Improving antimicrobial prescribing practice for sore ...

1 Improving antimicrobial prescribingpractice for sore throat symptoms in ageneral practice settingMohammad Razai, Kamal HussainTo cite:Razai M, Hussain antimicrobialprescribing practice for sorethroat symptoms in a generalpractice QualityImprovement Reports2017;6 CCG, London, UKABSTRACTA cute sore throat is a common presentation in primarycare settings. We aimed to improve our compliancewith national antibiotic guidelines for sore throatsymptoms to 90% in 3 months time period. Thenational guidelines are based on Centor criteria. Aretrospective audit of 102 patient records with sorethroat symptoms presenting between 1 January to 30 December 2015 showed that over 50% were givenantibiotics. Those who were prescribed antibiotics,27% did not meet NICE criteria and 85% of patientswere given immediate antibiotic prescription.

2 Centorcriteria was documented in just 2% of with correct antibiotic course length was15%. Antibiotic choice and dose was correct in 94%and 92% of cases respectively. Antibiotic frequencywas correctly prescribed in 100% of introduced interventions that included oral andposter presentations to multidisciplinary team,dissemination of guidelines through internal e-mail andsystemic changes to GP electronic patient recordsystem EMIS. This involved creating an automated sorethroat template and information page. On re-auditing of71 patients, after two PDSA cycles, compliance withNICE criteria was 87% with a significant reduction inimmediate prescribing (66%). Centor criteriadocumentation was 42%. Correct antibiotic courselength was prescribed in over 30% of cases.

3 Otherantibiotic regimen parameters (choice, dose andfrequency) were correct in 100% of initial results demonstrated that significantchanges were needed. In particular, reducing theamount of antibiotics prescribed by increasingcompliance with NICE criteria and ensuring allparameters of antibiotic prescription were correct. Weshowed that significant sustainable improvement isachievable through carefully devised automatedsystemic changes that provides critical information inreadily accessible format, and does not solely rely onprescribers knowledge and initiative. The outcome ofthese interventions are a decrease in immediateantibiotic prescription, significant increase in Centorcriteria documentation and an increase in compliancewith the correct course length of antibiotics.

4 All thesemeasures would contribute to reduction inantimicrobial resistance and improvement in patientcare in the community. Future work must focus onimproving compliance with correct antibiotic throat is a common usually self-limitingupper respiratory tract infection. Ninetypercent resolve in one week without anti-microbial therapy. However, antibiotic pre-scription for sore throat is common ingeneral 10 Inappropriate andoveruse of antibiotics has led to increasingantibiotic resistance, which is a serious threatto public health, as well as increasing costs tohealthcareservicesandgrowingantibiotic -related adverse side was a clear need to assess whetherantibiotic prescription for sore throat symp-toms complied with the national guidelinesset out by National Institute for Health andCare Excellence (NICE) and Public HealthEngland (PHE).

5 11 12 Although the guidanceis not new, no quality improvement projectto assess compliance had been undertakenfor the local population and anecdotalreports suggested high levels of antibioticprescription. This project aimed to improvecompliance with NICE and PHE antibioticguidelines for sore throat symptoms in ageneral practice setting to 90% within 3month intervention time resistance is a serious threat tohealth both at population and individualpatient key driver of increasingresistance to antibiotics is their highest rates of antibiotic prescriptionin the UK takes place in general practice andmost are for common respiratory tract infec-tions (RTIs) such as sore is also where most antibiotic treat-ment failures for RTIs, due to resistance andadverse side effects, increasingly throat symptoms is one of the mostcommon presentations in general practiceworldwide, ranging from 2-4 due to viral infections and 90% resolveRazai M, Hussain Quality Improvement Reports2017;6 AccessBMJ Quality Improvement ProgrammeProtected by copyright.

6 On November 26, 2019 by Qual Improv Report: first published as on 27 April 2017. Downloaded from in 7 days without antibiotics. Antibiotic use has modestbenefit in shortening the duration of illness with painonly reduced by 16 antibiotictherapy reduces the risk of very rare complications ofGroup A streptococcal pharyngitis such as rheumaticfever, otitis media, acute sinusitis and quinsy8thenumber needed to treat to prevent these complicationsis very , in clinical practice it is diffi-cult to determine the bacterial aetiology of sore , the current guidelines fromNICE and PHE in the UK recommend antibiotic useshould be avoided for sore throat 13 Theguidelines further recommend that clinical assessmentbased on the four Centor criteria (Lymphadenopathy;No Cough; Fever.)

7 Tonsillar Exudate)14should be usedto decide antibiotic prescription. For Centor score threeor four, 2 or 3-day delayed or immediate antibiotic pre-scription could be also statethe parameters of antibiotic prescribing : antibioticchoice, dose, frequency and duration. The recommen-dation of the duration of antibiotic use is based onRandomised Control Trial (RCT) in <18 year olds, thatshows 10 days phenoxymethylpenicillin course had lowerrelapse , antibiotic resistance ismore likely if patients received longer duration, incom-plete courses and broad spectrum antibiotics such , the guidelines recom-mend that phenoxymethypenicillin should be used astreatment of choice and a short course of clarithromycinmust be reserved for those with true penicillin guidelines have introduced evidence-basedrecommendations to reduce inappropriate antimicrobialprescription in general practice .

8 Thus, Improving com-pliance with national policies will reduce antibiotic resist-ance and healthcare costs, it will also contribute tobetter patient care by reducing antibiotic-associatedadverse side MEASUREMENTS earch tools and data collectionWe collected retrospective data for 17 clinical conditionsrelating to sore throat symptoms from general practiceelectronic patient record system EMIS for the period 1 January to 30 December 2015 using the Royal College ofGeneral Practitioners (RCGP) audit wasa total of 383 patients (154 males, 229 females). We pro-cessed the data and looked at EMIS consultation recordsof 102 patients who were selected randomly based ontheir EMIS analysisEach consultation was reviewed and data on diagnosis,Centor criteria and score, antibiotic choice, dose, fre-quency and course length were entered manually by thelead investigator on Microsoft Excel Spread Sheet.

9 Thedecision whether the NICE and PHE guidelines weremet was determined based on the standards in the afore-mentioned results showed that out of 102 consultationsreviewed overall compliance with NICE guidance(whether to prescribe antibiotics) was 73%. In total 51%of patients were prescribed antibiotics (85% immediateprescribing and 15% delayed prescribing ). OverallCompliance with PHE Primary Care guidance (all para-meters of antibiotic prescribing correct) was 15%.Antibiotic choice, dose and frequency were correct inover 90% of the cases. However, compliance with correctantibiotic course length was about 15%. Thus, reducingthe overall compliance to just 15%. Centor scoring wasused in just 2% of clinical quality improvement project was undertakenbetween January and March 2016 in an ethnicallydiverse suburban general practice in London with apopulation size of about 12,000.

10 The team undertakingthis project included GP principal partners, GP trainees, practice nurses, practice manager and the IT depart-ment of the baseline measurements was presented atthe multidisciplinary meeting that included all the keystakeholders in the practice . The issues of adherence toNICE and PHE guidelines were discussed following thepresentation. It transpired that most prescribers werenot aware of the guidelines and their , the steps involved in accessing relevantinformation was deemed too time-consuming during a10-minute consultation. The following actions wereagreed upon following an in depth discussion withmultidisciplinary prescribers were asked to document clearly Centorcriteria and scores for sore throat symptoms using thetemplate on EMIS.