, S et al. J Antimicrob Chemother 2004:54:661-72

• Seager JM et al. Br Dental J 2006:201:217-22.
 Audit and feedback
• Conflicting evidence on the use of feedback
materials alone (eg PACT data),
anonymous comparison with other data for
other doctors, and educational material
promoting optimal prescribing practices

• Arnold SR, Straus SE. Cochrane Database of Systematic Reviews 2005: issue 4.
Patient solutions?
Factors responsible for inappropriate
antibiotic use… cont
Hooton TM and Levy SB. Am Fam Physician 2001: 63:1087-1096.

Patient – Parent Factors:

• Anxiety
• Misconceptions about
• What antimicrobials do
• Fever requires antibiotics
• Belief in healing power of physician
• Economic concern for patients (missing work)
 What strategies can we use to
improve antibiotic prescribing?
 The patient consultation
 Patient information leaflets
 Patient decision aids
 Use short courses where effective
 No prescription or delayed prescription
 The patient consultation
 Treat the individual
 Ask about patient expectations
 Offer symptomatic relief, e.g. antipyrexia
and analgesia
 Patient information leaflets
 Explain the likely course of infection and
give a patient information leaflet.
cks.library.nhs.uk
 Written materials
Mason J et al BMJ 2001:323:1096-1097.

 colds, flu, chest cold,

runny nose and sore
throats were caused by
viruses and did not require
antibiotics.
 less sure that bronchitis
and ear infections were
caused by a virus and
more thought that these
infections should be
treated with antibiotics
Patient decision aids
Use of antibiotics - otorrhoea
Use of antibiotics – bilateral AOM
Harms of antibiotics
 No prescription or delayed
prescription
• providing a prescription
and asking the patient
not to redeem it unless
symptoms persist.
Eg.
• Otitis media
• Acute Sinusitis
• Upper Respiratory tract
infections
• Acute Infective
conjunctivitis
 Use of Delayed Prescriptions -
Patient Feedback
• "I like the fact that a delayed prescription
gives me the chance to decide if I (or my
child) need antibiotics" - 82% agree
• “It is time saving” - 78% agree
• "If I experience similar symptoms again I
would visit the same GP"- 93% agree
• 87% are "willing to accept a delayed
prescription for myself (or child) in the future”
 Use of Delayed Prescriptions -
Patient Feedback
• There is a significant expectation (55%) that
antibiotics will be prescribed.
• 23% of patients actually requested
antibiotics of their doctor
• 38% of patients would have felt short
changed if they had not received a
prescription.
• 69% of patients cashed in the delayed
prescription, 60% of these were within the first
two days after visiting the surgery.
 Common RTIs
NICE. Respiratory tract infections. CG69. July 2008
 Adults and children aged over 3 months presenting with the
following conditions should be offered a clinical assessment,
including a history and, if indicated, an examination to identify
relevant clinical signs:
 Acute otitis media
 Acute cough/acute bronchitis
 Acute sore throat
 Acute rhinosinusitis
 Common cold
 A no-antibiotic or a delayed-antibiotic prescribing strategy
should be agreed for patients with these conditions
 Patients’ concerns and expectations should be determined and
addressed
Nice advice
Natural history of illness
Is it working?
 Does local enhancement of a national
campaign to reduce high antibiotic prescribing
affect public attitudes and prescribing rates?
• .. did not appear to influence the public’s
attitudes towards antibiotic prescribing in an area
of high prescribing.
• “Assessment of the attitudes of those who had
definitely been exposed to the campaign and
greater promotion of the campaign and its
messages to, and by GPs, might be more likely to
produce a demonstrable change in attitudes.”
• Parsons S et al. Eur J Gen Pract 2004:10:18-23.
 The public’s attitudes to and compliance
with antibiotics
Cliodna A. M. et al. Journal of Antimicrobial Chemotherapy (2007) 60,
Suppl. 1, i63–i68
• a third of the public still believe that antibiotics work
against coughs and colds…

• A large Department of Health sponsored household

survey demonstrated that ….
“those with a greater knowledge about antibiotics
were no less likely to be prescribed an antibiotic, and
although those with increased knowledge about
antibiotics were more likely to complete a course they
were also more likely to self-medicate and to keep
left-over antibiotics”.
 Summary
– What can be done?
“Multifaceted strategies and
implementation methods are
likely to be more effective than
single interventions”.

NHS Centre for Reviews and Dissemination. Getting

evidence into practice, Effective Health Care 1999; 5(1):1-
16.
 Summary
• Prescribing antibiotics is common practice.
 Overuse of antibiotics poses a serious threat to public
health.
 Few new antibiotics are being developed
 Antibiotic use was declining, but over the past few years it
has been slowly but consistently rising again.
 Antimicrobial use must be weighed against the harms of
treatment.
 Alternative management strategies to issuing an immediate
prescription should be considered for a number of common
infections.
• Try flexible multi-faceted management strategies.
 Questions to consider
 Do I need to rethink when I routinely use
antibiotics?
 Can I employ strategies other than
prescribing an antibiotic in some commonly
seen infections?
 How can I better explain the harms versus
benefits to my patients?
 Should I consider the use of a delayed
prescription strategy in some patients?
‘Antibiotics should be thought of like oil,
a non-renewable resource to be
carefully husbanded’
(Del Mar. BMJ 2007;335: 407–408)