Antimicrobial stewardship strategies fail to reduce antibiotic prescribing

Research into prescribing behaviours in high prescribing practices found that introducing antimicrobial stewardship strategies had little impact on antibiotic prescribing, according to a new study published in the British Journal of General Practice.

In clinical trials, the use of antimicrobial stewardship (AMS) strategies – such as enhanced communication strategies, delayed prescriptions and point-of-care C-reactive protein tests (POC-CRPTs) – have been shown to reduce antibiotic use in primary care. However, these strategies are not commonly used in routine practice.

In this study, nine high-prescribing practices were offered access to all three AMS strategies for 12 months, via a website, with practices required to identify an ‘antibiotic champion’. Routinely collected prescribing data were compared between the intervention and control practices. Surveys were conducted at baseline, at 2 months and at 12 months, and interviews with participants were conducted at 6 and 12 months.

Champions in five practices initiated changes to encourage use of at least one AMS strategy – mostly POC-CRPTs, and one practice chose all three.

However, the study found there was no evidence that the intervention affected prescribing. Engagement with the intervention materials varied substantially between practices and depended on individual champions’ preconceptions of the strategies and the time and opportunities available to carry them out.

Champions

Of the 11 champions across nine practices, six found they were able to engage and encourage colleagues to use the resources. Of survey respondents, 76% knew who their champion was. Of those who did not, five were from one practice. Interviews found significant variation in champion engagement: champions who volunteered for the role were more enthusiastic than those who were nominated. Lack of time was given as the reason for less engagement.

Website

Data showed that the website set up to support practices during the study had 75 new users, but at 2 months, 52% had only visited the website once, and only 21% had visited it twice or more. Of those who visited the website, most found the content helpful, but some interviewees thought it was aimed at patients, not clinicians, and some said they were already familiar with the content. Even the ‘champions’ tended to focus on physical materials that were delivered to the practices, rather than on the website. Lack of engagement with the website meant prescribers did not know how AMS strategies could benefit them and their patients.

Enhanced communication strategies and patient leaflets

At the 2-month survey, 80% of prescribers were confident that they could communicate a ‘no antibiotic’ decision without affecting patient satisfaction, up from 49%. Prescribers reported that using patient leaflets interactively in consultations had helped reduce antibiotic prescribing. When interviewed, prescribers were enthusiastic about leaflets, but pointed out that they had to be close to hand for the prescriber to use them – if not, it was a case of ‘out of sight, out of mind’.

Delayed prescriptions

At the start of the study, most prescribers were confident that they could explain a delayed prescription to a patient, and 2 months into the study, 83% of survey respondents reported that they were using this strategy. But when interviewed, respondents said they did not think delayed prescriptions were useful and did not use them frequently or at all. Clinicians felt that patients would take antibiotics regardless of what they were told, and would perceive them as a way of preventing access to treatment. Three of the practices were dispensing practices and patients usually picked up any prescribed medication before they left the surgery. But in one practice, which dispenses to 99.5% of its patients, they gave patients a leaflet with instructions on when and where to obtain the antibiotic if their condition did not improve. This practice also changed the way it discussed delayed prescriptions with patients, from ‘if your condition doesn’t get better in 48 hours, come back [for antibiotics]’ to ‘we don’t know what the natural cause of a disease is, and if things change, then it may be appropriate to use [an antibiotic].’

POC-CRPT

Eight of the practices accepted POC-CRPT equipment – one opted out because they didn’t think it was feasible to have to share one machine – but in four of these practices, only one person – a GP, nurse or ambulatory clinician did the tests. Most participants said the POC tests were most useful to convince patients that they did not need antibiotics, rather than for the intended purpose, to determine whether or not antibiotics were needed.

In some practices, participants claimed lack of training deterred use, and one practice did not use the equipment because they couldn’t find anywhere to put it.

Conclusion

The authors concluded that prescribers needed detailed information on exactly how to adopt AMS strategies. When AMS strategies were used, their use was often suboptimal, compared with use in clinical trials. Successful adoption may be achieved by triaging patients and allocating one or two people in the practice to use AMS strategies. The authors said: ‘There was no evidence that providing an intervention to support practices where there is high antibiotic prescribing affects antibiotic prescribing,’ adding: ‘Remote, one-sided provision of AMS strategies should be used cautiously. Initial clinician engagement and understanding needs to be monitored to avoid misunderstandings and suboptimal use.’

Reference

Tonkin-Crine S, McLeod M, Borek AJ, et al. Implementing antibiotic stewardship in high-prescribing English general practices. Br J Gen Pract 21 February 2023; https://doi.org/10.3399/BJGP.2022.0298