FREEDOM OF INFORMATION ACT 2000 Dudley CCG: Prescribing of Antibiotics Ref: RFI0861

Transcription

1 Freedom of Information Team Dudley CCG 17 November nd Floor, Brierley Hill Health and Social Care Centre Venture Way Brierley Hill DY5 1RU FREEDOM OF INFORMATION ACT 2000 Dudley CCG: Prescribing of Antibiotics Ref: Thank you for your request received 6 November You asked for information regarding the above. Your request for information has now been considered. I will answer your queries below: 1. Do you have a formulary used by primary care prescribers? Yes, please refer to formulary site If so, what is the current status of nitrofurantoin and trimethoprim with respect to urinary tract infections (e.g. first line, second line, etc). This depends on the individual being treated and is detailed in the formulary site: Chair: Dr David Hegarty MBE Chief Executive Officer: Mr Paul Maubach

2 2. Has the status of either nitrofurantoin or trimethoprim changed in the formulary since November 2014? If so, can you please provide the previous status(es) and details of the date(s) of change. No 3. Have you had any work plans in place with respect to nitrofurantoin and trimethoprim prescribing since 2014? If so, can you please provide documents and start date. See attached document. The audit date was 20 December Have you had any GP prescribing incentive schemes or similar which relate to trimethoprim or nitrofurantoin prescribing since November 2014? If so, can you please provide the documents. Yes, relevant extract from PIS included below: Prescribing Incentive Scheme 14/15 - To reduce overall antibiotic prescribing rates (or maintain them below CCG average) Prescribing Incentive Scheme 15/16 - To reduce overall antibiotic prescribing rates (or maintain them below CCG average) Prescribing Incentive Scheme 16/17 - To reduce the inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care (Trimethoprim/Nitrofurantoin DDD per STAR PU %) (items prescribed) by 10% (or maintain them below CCG average) Any queries or concerns, or if you are dissatisfied with the handling of your request please contact the Director of Communications & Public Insight at Dudley CCG, Brierley Hill Health & Social Care Centre, Venture Way, Brierley Hill DY5 1RU. The contact telephone number is or alternatively Laura.Broster@nhs.net You can also refer to the Information Commissioner at: Information Commissioner s Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF Telephone: or Helpline: Yours sincerely Matthew Hartland Chief Operating & Finance Officer Chair: Dr David Hegarty MBE Chief Executive Officer: Mr Paul Maubach

3 Retrospective audit to review the diagnosis and management of urinary tract infection in adult patients in primary care Practice Name Audit completed By: Audit Title Retrospective audit to review the diagnosis and management of urinary tract infection in adult patients in primary care Date of Audit December 2016 Aim To assess the management of urinary tract infections (UTI) in primary care in women aged 65 years and over and all adult patients with indwelling urinary catheters. Background Antibiotics for presumed urinary tract infections (UTIs) are often prescribed (Reason for audit in elderly people based on little more than a positive dipstick test. being undertaken) Reviewing and where necessary amending the prescribing of antibiotics for the treatment of UTIs will support the CCG in its antimicrobial stewardship campaign. UTI was one of the most frequent reasons for emergency admission to hospital with UTIs accounting for the second largest group of healthcareassociated infections in the UK (19.7% of all hospital acquired infections). 2&3 A quarter of all nursing home patients that are admitted to hospital are dehydrated. 4 However the problem is widespread and evidence suggests that the assumption that older people with higher levels of independence and regular access to fluids are less likely to experience dehydration is incorrect. 5 The NICE Quality Standard 90 (QS90) published in June 2015 provides the following quality statements on UTIs in adults 1 : Statement 1. Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made. Statement 2. Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters. Statement 4. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. For patients with symptoms of urinary tract infection and bacteriuria the main aim of treatment is the relief of symptoms followed by adverse effects of treatment or recurrence of symptoms. For asymptomatic patients the main outcome from treatment is prevention of future symptomatic episodes. 1 1

4 In people aged over 65 years asymptomatic bacteriuria is common but is not associated with increased morbidity. The diagnosis of UTI is particularly difficult in elderly patients, who are more likely to have asymptomatic bacteriuria as they get older. The prevalence of bacteriuria may be so high that urine culture ceases to be a diagnostic test. Elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit Statement 6. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with long-term indwelling catheters to prevent urinary tract infection unless there is a history of recurrent or severe urinary tract infection 1. Audit Criteria/Audit Standards Standards Method 1: Antibiotics are prescribed in line with local antimicrobial guidance Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Method 2: Statement 1. Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made. Statement 2. Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters. Statement 4. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Statement 6. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with long-term indwelling catheters to prevent urinary tract infection unless there is a history of recurrent or severe urinary tract infection 1 Antibiotics prescribed are in line with local antimicrobial guidance Audit Period Description of Method 3 months retrospective data Data Collection Sheet See attached: 2

5 UTI audit Data collection sheet v2.0. Method 1: Assess all records with a diagnosis of UTI (female only). Please note that the advice to record the cloudiness of urine is new (2014) and may not be recorded in consultations for the first cycle of the audit. Complete data collection sheet (worksheet named: Audit method 1) Population eligible for participation: Patients presenting to this medical practice: Between dates 1 st August th November 2016 Female Age 65 year and over Populations excluded from participation: Pregnancy Male Acute pyelonephritis Females under age of 65 years EMISWeb searches method 1: Women over 65years with UTI Auto Method 2: People with indwelling urinary catheters Identify all patients who use indwelling urinary catheters in primary care, methods to identify patients using catheters will vary between practices. Consider: I. Search for patients who have had an acute/repeat prescription for catheter items issued in the last 3 months. This report will include catheters issued for intermittent selfcatheterisation. Before undertaking the audit, confirm that the patient has an indwelling urinary catheter. These are issued in small numbers unlike intermittent catheters which are normally issued in larger quantities e.g. over 28/month. II. Informal enquiry of nursing home and care homes or the district nursing team. Complete data collection sheet (Worksheet named: Audit method 2) Population eligible for participation: Patients presenting to this health centre Between dates 1 st August th November 2016 Age 65 years of age and over Populations excluded from participation: Pregnancy 3

6 Acute pyelonephritis Male and Females under the age of 65 years EMIS Web searches method 2: Catheters Auto Report V2.0.zip I. Raise any concerns with appropriate GP especially where prompt review is indicated. Results and Action Plan Expected time II. Discuss overall findings with GP practice prescribing lead and share any learning points with rest of practice as appropriate. Record findings on audit summary and action plan sheet on page 6. Use local UTI guidance in appendix 1 to support decision making. Please submit completed data collection sheet (anonymised) and audit results and action plan below by Friday 20 th January 2016 to Joanne.Turner2@dudleyccg.nhs.uk 8 hours if further time required to be discussed with Pharmaceutical Public Health Team) References 1. National Institute for Health and Care Excellence. Quality Standard 90. Urinary tract infections in adults. Jun Available at: October NHS England. (2014). Emergency admissions for ambulatory care senstive conditions-characteristics and trends at a national level, London: NHS England. Accessed October Department of Health. (2007). Saving Lives high impact intervention No.6 Urinary catheter care bundle. London: Department of Health. Accessed October Schols, J.M.G.A., De Groot, C.P.G.M., Van der Cammen, T.J.M. & Olde Rikkert, M.G.M. (2008) Preventing and treating dehydration in the elderly during periods of illness and warm weather, The Journal of Nutrition Health and Aging, 13(2), pp Accessed October Wotton, K., Crannitch, K. & Munt, R (2008) Prevalence, risk factors and strategies to prevent dehydration in older adults, Contemporary Nurse, 31(1), pp Accessed October 2016 Outcomes 1. Practice based Pharmacist to complete Appendix 2 and provide audit summary to practice 2. Baselines audit completed audit summary sheet and action plans to be submitted by Friday 20 th January Audit summary report to be submitted to Prescribing Subcommittee and Quality and Safety Committee May

7 Appendix 1 ILLNESS COMMENTS DRUG DOSE URINARY TRACT INFECTIONS As E. coli bacteraemia in the community is increasing ALWAYS safety net and consider risks for resistance 1C Uncomplicated UTI i.e. no fever or flank pain in Treat women with severe/or 3 symptoms1, 2A, 3C Women mild/or 2 symptoms AND a) Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection. b)if cloudy urine use dipstick to guide treatment. Nitrite plus nitrofurantoin A- (Unless egfr less than 45ml/min/1.73m 2 )* men & women blood or leucocytes has 92% positive predictive value; nitrite, leucocytes, blood all negative 76% NPV4Ac) Consider a back-up / delayed antibiotic option20a or Men: Consider prostatitis and send pre-treatment MSU1,5C OR if symptoms mild/non-specific, use negative dipstick to exclude UTI.6C Always safety net.. trimethoprim B+ (note: local resistance of >25% so recommend urine for MC&S first) 100mg modified release (MR) BD 200 mg BD DURATION OF TX 3 days B+ (7 days in diabetics and men) All urine samples which require MC&S please use RED top bottle Second line: depends on susceptibility of organism isolated ESBLs are multi-resistant but often remain sensitive to nitrofurantoin * can be used in patients with egfr ml/min/1.73m 2 with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects. Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones 19 People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity 1B+ Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely 2B+ Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma 3B (NICE & SIGN guidance). See link: 5

8 Appendix 2 Please submit audit returns by Friday 20 th January 2017 Practice Audit Summary Form Practice Name: GP Prescribing lead: Practice Based Pharmacist: Date of Audit: Audit Title: Retrospective audit to review the diagnosis and management of urinary tract infection in adult patients in primary care Aim: To assess the management of urinary tract infections (UTI) in primary care and will focus on women aged 65 years and over and all adult patients with indwelling urinary catheters. Audit standards: Method 1: Antibiotics are prescribed in line with local antimicrobial guidance Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Method 2: Statement 1. Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made. Statement 2. Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters. Statement 4. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Statement 6. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with long-term indwelling catheters to prevent urinary tract infection unless there is a history of recurrent or severe urinary tract infection 1 Antibiotics prescribed are in line with local antimicrobial guidance Methodology: Method1: Assess all records with a diagnosis of UTI (females only). Please note that the advice to record the cloudiness of urine is new (2014) and may not be recorded in consultations for the first cycle of the audit. EMIS Web search was used to identify patients Method 2: People with indwelling urinary catheters Identify all patients who use indwelling urinary catheters in primary care, methods to identify patients using catheters will vary between practices. Consider: I. Electronic identification. Search for patients who have had an acute/repeat prescription for catheter items issued in the last 3 months. This report will include catheters issued for intermittent self-catheterisation. Before undertaking the audit, confirm that the patient has an indwelling urinary catheter. These are issued in small numbers unlike intermittent catheters which are normally issued in larger quantities e.g. over 28/month. II. Informal enquiry of nursing home and care homes or the district nursing team. EMIS Web search was used to identify patients 6

9 Results: Method 1 Audit Standards Target Actual Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Antibiotics prescribed are in line with local antimicrobial guidance Method 1: Total Number of UTI related admission in last 12 months = % of Patients that have hydration status noted in records = List of codes/diagnosis used by secondary care when patients were admitted = Method 2 Audit Standards Target Actual Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with longterm indwelling catheters to prevent urinary tract infection unless there is a history of recurrent or severe urinary tract infection 1 Antibiotics prescribed are in line with local antimicrobial guidance Method 2: Total Number of UTI related admission in last 12 months = % of Patients that have hydration status noted in records = List of codes/diagnosis used by secondary care when patients were admitted = 7

10 Discussion: Enter the practice discussion here Recommendations Enter the practice recommendation here References 1. National Institute for Health and Care Excellence. Quality Standard 90. Urinary tract infections in adults. Jun Available at: October NHS England. (2014). Emergency admissions for ambulatory care senstive conditions-characteristics and trends at a national level, London: NHS England. Accessed October Department of Health. (2007). Saving Lives high impact intervention No.6 Urinary catheter care bundle. London: Department of Health. Accessed October Schols, J.M.G.A., De Groot, C.P.G.M., Van der Cammen, T.J.M. & Olde Rikkert, M.G.M. (2008) Preventing and treating dehydration in the elderly during periods of illness and warm weather, The Journal of Nutrition Health and Aging, 13(2), pp Accessed October Wotton, K., Crannitch, K. & Munt, R (2008) Prevalence, risk factors and strategies to prevent dehydration in older adults, Contemporary Nurse, 31(1), pp Accessed October

11 Notes Page: 9