Actions to avoid inappropriate use of Co-amoxiclav in A&E

The work described here was presented at the Pharmacy Together 2019 conference.

Co-amoxiclav is a broad-spectrum antibiotic in the ‘watch’ group of the modified WHO AWaRe categories from NHS Improvement England. A 2018-19 CQUIN target was to increase the proportion of ‘access’ group antibiotics by ≥3 percent, compared with ‘watch’ and ‘reserve’ antibiotics. Furthermore, the importance of this has been detailed in the 5-year action plan for tackling antimicrobial resistance (AMR) 2019-24. 

Co-amoxiclav should be limited in order to minimise the spread and emergence of AMR, thereby improving long term patient outcomes. Annual antibiotic audit is recommended in the Start Smart – Then Focus antimicrobial stewardship toolkit to promote safe and appropriate use of antimicrobials. However, at Nottingham University Hospitals (NUH) this does not include outpatient prescribing in the Emergency Department (ED). 

Our objective was to determine whether co-amoxiclav was being used according to NUH guidelines by auditing against the following standard: 95 percent of oral co-amoxiclav outpatient prescriptions should be in line with antibiotic guidelines or based on documented microbiology advice or with clinically valid rationale. This standard is used for all NUH antimicrobial audits.

Only a third of respiratory infections and lacerations were treated with co-amoxiclav appropriately

The audit took place in October 2018. Patients that attended adult or paediatric ED between 27 July and 27 September 2018 who were issued oral co-amoxiclav on an outpatient prescription were identified using the electronic pharmacy dispensing system Ascribe.

108 prescriptions were identified and reviewed by an antimicrobial pharmacist and/or consultant microbiologist using clinical information (such as indication, clinical signs and symptoms) and documented on the ED electronic notes database (Medway). Appropriateness was determined according to local guidelines if available and/or clinical judgement. Almost half of oral co-amoxiclav prescriptions were deemed appropriate. 

The main indications for co-amoxiclav were human or animal bites, lacerations and respiratory infections. All bites were appropriately treated with co-amoxiclav. However, only around a third of respiratory infections (31%) and lacerations (34%) were treated with co-amoxiclav appropriately. Five out of 108 cases were excluded due to lack of information about indication.

Trust guidelines were available for the treatment of animal or human bites and respiratory infections; however, no guideline exists for the treatment of lacerations.

Action is required to improve the appropriateness of oral co-amoxiclav outpatient prescriptions from the ED at NUH in order to meet Trust standards, improve antimicrobial stewardship and long-term patient outcomes around AMR. Documentation of clinical information may have been lacking in some cases which could have led to poorer results and decreased validity.

We identified the following actions:

  • Write and publish a local guideline for the antibiotic treatment or prophylaxis of lacerations in the Emergency Department
  • Provide teaching and training materials to prescribers in the Emergency Department about the correct antibiotic treatment for respiratory infections
  • Re-audit in one year after above actions are completed.

This work was presented as a poster at the Pharmacy Together 2019 conference, organised by UKCPA and Pharmacy Management.

Additional authors:

Christie Fung, University of Nottingham, and Vivienne Weston, Christopher Gough and Tim Hills at Nottingham University Hospitals NHS Trust.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.


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