Members are asked to: Support the uptake and development of the AWMSG National Audit: Focus on Antibiotic Prescribing.

Enclosure No: Agenda Item No: Author: Contact: 7/AWMSG/0215 11 Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013 2015 All Wales Prescribing Advisory Group (AWPAG) Lead: TL Lewis (GP & Medical Advisor in Therapeutics) Tel: 02920 71 6900 awttc@wales.nhs.uk 1.0 ACTION FOR AWMSG Members are asked to: Support the uptake and development of the AWMSG National Audit: Focus on Antibiotic Prescribing. 2.0 RECOMMENDATIONS AWMSG is requested to support the uptake of the AWMSG National Audit: Focus on Antibiotic Prescribing for 2015 2016. AWPAG and AWTTC to: review and update the audit; investigate the use of electronic templates for the specified conditions, and the on-line completion and submission of audit findings to support feedback to prescribers; continue promoting antimicrobial stewardship, for example by investigating mechanisms to support the use of delayed prescriptions and the impact of interventions on consultation rates. 3.0 SUMMARY Variation in antimicrobial prescribing exists between UK nations, health boards and practices (see National Prescribing Indicators: Analysis of Antibacterial Prescribing Data to March 2014). In 2013 2014, there was variable uptake of the National Audit: Focus on Antibiotic Prescribing. The percentage of practices within a health board undertaking a section of the audit varied between 0 and 100%. Only one health board undertook the Conditions section of the audit. This section addresses antibiotic volumes. Audit outcome data from the health board undertaking the Conditions section of the audit showed significant variation (10 100%) in documentation of clinical features. 4.0 PURPOSE This discussion document reviews the rationale and uptake for the AWMSG National Audit: Focus on Antibiotic Prescribing 2013 2015. At the September 2014 AWPAG meeting, members agreed to continue the audit as an option for 2015 2016, alongside the tramadol audit. This document considers the uptake, feedback and outcomes reported to date. Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 1 of 13

The existing audit will require updating in light of changes to the Public Health England guidance underpinning the audit, Management of infection guidance for primary care for consultation and local adaptation. This document is pertinent to: (i) AWMSG Five-year Strategy 2013 2018 Improving the patient s experience of medicines in Wales : Recommendation 2: Improving health Prescribing guidance AWMSG will work with health boards and other stakeholders to promote the safe, effective and cost-effective use of medicines in Wales. (ii) UK Five Year Antimicrobial Resistance Strategy 2013 to 2018: The overarching goal of the Strategy is to slow the development and spread of AMR. It focusses activities around 3 strategic aims: improve the knowledge and understanding of AMR, conserve and steward the effectiveness of existing treatments, stimulate the development of new antibiotics, diagnostics and novel therapies. 5.0 PROCESS September 2014 AWPAG meeting preliminary discussion December 2014 AWPAG meeting January 2015 AWMSG Steering Committee meeting February 2015 AWMSG meeting Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 2 of 13

CONTENTS 1.0 REVIEW OF THE AUDIT BACKGROUND, UPTAKE, FINDINGS AND REVIEW... 4 1.1 Current practice... 4 1.2 Background... 6 1.2.1 Rationale for audit... 6 1.3 Audit development... 6 1.4 Audit aims... 7 1.5 Audit contents... 7 1.6 Audit uptake 2013 2014... 7 1.7 Audit feedback... 7 1.7.1 Audit section 1: Antibiotic prescribing for sore throat... 8 1.7.2 Audit section 4. Antibiotic prescribing for acute cough/acute bronchitis... 9 1.8 Trends... 10 APPENDIX 1. ASF/WMP WORKSHOP... 11 Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 3 of 13

1.0 REVIEW OF THE AUDIT BACKGROUND, UPTAKE, FINDINGS AND REVIEW 1.1 Current practice Antimicrobial prescribing has been included within the National Prescribing Indicators (NPIs) since 2010 2011. Variations in antimicrobial prescribing rates remain between: England, Scotland and Wales; in 2013 2014, Wales prescribed 20% more antibiotics per 1,000 patients than England (Figure 1) English clinical commissioning groups (CCGs), Scottish health boards and Welsh health boards (Figure 2) Practices within and between Welsh health boards (Figures 3 & 4) Figure 1. Antimicrobial prescribing in England, Scotland and Wales (2013 2014) 800 Items per 1,000 patients 600 400 200 0 England Scotland Wales Figure 2. Variation in rate of prescribing between English CCGs (blue columns), Scottish health boards (black columns) and Welsh health boards (red columns) (2013 2014) Items per 1,000 patients HB/CCG Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 4 of 13

Figure 3. Antimicrobial prescribing variation among practices within Welsh health boards Quarter to March 2014 Antibacterial items per 1,000 STAR- PUs Figure 4. Antimicrobial prescribing variation between practices Quarter to March 2014 Antibacterial items per 1,000 STAR- PUs Practices (grey: all health boards; blue: one particular health board) Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 5 of 13

1.2 Background In April 2010, antibacterial prescribing (items per 1,000 PUs) became an NPI at the recommendation of AWMSG. However, despite its inclusion, a review of CASPA prescribing data in 2011 noted that prescribing volumes had remained static. 1.2.1 Rationale for audit The antimicrobial audit toolkit was developed following collaboration with colleagues across Wales and in response to the joint workshop outlined below: Antimicrobial Stewardship Forum/Welsh Medicines Partnership workshop Following discussions with colleagues in Public Health Wales, a joint meeting was held in September 2011 between the Antimicrobial Stewardship Forum (ASF) and Welsh Medicines Partnership (WMP) with attendance from AWPAG and representation from across Wales. WMP facilitated the workshop, which aimed to identify and prioritise messages related to antimicrobial prescribing that were not reaching clinicians. Using a modified nominal group technique (NGT), the group identified and prioritised messages, related to antimicrobial prescribing, that they would like to see promoted in the hospital and community setting. This was achieved by focusing the workshop on the question: What messages would you like to promote to clinicians to support appropriate prescribing of antimicrobials? By the end of the workshop there were six prioritised messages. Delegates indicated their three preferred priorities in rank order. The most popular was Use the guidelines (national, local electronic, joint primary and secondary care) and justify deviation. Also pertinent to the National Audit was the message Adequate documentation of indication and clinical assessment, which was highlighted as a priority by the group. What messages would you like to promote to clinicians to support appropriate prescribing of antimicrobials? Use the guidelines (national, local electronic, joint primary and secondary care) and justify deviation. Adequate documentation of indication and clinical assessment. To support the findings, AWPAG agreed to work with stakeholders to develop a National Audit focusing on antimicrobials. This was recommended for inclusion within the Clinical Effectiveness Prescribing Programme (CEPP) from 2013. (See Appendix 1 for more details on the ASF/WMP workshop.) 1.3 Audit development A pilot for the audit was based on Health Protection Agency (HPA) guidance by Dr Sean Young (Abertawe Bro Morgannwg University Health Board). The project was led by Sean Young and Tessa Lewis, and developed via AWPAG. Following the initial pilot, a number of additional sections were included: Cough and bronchitis added (at request of colleagues). Process measures added. Healthcare-acquired infections (HCAI) added following discussion with Decontamination, Antimicrobial Resistance and Healthcare-Acquired Infection (DARHAI) group. Delayed prescriptions added as per NICE Clinical Guideline (CG) 69: Respiratory Tract Infections Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 6 of 13

1.4 Audit aims To promote antibiotic prescribing in accordance with existing guidelines: HPA, NICE CG69. To support clinicians in promoting quality improvement by reviewing antimicrobial prescribing within their teams. This was endorsed by AWMSG and recommended for inclusion in the CEPP as a national audit option for 2013 2014. 1.5 Audit contents Available at: www.awmsg.org/medman_cepp.html. Each section is available as a separate link: 1. Sore Throat 2. Acute Rhinosinusitis 3. UTI in Females 4. Acute Cough or Bronchitis 5. Quinolone Prescribing 6. Cephalosporin Prescribing 7. Co-amoxiclav Prescribing 8. Hospital Prescribing of Antibiotics 9. Delayed Prescriptions 10. Read Coding to Identify HCAI 11. Practice Review Sheet 12. CPD Sheet 1.6 Audit uptake 2013 2014 Out of 2,000 GPs, from 500 GP practices in Wales, health board feedback suggests: 140 practices (28%) completed at least one section of the audit. Uptake varied according to locality: 0 100%. In Abertawe Bro Morgannwg University Health Board (Neath Port Talbot, Swansea, Bridgend), all 55 practices undertook all condition sections of the audit. All participating practices from other health boards undertook one antibiotic choice section of the audit (cephalosporin, co-amoxiclav, quinolone). 1.7 Audit feedback Practices may choose to undertake an in-depth review using a single specific audit section, e.g. ten cases per prescriber within the practice, or choose a smaller case selection of several criteria, depending on their priorities. Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 7 of 13

1.7.1 Audit section 1: Antibiotic prescribing for sore throat Audit features: Short One side of A4 with data collection sheet. Background: HPA Management of Infection Guidance for Primary Care (see Table 1). Table 1. Information from HPA Management of Infection Guidance for Primary Care Illness Comments Medicine Adult dose Duration of treatment Acute sore throat CKS Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours A+ If Centor score 3 or 4: (lymphadenopathy; no cough; fever; tonsillar exudate) A- consider 2 or 3 day delayed or immediate antibiotics A+ or rapid antigen test. RCT in < 18 year olds shows 10d had lower relapse Phenoxymethylpenicillin B- 500 mg QDS 1 g BD A+ (QDS when severe D ) 10 days A- Antibiotics to prevent quinsy NNT > 4000 B- Penicillin allergy: Clarithromycin 250 500 mg BD 5 days A+ Antibiotics to prevent otitis media NNT 200 A+ Suggested search codes. Outcomes measured: No antibiotic prescribed OR Immediate/delayed antibiotic with Centor score = 3 or 4? Audit data from Abertawe Bro Morgannwg University Health Board and one other GP practice noted variation in response to All criteria for Centor score recorded, with proportion of positive responses between 0 and 100%. One respondent noted that absence of cough was the most commonly omitted. Comments: The audit has raised awareness of Centor criteria. The audit can be a useful tool for reflection within the practice but caution should be exercised in comparing findings between practices. A selection of read codes is provided to identify suitable patients for review. The codes chosen will significantly affect the cohort sampled. For example, patients with milder symptoms may be coded as sore throat, while those with more severe symptoms may be coded as tonsillitis. Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 8 of 13

1.7.2 Audit section 4. Antibiotic prescribing for acute cough/acute bronchitis Audit features: Table 2. Antibiotic Prescribing for Acute Cough/Acute Bronchitis Data Collection Sheet Patient Documented clinical features, both temperature, and chest examination? (Y/N) Additional clinical features of severity/ systemic upset recorded? (pulse, respiratory rate or oximetry) (2 or more = Y) Antibiotic prescribed? (Y/N/ delayed) Amoxicillin, clarithromycin, erythromycin or doxycycline? (Y/N) If antibiotic supplied, does patient fit NICE guidance (systemically very unwell, symptoms and signs of serious illness or of serious complications, or preexisting comorbidity) (Y/N) (provide reason) NICE criteria 6 met? (Y/N/ Other) Total % Yes Standard 100% No standard set 95 % 90% 90% Figure 5. Abertawe Bro Morgannwg University Health Board GP practice responses to Documented clinical features, both temperature and chest examination? (Audit standard 100%) Percentage of audit patients with cough who had documented temperature and chest examination Practice Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 9 of 13

1.8 Trends Abertawe Bro Morgannwg University Health Board has focused on antimicrobial prescribing in recent years and has addressed this area with a variety of initiatives. Figure 6. Cephalosporin items as a percentage of antibacterial items Abertawe Bro Morgannwg University Health Board highlighted Figure 7. Quinolone items as a percentage of antibacterial items Abertawe Bro Morgannwg University Health Board highlighted Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 10 of 13

APPENDIX 1. ASF/WMP WORKSHOP 1.1 Purpose This multiprofessional workshop was intended to support movement against the AWMSG antimicrobial NPIs. The aim was to use an NGT using the expertise of clinicians to agree key messages or interventions to support appropriate prescribing of antimicrobials. 1.2 Method Prior to the meeting colleagues were asked the following question: What messages would you like to promote to clinicians to support appropriate prescribing of antimicrobials? Please list up to three messages, they can be relevant to primary or secondary care. (One sentence, with or without an example, is all that is needed.) This was sent electronically to AWPAG members and the circulation list of the ASF. This enabled responses from colleagues unable to attend the joint meeting. At the start of the meeting, all delegates were asked to write their responses to the same question without discussion with colleagues. These were collated and new messages added to the summary of electronic responses. Delegates were given a brief verbal summary of the responses and provided with a detailed written summary. These were discussed in groups and priorities identified. Each group reported back to the meeting. The resulting priorities were collated onto a voting form and each delegate identified their individual first three ranked priorities. By allocating a score on a 3-point scale to each vote, the priorities of the group were identified. 1.3 Results Prior to the meeting, over 50 responses were received from 16 individuals. These included pharmacists, consultant physicians, GPs and Public Health Wales representatives. For the purposes of the meeting, responses were categorised under the following headings: 1. Knowledge (ask, evidence/education, Clostridium, feedback, under-treatment) 2. Consultation (interprofessional, risk, review, defer) 3. Waste (sampling, natural history, duration, choice of agent, allergy) At the meeting, 82 responses were received from 26 delegates. Any new messages not previously noted were added to the summary. The responses received from individuals were diverse and pertinent, reflecting their experience in daily practice. Messages that colleagues would like to promote to clinicians to support appropriate prescribing of antimicrobials included the following examples: Knowledge When deciding on which antibiotic to prescribe use evidence base for choice rather than using habit or past experience as guide. BNF 5.1 should not be overlooked. Consultation/interprofessional We need to ensure that no health care worker (community pharmacist, nurse, care home staff etc.) refers someone to their clinician for an antibiotic undermines the opening position of the clinician. Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 11 of 13

Consultation/risk Careful assessment and good safety netting more important in preventing complications than liberal prescribing of antibiotics. Consultation/risk Identify to clinicians Number Needed to Treat (NNT) to avoid an admission/number Needed to Harm (NNH). Following feedback from the group discussions, the preferred messages were collated onto a voting form. Eighteen delegates voted on 11 themes and the six key outcomes are tabulated below. Please refer to section 1.4 Limitations when considering this table. Table I. Key messages that the group would like to promote to clinicians to support appropriate prescribing of antimicrobials Messages Use the guidelines (national, local electronic, joint primary and secondary care) and justify deviation Total points Senior clinician show leadership and take responsibility 20 Treat the patient not the result/appropriate swabbing 14 Adequate documentation of indication [and] clinical assessment 11 Understand risks of antibiotics (NHS and patient)/use tools 11 Tell patients the natural history/what to expect 7 1.4 Limitations It was expected that some comments would fall into several categories. The presentation of results was dependent on the interpretation of data on the day. There was limited time for the discussion stage of the NGT, so delegates would not have been able to note all responses and some good ideas may not have been discussed when considering priorities. Similarly, the final voting form contained categories of varying scope and the number of voters for the final prioritisation was small. 1.5 Recommendations from workshop 1.5.1 Use of guidelines The key message identified was for clinicians to use the existing guidelines and justify deviation from these. There is clear guidance available to prescribers within the BNF and in health board formularies. Identifying drivers and mechanisms to audit and promote adherence to the guidance was considered a priority by the group, and the AWMSG CEPP National Audit was developed as a response. 1.5.2 Leadership The group identified the senior clinician leadership as a key priority. Some regions are already addressing this component. Experience in primary care has demonstrated the benefits of sharing prescribing data amongst peers. AWPAG and the Welsh Analytical Prescribing Support Unit are developing aligned indicators for hospital prescribing for the AWMSG antimicrobial NPI. 1.5.3 Treat the patient not the result/appropriate swabbing The key messages (Table I) also included Treat the patient not the result/appropriate swabbing. Detailed advice is now available, e.g. SIGN 88 Management of suspected bacterial UTI in adults, which states Do not use dipstick testing to diagnose UTI in patients with catheters. 36 Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 12 of 13

1.5.4 Adequate documentation To address the message, Adequate documentation of indication [and] clinical assessment, appropriate audit criteria were developed e.g. those used in the Antibiotic prescribing for acute cough/acute bronchitis section of the audit. 1.6 Conclusion The workshop highlighted the fundamental importance of an adequate assessment and diagnosis, with appropriate laboratory testing. The National Audit: Focus on Antibiotic Prescribing was developed in response to these messages. Review of the AWMSG National Audit: Focus on Antibiotic Prescribing 2013-2015 v1.18 January 2015 Page 13 of 13