Oral antibacterial drug prescribing in primary care out-of-hours services in Wales: a secondary analysis study
Authors: Al Hussain S , Deslandes R , Hodson K 
Published: April 2024

Abstract

Introduction
Antibacterial drug consumption is posing significant threats and contributing to antimicrobial resistance.[1] Individuals are frequently exposed to antibacterials, either with intentional use or unintentionally through environmental contamination, such as when drug residues are excreted into water resources.[2] To address these concerns and promote sustainability in human health and the environment, adopting rational prescribing practices is essential, especially in primary care (PC) settings where antibacterial prescribing is high. Healthcare practitioners often face various challenges when prescribing these drugs. The challenges are more pronounced in out-of-hours (OOH) encounters, where additional factors, including managing unfamiliar patients and limited safety netting, further complicate their prescribing decisions. Limited research has been conducted in these settings until recently, and the evidence in Wales is lacking.

Aim
Investigate oral antibacterial drug prescribing volume over time in PC, focusing on OOH services.

Methods
Retrospective descriptive analyses on All-Wales antibacterial prescriptions were carried out using longitudinal secondary data that were readily available when data was accessed, i.e., between the financial years 2015-16 and 2021-22. National Health Service financial years cover the period from April to March. These routinely collected data, which are not publicly available, were requested from All-Wales Therapeutics and Toxicology Centre and extracted from the Comparative Analysis System for Prescribing Audit (CASPA), an electronic-based system used by Wales Shared Services Partnership to maintain records of PC prescriptions dispensed in the community. Number of items prescribed during daytime and OOH services was obtained for all antibacterials and the 4Cs associated with Clostridioides difficile infections (co-amoxiclav, clindamycin, cephalosporins, quinolones). Data were processed and adjusted per 100,000 population using mid-year estimates, and the overall percentage changes in volumes were calculated.

Results
The total number of items prescribed in PC was 14,997,291, of which 1,265,499 (8.44%) were 4Cs. For OOH services, the total number of items was 445,339 (3% of PC); 4Cs accounted for 50,527 (11.35% of OOH, 4% of PC 4Cs). OOH antibacterial and 4Cs prescribing represented relatively small proportions over the 7-year period in relation to PC, ranging between 2.7%-3.2% and 3.6%-4.2%, respectively. Data revealed a decline in prescribing in PC as a whole and OOH services, reaching its lowest in 2020-21 when COVID-19 hit. Throughout the study, prescribing volume per 100,000 population decreased by 20.7% in PC and 31.2% in OOH services when examining all oral antibacterials, and by 40.9% and 38.5%, respectively, when examining 4Cs. Data from 2021-22 indicated a rise (14% in PC; 19% in OOH) in total antibacterial prescriptions from the previous year.

Conclusion
To our knowledge, this study is the first to examine oral antibacterial prescribing volume in Wales OOH services, revealing downward trends of prescribing in PC generally and OOH services. The reduction in PC was primarily driven by daytime prescribing, where most consultations usually take place. Various factors may contribute to this reduction, warranting further exploration of antimicrobial stewardship activities. Additionally, investigating COVID-19 potential impact on prescribing and its sustainability is crucial. Qualitative interviews are ongoing with lead antimicrobial pharmacists in Wales, to understand the observed trends and uncover their underlying driving causes.

References
1. Bell BG, Schellevis F, Stobberingh E et al. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis. 2014;14(1):13.
2. Ben Y, Fu C, Hu M et al. Human health risk assessment of antibiotic resistance associated with antibiotic residues in the environment: A review. Environ Res. 2019;169:483-493.