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Inappropriate antibiotic prescribing found in A&E department

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

Antimicrobial resistance (AMR) is a threat to modern medicine and healthcare systems that requires coordinated action on a local and international level. In 2009, Commissioning for Quality and Innovation (CQUIN) national goals were introduced to incentivise change in order to encourage clinical quality improvement. 

Given the alarming public health implications that AMR poses, a CQUIN target for 2017/2018 concerns reduction in antibiotic consumption. Despite discounting IV antibiotics in light of the sepsis CQUIN target, audits carried out at the Trust identified A&E as the department with the highest usage of oral antimicrobials. In order to meet the CQUIN target, it was imperative to examine the use of TTO oral antibiotics in the A&E department.

This study aimed to quantify antibiotics prescribed in A&E for a two-week period and to determine whether these were prescribed in line with Trust guidelines. The objectives were to record TTO oral antibiotic prescriptions dispensed in A&E and to compare treatment and indication of dispensed oral antibiotics to the Trust guidelines in order to ascertain clinical appropriateness

A two-week prospective, observational study was conducted in the A&E department at a secondary care, district general hospital in Sussex. The cohort comprised of patients who were prescribed TTO oral antibiotics when they were seen in A&E between 1 and 15 November 2017. 

The disproportionate number of inappropriate antibiotic prescriptions demonstrates the need for further guidance to support prescribers

A&E department staff members completed a paper-based data collection tool. Clinical appropriateness of antibiotic prescribing was assessed by comparing the diagnosis and choice of antibiotics prescribed to the Trust’s Adult Empiric Antimicrobial Treatment Guidelines. Indications were classified according to body systems categories in the Trust guidelines. 

Out of 75 data entries identified and included in the audit, the majority (47 percent) of diagnosed infections fell into the ‘skin and skin structure’ category, followed by ‘respiratory’ and ‘head and neck’. Twelve prescriptions (16 percent) were identified as inappropriate use of antibiotics when referenced against Trust guidelines. The majority (67 percent) of these prescriptions were issued for ‘skin or skin structure’ related infections. Co-amoxiclav was the antibiotic that was most commonly prescribed inappropriately.

The disproportionate number of inappropriate antibiotic prescriptions for ‘skin and skin structure’ infection demonstrates the need for further guidance to support prescribers. Co-amoxiclav was most commonly prescribed inappropriately; this is likely to be due to its broad-spectrum action. Prescribers may prefer to prescribe co-amoxiclav for wounds whereby the causative agent is unknown or in cases where multiple groups of bacteria are suspected. 

The Trust is currently reviewing A&E specific ambulatory guidelines with the involvement of the Antimicrobial Stewardship Group, and an A&E consultant to implement new guidelines and support education of staff. The reported findings also support the involvement of non-medical prescribers such as independent prescribing pharmacists who can act as gatekeepers to appropriate antibiotic prescribing. 

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

Additional authors:

Joanne Munns, Western Sussex Hospitals NHS Foundation 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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