Clinical Notes : Pharmacology

96. Prescribing Antibiotics

Guidelines to good prescribing

 

It is estimated that 9/10 GPs in daily practice feel pressurised by patients to prescribe antibiotics.

It is estimated that as many as 9/10 patients denied an antibiotic by their GP will seek one from the OOH service (1)

 

The higher rate of antibiotic prescribing in OOH settings is well documented.

However, antibiotic prescribing quality and standards in the OOH setting need not be worse than in daily practice (2) 

Aiming to "Prescribe the right antibiotic, at the right dose and at the right time" (3), it is recommended :

  • Prescribe only when a clear clinical benefit is likely

    • document reasons for prescribing and for denying prescription of antibiotics

  • Use simple generic antibiotics such as amoxicillin first whenever possible

    • avoid broad spectrum antibiotics ( (co-amixiclav, cephalosporins, quinolones such as ciprofloxacin) when narrow spectrum antibiotics remain effective, as they increase the risk of C.difficile, MRSA and resistant UTIs

    • document reasons for choosing broad spectrum antibiotics where appropriate

  • Make use of delayed prescribing techniques

    • document education provided for patients in the use of delayed scripts

  • Document inappropriate requests for antibiotics​

    • document reasons for denial of request for anibiotic 

    • document reasons for denial of delayed prescription

  • Do not issue repeat scripts

    • refer back to family GP for chronic medication

 
 
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Delayed prescribing

 

Recommended by NICE (1), and endorsed by Cochrane review (4)

  • Useful tool in difficult consultations 

    • Do not issue delayed script when compliance with instructions for administration is deemed unlikely

  • Can reduce antibiotic use to less than 40% with no difference in symptoms duration or satisfaction scores (5)

 

Patient Information

Doctors' judgment of patient expectations is a major influence on prescribing.

GPs may prescribe unwarranted antibiotics to avoid confrontation with patients they believe expect an antibiotic prescription.  However, patient satisfaction with the consultation does not simply revolve around whether antibiotics are prescribed. Patients rate not being rushed and being taken seriously as more important than obtaining an antibiotic (6).

Fever, cough, and the possibility of meningitis are parents' primary concerns when their children became acutely ill.

Parental concern about failing to recognise a serious problem is grounded in two linked factors: parents' sense of personal control when faced with illness in their child, and the perceived threat posed by an illness (7).

Patient information leaflets issued during general practitioners consultations for common infections (8)

  • reduce antibiotic prescriptions

  • increase the patient satisfaction rate

  • lead to a lower re-consultation rate

Few OOH services are equipped with a set of patient education leaflets.

Patient education in OOH services relies on :

  • in-consultation advice 

  • referral to selected web based information

 

Feeling Under the Weather ?

Practical advice on how to mind yourself or your family when you’re sick.  

From the HSE, GPs and Pharmacists

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http://undertheweather.ie/

 
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1. NICE NG15

Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use

Published August 2015

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2. Debets VE et al

Antibiotic prescribing during office hours and out-of-hours: a comparison of quality and quantity in primary care in the Netherlands.

Br J Gen Pract. 2017 Mar;67(656)

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3. GOV.UK

Primary care guidance: diagnosing and managing infections

Published 1 February 2013

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4. Spurling et al

Delayed antibiotics for respiratory infections

Published 30 April 2013

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5. Little P et al

Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial

BMJ 2014;348:g1606

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6. Butler CC

Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats

BMJ 1998;317:637

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7. Kai J

What worries parents when their preschool children are acutely ill, and why: a qualitative study

BMJ 1996;313:983

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8. de Bond EGPM, et al

Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review

BMJ Open : Vol.5, Issue 6, 2015 

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9. Noonan L

ICGP Forum Article

Published July 2011

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Management and treatment of common infections

Public Health England (PHE)

October 2017

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A study of patient’s knowledge and attitudes in Ireland regarding antibiotic use for uncomplicated upper respiratory tract infections (URTIs) revealed the following (9):

  • Consultation rate

    • 50% of patients when unwell try an over the counter medication first and 20% usually see the doctor when they have a URTI 

  • Expectations

    • 43% of patients attend the GP to relieve symptoms

    • 30% report “to get an antibiotic” as their reason for consulting the doctor

    • 13% of patients attend the GP to clarify the diagnosis or to get a cert for work

  • Doctor-patient relationship

    • 56% of patients do not feel that the GP is dismissive of their symptoms when they do not receive a prescription for an antibiotic

    • 26% of patients report they do feel the doctor doesn’t understand the severity of their symptoms when they do not receive a prescription for an antibiotic

  • Knowledge base

    • A significant difference in knowledge was identified between medical card (60%) and private patients (80%)

    • The same difference was noted for having heard of antibiotic resistance with 40% of medical card patients having heard of resistance compared to 95% of private patients who reported having heard of resistance

2016

Prescription of antibiotics in young children is associated with increased risk of obesity at the age of 4 years

A retrospective cohort study conducted in the United Kingdom included a representative sample of 21,000 children and showed a gradual increase in the risk of obesity at the age of four years with the number of courses of ATB received during early childhood: the relative risk is increased by 41% after 3 to 5 courses, and by 47% after 6 courses or more.

Reference :

Scott FI et al. Administration of Antibiotics to Children After Age 2 Years Increases Risk for Childhood Obesity. Gastroenterology 2016; 151 (1): 120-129.

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