Retrospective observational study of antibiotic prescribing in an out-of-hours doctors service
Authors: Shah M , Barbosa T M , Stack G , Fleming A 
Published: April 2024

Abstract

Introduction
Surveillance of antibiotic use is a key part of Ireland’s National Action Plan for Antimicrobial Resistance 2021-2025. A higher proportion of patients are reported to be prescribed antibiotics in out-of-hours (OOH) doctors services compared to daytime general practice.[1] Challenges with antibiotic prescribing in this setting include unfamiliarity between doctor and patient, lack of follow-up, access to medical history and diagnostics. Surveillance of antibiotic use in OOH services is important to develop tailored antimicrobial stewardship (AMS) interventions in this setting. In Ireland, a national Preferred Antibiotic Initiative encourages prescribers in community settings to avoid, where possible, a list of Red (less preferred) antibiotics, and choose from a Green (preferred) list, if an antibiotic is required.

Aim
To evaluate antibiotic prescribing patterns in OOH services in the Cork/Kerry region to inform future AMS interventions and to ascertain trends in prescribing of Red antibiotics.

Methods
A retrospective, observational study was conducted of all oral antibiotic prescriptions in OOH doctors’ consultations between 1st December 2019 and 31st December 2021 in the region. Data were gathered on age, gender, date and time of consultation, consultation method (in person, remote), antibiotic and its indication. Data were analysed using Microsoft Excel v2018 and SPSS v28.

Results
Overall, 17% (69,017 of 406,812) of the OOH doctors’ consultations resulted in an antibiotic prescription, with considerable variation over the study period just prior to and during the COVID-19 pandemic, ranging from 31% in December 2019 to less than 2% in April 2020 and 22% in December 2021. During the COVID-19 pandemic part of the study period (April 2020 to December 2021), 66% of antibiotics prescribed were from remote consultations, prior to which antibiotic prescribing from remote consultations was rare. Of the antibiotics prescribed, 21% were in children under 6 years old. Respiratory tract infections (RTIs) were the most common indication for antibiotics (60%). Amoxicillin was the most commonly prescribed antibiotic (40% of all prescriptions). Red (reserved) antibiotics accounted for 19% of all prescriptions, which is substantially lower than national figures reported for the study period (35-45%)[2] and the national target of less than 34% for 2021. Red antibiotics were more commonly prescribed during the overnight shifts and in older adults, and less commonly prescribed in remote consultations.

Conclusion
Low antibiotic prescribing levels during the early stages of the pandemic were not sustained. Antibiotic prescriptions from remote consultations were common. Red antibiotic prescribing proportion is lower than the national mean in this OOH service. Key opportunities for AMS are addressing the volume of antibiotic prescribing for RTIs, particularly in children, AMS in telemedicine and the higher proportion of Red antibiotics prescribed by the overnight shift doctors.
This is the first study describing indications antibiotic prescriptions in the OOH setting in Ireland. A limitation of this study is clinical presentation was not available for all OOH consultations. This would have given opportunity to assess the proportion of infectious presentations resulting in an antibiotic prescription to identify further of areas for AMS intervention.

References
1. Edelstein M, Agbebiyi A, Ashiru-Oredope D et al. Trends and patterns in antibiotic prescribing among out-of-hours primary care providers in England, 2010-14. J Antimicrob Chemother. 2017; 72: 3490-3495
2. Antimicrobial Resistance and Infection Control Team, Ireland. PCRS Greed Red Report September 2021. Available from: https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/safe-prescribing/pcrs-green-red-report-09-2021-positive-trends-and-introduction-of-rate.pdf