Prescribing
Repeat antibiotic prescriptions within the same episode of respiratory tract infection- opportunities for improvement
A cohort study investigated repeat prescriptions of antibiotics within the same episode of a respiratory tract infection (RTI). 530 English General Practices were sampled within the Clinical Practice Research Datalink. 905,964 RTI episodes were identified between March 2018- February 2022.
In adults, 19.9% (95% CI 19.3–20.5%) had at least one within-episode repeat prescription for a lower RTI, compared to 10.5% (95% CI 10.3–10.8%) for an upper RTI. In children, this was around 10% irrespective of RTI type. 48.3% of repeat prescriptions were for antibiotics from the same class as the original course.
WiseGP action:
Consider an audit of antibiotics prescribed for RTIs in your practice- if second antibiotic prescriptions within the same episode of RTI are from the same class, they are unlikely to confer clinical benefit.
In low prescribing practices, GPs have reported being supported by practice policies, opportunities for discussion with colleagues, consistent prescribing patterns within their practice and consultation time. Do you have a consistent practice-based approach to support low antibiotic prescribing- could you discuss this as a team?
Read more about the research informing this GEM:
https://www.sciencedirect.com/science/article/pii/S0163445324000690?via%3Dihub
https://link.springer.com/article/10.1186/s12875-019-1065-x
Overuse of antibiotics for insect bites
It can be difficult to differentiate inflammation from infection in patients presenting with insect bites. Between April to September 2021, the management of insect bites at 10 general practices in England and Wales was investigated.
Vital signs were rarely recorded. Only 22% were taking an antihistamine despite 45% complaining of itching. Nearly ¾ were prescribed oral antibiotics.
Antibiotics are likely to be overused for insect bite management. Patients could make more use of antihistamines and topical hydrocortisone before consulting.
WiseGP actions:
Share a post on how to manage insect bites on your practice facebook page, linking to NHS advice https://www.nhs.uk/conditions/insect-bites-and-stings/
Advise patients to trial antihistamines +/- topical steroids before initiating antibiotics, unless there are clear signs of cellulitis or systemic illness
Read more about the work by front-line WiseGPs informing these recommendations here:
https://doi.org/10.1093/fampra/cmad051
Consider a delayed rather than immediate prescription of antibiotics for sore throats
The majority of sore throats are caused by viruses. If bacterial, antibiotics typically only reduce symptoms by less than a day. Prediction scores (eg. FeverPAIN) can help target antibiotic use. A delayed script yields similar symptomatic benefit compared to immediate antibiotics, whilst lowering re-consultation rates and overall antibiotic use and not increasing the risk of complications.
Suggested WiseGP actions:
1. Consider sharing this delayed prescribing educational resource with clinicians in your practice- patients are more likely to accept a delayed prescription if they understand the reason for it, number of days to wait and symptoms to watch out for.
https://antibioticoptimisation.co.uk/using-delayed-prescribing#collapse1338561
Read more about the research informing these recommendations here: https://bjgp.org/content/72/716/136
Improve your communication about antibiotic prescribing
Better communication with patients about the benefits and harms of antibiotics and the natural history of infections, supplemented by information leaflets, can have enduring effects on reducing antibiotic prescribing.
Suggested WiseGP actions:
1. Share the RCGP target antibiotic toolkit link with colleagues and encourage use of patient information leaflets to support delayed or no prescribing of antibiotics.
https://elearning.rcgp.org.uk/course/view.php?id=553
2. Consider setting up accuRx text messages with links to appropriate leaflets on delayed/no prescribing.
Read more about the research informing these recommendations by looking at our WiseGP newsletter on antibiotic prescribing, available here:
https://www.wisegp.co.uk/newsletter/can-i-have-antibiotics%3F
CRP point of care testing to reduce antibiotic use
Point-of-care CRP testing in patients with an acute COPD exacerbation has been found to result in a 20% absolute reduction in patient-reported antibiotic consumption over 4 weeks, without impairing COPD health status. Similar testing for nursing home residents with suspected lower respiratory tract infection has also been found to safely reduce antibiotic prescribing compared to usual care. Time to prepare equipment for testing and cost are potential barriers to use and longer term effects are unclear.
Suggested WiseGP actions:
1. If CRP point of care testing isn’t available in your area, consider approaching your local commissioners for funding.
2. Suggest your GP registrar performs an audit on rescue antibiotic use for infective exacerbations of COPD on repeat prescriptions. Consider inviting those with high antibiotic use for a COPD review.
Read more about the research informing these recommendations here:
https://www.journalslibrary.nihr.ac.uk/hta/hta24150#/full-report
https://bjgp.org/content/70/696/e505
https://www.bmj.com/content/374/bmj.n2198
Avoiding antibiotics in asymptomatic bacteriuria
Asymptomatic bacteriuria (ASB) is common in residents of residential aged care facilities. Although antibiotic treatment is associated with bacteriological cure, it is associated with significantly more adverse effects.
Suggested WiseGP actions:
1. Check your practice protocol for managing suspected UTIs in patients from residential aged care facilities. Is treatment guided by symptoms rather than dipstick testing? If not, consider auditing antibiotic prescribing in this cohort and sharing an updated protocol with your practice team.
Read more about the research informing these recommendations here: https://bjgp.org/content/72/722/e649
