Reducing the risk of C Difficile by reviewing the prescribing of high risk antibiotics

To identify and audit high risk antibiotic prescribing over the past twelve months across 20 GP practices in Fylde and Wyre CCG:
- To reduce the prescribing of high risk antibiotics linked with C Difficile Infection (CDI)
- To promote and improve antibiotic prescribing in accordance with local guidelines

It can be seen from the graphs in the supporting material that there is a twofold difference in the number of items prescribed by practices. In addition, 50% of practices prescribed more antibiotics than the previous year. QIPP indicators: An increase in the number of items prescribed might be expected in Q3 &Q4 (October to March), however 9 practices appear to be prescribing at a high level throughout the year.

High risk antibiotic prescribing: There is an eight fold difference in the prescribing of high risk antibiotics. Again, 50% of practices prescribed more high risk antibiotics than the previous year. QIPP indicators: Some practice have shown a steady reduction in the use of high risk antibiotics, the momentum of which needs to continue.

The audit identified prescribing over 12 months of:
- Broad-spectrum antibiotics
- Topical antibiotics
- The number of people prescribed >5 courses
Audit question: What is the quality of the prescribing of high risk antibiotics across GP practices?
The audit standards were difficult to set due to prescribing for several conditions regularly seen in primary care, but are not on the formulary. Since these are accepted treatment for the condition, e.g. diverticulitis, a low standard was set. The outcomes of the audit may indicate that wider discussion regarding appropriate prescribing is needed.
Target Part 1 - the prescribing of high risk antibiotics is below the 25th national centile (Q2) Below 4.74% Part 1 - the prescribing of topical antibiotics is not carried out unless for accepted conditions not in formulary or at the request of dermatologists. 0 patients Part 1 - there is minimal prescribing of high risk antibiotics for people with low co-morbidities (in younger age groups) 30%

Part 2 - the prescribing of high risk antibiotic is according to formulary or lab sensitivity 50%
Additional recommendations:
1. The prescribing of high risk antibiotics is not on more than one occasion in 12 months, unless at the advice of microbiologists.
2. The prescribing of antibiotics should always have a diagnosis recorded.
3. The prescribing of high risk antibiotics with PPIs
Audit method: Firstly, a standard data set was collected. Each practice carried out their own audit, based on a sample size of 50 patients for small practices or 100 patients for all other practices. The data included:
- Number of patients prescribed a high risk antibiotic in the past twelve months
- Number of issues of high risk antibiotic in the past twelve months
- Age of patient
- Antibiotic prescribed
- Number of patients also prescribed a PPI as well as a high risk antibiotic in the past twelve months. Searches were also carried out to identify the numbers of people receiving prescriptions for topical antibiotics and several high risk antibiotic courses. The data was recorded, percentages of antibiotics and numbers of patients also prescribed a PPI were calculated. The second part of the audit used a sample of 100 issues of antibiotics, to determine:
- Indication recorded
- Formulary adherence
- Infection sampling
- Prescribing linked to sensitivity reporting
- Contact with microbiologists
- Conditions being treated

Results - Part 1 The first part of the audit was an overview of the prescribing of high risk antibiotics (cefalosporins, quinolones and co-amoxiclav) in the past twelve months. Fylde and Wyre population = 150656 5122 courses of high risk antibiotics were prescribed in the past year 3909 (2.8%) patients were prescribed a high risk antibiotic in the past year 1334 (33%) of these were also on a PPI 194 people were prescribed high risk antibiotics for prophylaxis (usually UTI) 2153 people were prescribed a topical antibiotic.

Results - Part 2 The second part of the audit looked at the conditions that the antibiotics were prescribed for and whether these had been prescribed according to the formulary. Results for 20 practices (a sample of 50/100 issues were audited for each practice):
Percentage of antibiotics in formulary = 18%
Percentage of lab tests sensitive for antibiotic prescribed = 5%
Percentage of antibiotics indicated = 23%

1. Prescribing for indicated high risk antibiotics in formulary conditions such as prostatitis or when sensitivities were reported was well documented and a clear rationale was provided.
2. There were a wide range of conditions not in the formulary and where high risk antibiotic prescribing was not appropriate. Standard antibiotics should have been prescribed if treatment was needed. X practices had particularly low results.
3. Lab testing was not carried out consistently where this was appropriate e.g. for UTI/LRTI.
4. From the case studies it was noted that microbiologists were not frequently contacted for UTI/LRTI as advised in the formulary. difficult to contact microbiology and also that specimen results do not list all sensitivities so GPs encouraged to ask ahead of prescribing a high risk AB.
5. UTI was the most frequently identified condition that was poorly managed and where high risk antibiotics could have been avoided.
6. There was evidence to suggest that: nurses may in a few cases have made assessments of patients and then asked GPs to prescribe; there was some prescribing via phone; on some occasions the patient has asked (insisted) for a particular antibiotic.
7. There was evidence to suggest that no diagnosis had been recorded for a small number of instances of prescribing.