An audit of high oral broad-spectrum antibiotic prescribing within a Bristol-based general practice
Authors: Chan C K Y , Shah P 
Published: November 2022

Abstract

Introduction
Oral broad-spectrum antibiotics (OBSAs), defined here as cephalosporins, fluoroquinolones and co-amoxiclav, are associated with AMR and adverse events in the elderly (ie. over 60s). Despite stringent national and local system-wide approaches aimed at reducing their inappropriate prescribing, the regional care commissioning group (CCG) alerted that OBSA prescribing within this practice between February and August 2021 at up to 14% of antibiotics prescriptions, has exceeded both the national and CCG limit which is 10%.1,2 This necessitates minimising OBSA prescribing among the over 60s in this practice.

Aim
To identify the percentage of inappropriate prescribing of OBSAs at Downend Health Group and investigate factors leading to their high prescribing rates using the following standard: 0% of OBSAs were prescribed inappropriately within a 7-month period, which includes prescribing outside of regional guidance without specialist input or evidence of infection.

Methods
The study design, data collection and analysis were conducted by the foundation trainee, supervised by the lead pharmacist. A retrospective population reporting search was run on our prescribing system (EMIS) to identify active patients over 60 years prescribed OBSAs between February and August 2021. To produce our IT data collection tool, the inclusion criteria were ages over 60 years, name of antibiotic, location of consultation, authorising user and prescribing indication. The search was piloted with 235 patients and narrowed down to 208 patients by adding acute (ie. one-off) prescription type as another inclusion criteria. Inactive and deceased patients at the time of the search were excluded. Data from the search was then compared against the regional guidance and further analysed. Ethics approval was not required for this audit.

Results
The results did not meet the set standard. Out of 208 active patients over 60 years prescribed OBSAs on acute during the defined period, 107 (51%) prescriptions were inappropriate. 63 (30%) prescriptions had the wrong antibiotic choice whereas 44 (21%) prescriptions had no evidence of infection. The top conditions with inappropriate OBSA prescriptions include UTI (22%), diverticulitis without pyrexia (15%) and cellulitis (11%). Furthermore, remote consultations had higher inappropriate prescribing as the error bar comparison between face-to-face vs remote consultations on influencing inappropriate OBSA prescribing showed statistical significance (p &lt; 0.05). Although GPs authorised 188 (90%) of OBSA prescriptions, 15 out of the 20 (75%) OBSA prescriptions authorised by non-GPs were inappropriate. Despite the similar rates of appropriate (51%) and inappropriate (49%) OBSA prescribing among the GPs, four GPs had disproportionately high inappropriate OBSA prescribing.

Discussion/Conclusion
Further to excluding deceased patients from the sample size, another limitation is the lack of investigations to rule out the confounding variables of researcher bias and the potential influence of lockdowns in the high levels of remote consultations. Regardless, the results suggest that the practice can meet the national and CCG OBSA prescribing limit by reducing inappropriate OBSA prescribing from 51% to 0%. Following an internal clinical governance meeting with the authorising users, we will update relevant internal EMIS alerts and antimicrobial stewardship protocols, followed by a reaudit 7-months after implementing the updates.

References
1. Nice.org.uk. 2015. Overview | Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng15/ (accessed 14 March 2022).
2. Remedy.bnssgccg.nhs.uk. 2021: REMEDY. Available at: https://remedy.bnssgccg.nhs.uk/media/5026/antimicrobial-rx-guidelines-for-bnssg2019-version-83-including-covid.pdf/ (accessed 14 March 2022).