Shared learning database

Type and Title of Submission


Appropriate antibiotic usage in care homes


In 2008 NHS North Lancashire Primary Care Trust (PCT) initiated a joint campaign with the Association of British Pharmaceutical Industries (ABPI) to reduce the incidence of Clostridium difficile infection (CDI) within their community. Antimicrobial stewardship, through encouraging the appropriate use of antimicrobials in care homes was identified as a priority as some cases of inappropriate prescribing had been identified in local community settings. Limited access was found to guidance on appropriate prescribing at a community level. As inappropriate prescribing of antibiotics can damage the gut flora and make the patient more susceptible to CDI, antimicrobial stewardship was identified as a priority for the campaign. This case study outlines the Trusts' efforts to audit antibiotic usage within their care home settings, detailing the steps taken in planning and undertaking the audit and it outlines their proposed actions, including the development of a new antibiotic formulary.

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG139 - Infection control

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

The aim of the project was to:
- Reduce inappropriate antimicrobial prescribing within care homes in the NHS North Lancashire region - Encourage increased antimicrobial stewardship within the region - Reduce the incidence of community-acquired CDIs by 30% within the local area The project aims were delivered through the following work streams: - An audit of antimicrobial usage in care homes - Rewriting of the PCT antibiotic formulary - A communication campaign - Educational sessions for GPs, other primary care providers and care home staff.


NHS North Lancashire PCT commissions health services for residents of Lancaster, Fylde and Wyre Districts, including 175 residential care homes. An analysis of CDI incidence data at the start of this project revealed that in 2007-08 there were 454 cases of community-acquired Clostridium difficile (C. difficile).

The PCT's Infection Prevention and Control (IP&C) team conducted a series of route cause analyses (RCAs) of confirmed cases of Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemias and CDIs in care homes. They discovered that care home residents were often prescribed antibiotics on clinical diagnosis alone with no microbiological analysis or confirmation of infection taking place. The PCT found the RCAs invaluable in establishing whether a connection could be made between inappropriate antimicrobial usage and an occurrence of CDI. And the RCA findings confirmed that inappropriate prescribing of antibiotics had been taking place within the community. Based on the RCA results and data analysis the PCT set up a workstream to address inappropriate antibiotic prescribing within community settings. This workstream was incorporated into the wider PCT campaign to reduce the incidence of Clostridium difficile infections (CDIs) within the community.

Results from the RCA and data analysis also helped to inform the campaign planning, resourcing and prioritisation for this joint project with the ABPI. The PCT set a goal for the project of reducing community-acquired CDIs by 30%, to 136 cases.


The IP&C team drew on local expertise to help develop a suitable questionnaire framework and to also build their understanding of the clinical audit process. This work followed an earlier pilot audit that had been conducted in August 2008. The pilot results were assessed for learning and the questionnaire was redrafted to be more specific, while still being straightforward to complete. The audit used the principle of a point-prevalence or census study and was designed to capture a snapshot of prescribing at a particular point in time. Therefore it was conducted across the Trust on one day, and respondents were asked to quantify their actual antimicrobial usage at that point in time. To maximise the size of the sample collected, the whole team from the Trust's Quality Standards and Effectiveness Directorate assisted the audit by visiting care homes with the questionnaire, and ensuring that, as much as possible, the questionnaires were completed and returned.

Elderly people are more likely to be ill and so prescribed antibiotics during winter months, meaning that a fuller picture of routine antibiotic prescribing behaviour could potentially be gathered during a busy winter day. Therefore, the audit was carried out on 25 February 2009. The audit results were compared against the PCTs recently drafted antibiotic prescribing guidance and formulary. These results and the analysis enabled the PCT to tailor their communication efforts, the education and training being provided to GPs, other primary care providers and care home staff, and to help refine project's next steps.

Results and evaluation

A total of 126 residential and nursing homes completed and returned the questionnaire, giving a response rate of 72.4 %. Ninety residents were reported as taking antibiotics on 25 February 2009, equating to around 3-4% of all care home residents at the time of the survey. Some homes declined or did not provide full details. Calculations took this factor into account.

Chest infections were reported as the most common condition for the antibiotics prescribed during this period (37%), with treatment duration varying from 5-15 days. The penicillin group was most commonly prescribed (67% Amoxicillin). Worryingly, 31% of cases were prescribed antibiotics following telephone consultation and were not seen by a clinician. Seven residents had been prescribed cephalosporin for a chest infection, but cases of CDI are often linked to inappropriate prescribing of cephalosporin, and for this reason prescribing it goes against the PCT's antimicrobial formulary. The second most common condition for use of antibiotics was urinary tract infections (UTIs) (32%). Concern was raised again, as the most commonly prescribed treatment was cephalosporins (35%). The PCT's antimicrobial formulary recommends Trimethoprim as a first line treatment, with Nitrofurantoin as a second line and any further treatment should be determined by sensitivity studies. Duration of treatment for UTIs varied with the most common being 7 days, but the PCTs formulary recommends 3 days treatment for females. The third most common condition was the treatment of cellulitis and other related skin infections (15.5%). Penicillin's were most frequently used (67%), with a mean duration of treatment of 7 days, which is compliant with the PCT formulary.

Since the antibiotic audit, incidence of CDIs within the PCT's borders has reduced by 49%. Cases attributed to community providers had reduced by 28% in April 2010, and the PCT was on track to achieve the goal of 30% reduction for non-acute cases by 2011.

Key learning points

The audit highlighted the need for:
-A further review of prescribing protocols, and adding a greater emphasis that antibiotics should not be prescribed unless a clinical diagnosis can be established
-Further communication and education about the formulary and antimicrobial prescribing best practice, including developing education and training packages for GPs and care home staff regarding appropriate prescribing and best practice in the prevention and control of HCAIs
-Comparison of prescribing behaviour for the elderly living in their own homes to that of people within care homes to determine if more antibiotics are prescribed to residents in care homes compared to residents in the same age group living in their own homes
-A re-audit of the current work, to review and understand changes in practice and whether or not prescribing in care homes is moving closer to being compliant with the formulary.

Linking in to care homes involved in the 'end of life care' programme to detect if the homes that have this additional input have different prescribing practices.

Further analysis of the use of antibiotics for treating chest infections and UTIs to determine if practice has changed following the release of the new formulary and guidance, and the communication and training efforts.

View the supporting material


NICE handles personal information provided to the Institute in accordance with the Data Protection Act 1998. Find further details in our data protection policy.

This page was last updated: 02 July 2012

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.