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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR51

Impact of national recommendations on antibiotic prescribing in an NHS region

By J. M. Smith, H. E. Seymour, K. Snider and V. Hollyoak*

Introduction In April, 1998, the House of Lords science and technology committee concluded that there were wide variations in antimicrobial prescribing practice, that many prescriptions were unjustified on clinical grounds and that where an antibiotic was clinically indicated, the choice of agent was often inappropriate.1 The committee recommended that health authorities (HAs) should develop formularies and evidence-based guidelines, and step up their efforts in audit, feedback and educational outreach. The standing medical advisory committee (SMAC) reported in September, 1998, that the evidence that use of antimicrobials - whether appropriate or not - causes resistance was overwhelming; that there was excessive prescribing for trivial and non-bacterial infections; and that resistance was greatest where use of antibiotics was heaviest.2
The aims of the current study were to assess the early impact of these reports on antimicrobial prescribing in primary care, and to identify the need for further action by primary care groups and HAs in the NHS Northern and Yorkshire region.

Method and results Total numbers of GP prescriptions for the period January, 1998, to December, 1999, in each of the region's 13 HAs were derived from electronic PACT (Prescription Pricing Authority) for all antibacterial drugs (British National Formulary Section 5.1), for cephalosporins and other beta-lactams (BNF 5.1.2), for 4-quinolones (5.1.12) and for trimethoprim. To compare HAs, prescription volumes were adjusted for the age and sex profile of the population in which antimicrobial drugs are most likely to be used (specific therapeutic group age-sex related prescribing units or STAR-PUs).
Antibacterial prescribing frequency in 1999 was higher than the England average in all but two HAs. Prescribing rates declined sharply after publication of the House of Lords report; more than 4.9 million prescriptions for antibacterials were dispensed in the region in 1999, 11.5 per cent less than in 1998 (range 8.0-13.9 per cent).
Prescribing of cephalosporins and related beta-lactam antibiotics varied more than threefold, from 1.7 prescriptions/100 STAR-PUs in one HA to 5.5 (this HA had the highest prescribing rate in the region).
Prescribing of quinolones was low in comparison with other antibacterials, but with a twofold variation, from 0.6 to 1.2 prescriptions per 100 STAR-PUs.
Prescribing of cephalosporins and related drugs declined as a proportion of all antibacterials overall and in 11 out of 13 HAs.
Similarly, the percentage of all antibacterial prescriptions written for quinolones declined overall, and in five out of 13 HAs.
Mean trimethoprim course lengths varied widely, but the percentage of prescriptions for three days' treatment rose sharply in all 13 HAs; one HA achieved an increase from 8 per cent to 21 per cent, and the regional mean increased from 4 per cent to 14 per cent.

Focal points

  • Antibiotic prescribing has improved since April 1998 in line with national recommendations from the House of Lords select committee on science and technology and the standing medical advisory committee
  • Absolute prescription numbers decreased sharply in all health authorities studied, but levels of antibiotic usage remain high and cannot be justified by demographic or morbidity factors
  • Prescribing of cephalosporins and fluoroquinolones as a proportion of all antibiotics decreased in most, but not all HAs
  • The proportion of trimethoprim prescriptions for 3 days' treatment increased sharply in all HAs
  • These trends are encouraging but much inappropriate prescribing remains and needs to be addressed by PCGs and PCTs

Discussion Overall, antibiotic prescribing improved in line with recent recommendations. However, absolute levels of prescribing remain high, a profile which is determined only in part by demographic and morbidity factors.
Reductions in cephalosporin prescribing are welcome, as these antibiotics (including third generation agents) are increasingly associated with resistant strains of Staphylococcus aureus, Escherichia coli and Enterobacter species. Fluoroquinolones are the most powerful antibacterials to be used at significant volumes in the community and the SMAC report expressed
concern at the extent of their use and associated resistance, including methicillin-resistant S aureus (MRSA), Pseudomonas species, and many enteric pathogens. Decreased prescribing seen in five HAs is therefore welcome, but relative use of quinolones increased in eight HAs. The sharp increase in three-day courses of trimethoprim in all HAs is the greatest visible response to the House of Lords and SMAC recommendations.
Although these trends are encouraging, much inappropriate prescribing still occurs and this needs to be addressed vigorously by primary care groups and trusts. Further work in progress will explore the relationship between prescribing profiles and local antibiotic policies.

NHS Executive, Northern and Yorkshire Regional Office, Durham, UK; *Regional Public Health Laboratory Service, Leeds, UK NHS Executive, Northern and Yorkshire Regional Office, Durham, and *Public Health Laboratory Service, Leeds, UK

References

1. House of Lords select committee on science and technology. 7th Report. Resistance to antibiotics and other antimicrobial agents. London: Stationery Office; 1998. Available from: URL: http://www.parliament.the-stationery-office.co.uk/pa/ld/ldhome.htm.
2. Standing medical advisory committee. Report of sub-group on antimicrobial resistance. The path of least resistance. London: Department of Health; 1998. Available from: URL: http://www.doh.gov.uk/ smac1.htm.