Scoring systems and audit to improve antimicrobial prescribing decisions in primary care

image of antibiotics

08 November 2019

Dr Graham Duce, RCGP Clinical Champion for TARGET Antibiotics

In the UK, 73% of antibiotic prescribing takes place in primary care, with over half for respiratory tract infections. The appropriate use of antimicrobials is a key responsibility of general practice (ESPAUR Report, 2018). The RCGP and Public Health England (PHE)’s TARGET Antibiotic Toolkit contains a range of resources to support prescribers’ and patients’ responsible antibiotic use to help tackle increasing antimicrobial resistance.

Acute sore throat is a commonly presented condition in primary care. It is usually caused by a self-limiting upper respiratory tract infection, with 90% resolving in one week without antimicrobial therapy. However, antibiotic prescriptions for sore throat are common. Inappropriate and overuse of antibiotics has led to antibiotic resistance, increased demands on healthcare services and antibiotic-related adverse side effects.

Scoring systems can be part of the consultation to help guide clinicians

Using an evidence-based scoring system such as FeverPAIN or Centor Criteria can help to identify people likely to benefit from antibiotic treatment and advise when antibiotics are unlikely to be beneficial. This approach is supported by the National Institute for Health and Care Excellence (NICE) guideline NG84 'Sore throat (acute): antimicrobial prescribing'.

In practice, using scoring systems can easily be part of the consultation and help guide not only the clinician but also inform the discussion with the patient as to whether or not antibiotics are indicated. For example, someone with a FeverPAIN score of 0 or 1 (or Centor score of 0, 1 or 2) is unlikely to benefit from an antibiotic.

FeverPAIN provides the likelihood of a bacterial infection and the recommended management, for example, a FeverPAIN score of 0-1 is associated with 13-18% isolation of streptococcus (close to background carriage rates), hence a no prescribing strategy is appropriate after discussion. In addition to the use of a scoring system, all patients should be advised on self-care, using the opportunity to discuss the Treating Your Infection - Respiratory Tract Infection leaflet that is available via the Target Antibiotics Toolkit.

TARGET Antibiotics resources

The TARGET Toolkit contains other useful information, including audit toolkits. They provide templates for accurate and easy auditing, self-assessment of your prescribing, and for the development of antimicrobial stewardship action plans within practices. Audits available include those for acute cough, acute otitis media, acute rhinosinusitis, acute sore throat and urinary tract infections.

The use of audit templates will enable GP practices to assess the management of infection against current NICE and PHE prescribing guidelines, highlighting any areas for improvement. This can result in a practice action plan, which includes an overall aim for change in antibiotic use and how the practice aims to achieve this. Examples include agreeing how leaflets could be incorporated onto the practice clinical system, the use of posters or videos from the PHE Keep Antibiotics Working campaign and agreeing audit plans with a designated staff member.

All the above actions will improve compliance with national policies. Crucially, they also help to reduce antibiotic resistance and contribute to better patient care by reducing adverse side effects.

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