New initiatives to reduce antibiotic use
Excessive and inappropriate use of antibiotics is considered to be the most important cause of bacterial resistance1 and a number of studies published have shown a relationship between antibiotic prescribing and the development of resistance, including two key studies within primary care.
Goosens et al2 investigated reports of outpatient use of antibiotics and its association with resistance in 26 European countries between January 1997 and December 2002 that provided internationally comparable data. They found that primary care penicillin use varied greatly across Europe, with correlation between increased consumption of penicillin and increased resistance to penicillin-resistant Streptococcus pneumoniae.
Costelloe et al3 conducted a systematic review of the effect of antibiotic prescribing in primary care on antimicrobial resistance in individuals. It included 24 studies: 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. The results showed that studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Therefore, individuals prescribed any antibiotic in primary care are more likely to develop bacterial resistance to that antibiotic. Resistance is greatest in the month immediately after treatment but may persist for up to 12 months. This not only increases the carriage of organisms resistant to first-line antibiotics in the population, but also creates the conditions for increased use of second-line antibiotics in the community.
How things look
In the UK, infections account for 40 per cent of consultations in primary care,4 resulting in 80 per cent of antibiotic prescribing occurring in this sector, with approximately half being used to treat respiratory tract infections.5
NHS Business Services Authority data show that antibacterial prescribing in general practice in England has continually increased since April 2004. This is in contrast to the period between April 1997 and March 2003 when antibacterial prescribing gradually decreased following the publication of the 1998 Standing Medical Advisory Committee report, “The path of least resistance”.6
However, data also show that, despite the increase, there have been some notable reductions in the use of specific antibacterial groups since the publication of guidance aimed at controlling meticillin-resistant Staphylococcus aureus7 and Clostridium difficile:8 Prescribing of cephalosporins and quinolones has decreased by 49 per cent and 35 per cent, respectively, since the financial year 2007/2008. In contrast, the number of prescriptions for tetracyclines, macrolides, trimethoprim and nitrofurantoin (included in “all other antibiotics”) in English general practice during this period has increased, owing to their inclusion as first-line recommendations in national guidance.9
Next week (18 November) will see the fifth European Antibiotic Awareness Day, when the focus will be the continuation of the “Start smart — then focus” guidance in hospitals, originally released in 2011. The day will also be used as a platform for a number of new initiatives, developed by a multiprofessional group and published as a toolkit on the Royal College of General Practitioners (RCGP) website, called “TARGET [treat antibiotics responsibly, guidance, education, tools] antibiotics”. Their aim is to emphasise the need for both primary care staff and the public to use antibiotics responsibly, and they include an antibiotic information leaflet, an interactive self assessment tool, and updated management of infection guidance.
Antibiotic information leaflet
The leaflet (see below) makes it easy for prescribers to tell patients and carers about the management of infections presenting in primary care. It addresses:
- Why antibiotics were not prescribed
- The usual length of the illness
- What the patient or carer can do to help relieve symptoms of illness
- When the patient should go back to his or her GP
- General information about antibiotics and resistance
The aim is for clinicians to use this leaflet when agreeing a no or delayed antibiotic prescribing strategy with patients or their carers. Ideally the clinician will explain the leaflet content and complete the appropriate text and tick boxes during the consultation. The clinician can personalise the leaflet with the patient’s name and clinical scenario, and, if a delayed antibiotic prescribing strategy has been decided upon, when the delayed prescription can be collected.
Self assessment checklist
The primary care self assessment tool is a guide that provides strategies that may help to optimise antibiotic prescribing in primary care by highlighting initiatives that clinicians may not have considered previously (eg, using the antibiotic information leaflet in consultations, using delayed prescriptions for upper respiratory tract infections), but which may benefit their practice. The tool has been produced in two versions, aimed at clinicians and commissioners. The tool can be accessed as many times as needed — the aim is for clinicians to review and improve their practice continually, with results being benchmarked against those from other users.
Updated management of infection guidance
The guidance contains evidence-based guidelines aimed at primary care prescribers, that can be modified by pharmacists and microbiologists to suit local service delivery and sampling protocols. All the guidelines can be accessed via www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance. The guidance is updated biannually and the current update includes child doses and dental guidance, with a supporting rationale.
Over the next three years many more initiatives, in addition to those discussed in this article, will be made available on the RCGP website and pharmacists are ideally placed to play a pivotal role in helping fellow healthcare professionals implement, deliver and analyse the impact of these initiatives within their area. This has been highlighted within the commissioning self-assessment tool, with its focus on the employment of antibiotic prescribing advisors within primary care.
The aim now is to build on the progress made in reducing the use in key antibiotics by optimising overall antibiotic prescribing further. It is essential for pharmacists to continue collaborating with their fellow healthcare professionals to promote the responsible use of antibiotics.
About the author
Harpal Dhillon, PhD, MRPharmS, is project manager, primary care unit, at the Health Protection Agency
- Bjerrum L, Cots JM, Llor C, Molist N, Munck A. Effect of intervention promoting a reduction in antibiotic prescribing by improvement of diagnostic procedures: a prospective, before and after study in general practice. Eur J Clin Pharmacol 2006; 62:913-8
- Goossens H, Ferech M, Stichele RV, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005; 51: 365(9459):579-587.
- Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- House of Lords. Fourth Report: Fighting Infection. 2002. http://www.parliament.uk/business/committees/committees-archive/lords-press-notices/pn300702-sti/.
- Department of Health. The path of least resistance. 1998. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4120729.pdf.
- Department of Health Standing Medical Advisory Committee, Sub-group on Antimicrobial Resistance Occasional Report. The Path of Least Resistance. The Stationery Office, London, UK; 1998.
- Stone SP, Fuller C, Savage J, Cookson B, Hayward A, Cooper B, et al. Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study. BMJ. 2012;344:e3005. doi: 10.1136/bmj.e3005.
- Wilcox M H. Policy development for Clostridium difficile. J. Antimicrob. Chemother. 2012 67(suppl 1): i19-i22 doi:10.1093/jac/dks203
- Health Protection Agency. Management of Infection Guidance for Primary Care for consultation & Local Adaptation. Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1279888711402 (03 August 2012, date last accessed).
Citation: The Pharmaceutical Journal URI: 11110666
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