Antimicrobial Prescribing in Primary Care

The HPA was awarded a UKCRC Strategy Development Grant in December 2007 to establish a Research and Development multi-agency collaboration to improve antimicrobial prescribing in primary care.

The collaboration aims to address gaps in the following areas:

• What should GPs be prescribing based on current evidence to minimize antimicrobial resistance without unacceptable clinical consequences?
• How to achieve appropriate prescribing behaviour in primary care?
• How to measure what is being prescribed, whether it is appropriate and whether change is being achieved?
• What further research needs to be done?

The project is divided into four areas of work:

 

 

The project is led by HPA West Midlands and the collaboration has representation from the HPA's Knowledge Management Programme, LaRS, CfI, RMN and the University of Birmingham (Department of PH and Epidemiology, WMHTAC), Keele University (Medicines Management) and University College London (Infection and Population Health).

 

For further information contact:
Dr Jeremy Hawker
Email: Jeremy.Hawker@hpa.org.uk

 

Area 1

Updating prescribing guidance and improving its accessibility to primary care

Following the recommendations of the Standing Medical Advisory Committee report, guidance for prescribing in primary care was developed by the PHLS South West in 2000 in collaboration with general practitioners (GPs). This web based HPA primary care prescribing guide is evidence based, is consistent with NICE guidance where NICE guidance exists and is developed in close collaboration with Clinical Knowledge Summaries. It is easily accessible on line, is short, which GPs prefer and is fully referenced. It addresses the treatment of conditions such as respiratory tract infections and urinary tract infections which the data show are the most common conditions for which antibiotics are prescribed. The guide is endorsed by the HPA and the Association of Medical Microbiologists.

The objectives of this area: to put in place a system whereby this guide is reviewed, evaluated and marketed with a system for annual updating.
Expected outcomes: to improve prudent antimicrobial prescribing in primary care and thus limit the spread of antimicrobial resistance.

Area 2

Defining and updating the evidence base for achieving change in primary care

The Cochrane collaboration undertook a systematic review to estimate the most effective intervention to prevent the development of antibiotic resistance to common pathogens. This contained data up to the year 2000 and cost effectiveness of interventions was not considered. 

The objectives of this area:
- To update the Cochrane review using systematic review methodology
- To undertake an economic analysis for recommended interventions
- To make recommendations for practice and future research particularly in
the UK context
- To publish and publicise the findings
- To develop a process to support routine (annual) updating of the review

The current systematic review covers the period 2000 to 2008.

Expected outcomes: dissemination of the findings; establishing a system for regularly updating the review; and possibly trialing the best intervention highlighted by the review.

Area 3

Developing and testing a routine system for analyzing antimicrobial prescribing in primary care

The 'SMAC' report published by the DH in 1998 made recommendations to limit inappropriate prescribing. Although some changes in behaviour have occurred, translating these recommendations into clinical practice has so far met with limited success.

The General Practice Research Database (GPRD) is a large primary care database of consultations and prescriptions. The SACAR surveillance subgroup explored GPRD data from 60 GPs to monitor antibiotic prescribing in primary care. The 'THIN' dataset' is derived from the GPRD system and contains all the key variables. THIN currently collects consultation data from over 300 General Practices, covers about 2 million actively registered patients and is updated quarterly. It can be broken down by diagnosis, age-group, sex, geography (including markers of social deprivation, based on patients' postcodes) and first/subsequent consultation episode.

The objectives of this area: to explore the feasibility of developing a dataset for monitoring antimicrobial prescribing in primary care using GPRD/THIN like datasets.

Expected outcomes: to allow more up to date analyses and lead to the establishment of a system which should allow these analyses to be undertaken on a regular basis resulting in more meaningful and timely analyses to allow the tracking of new problems as they arise.

Area 4

Developing a wider collaboration and developing specific further research

The collaborators on this project represent the HPA and academic institutions.

The objectives of this area: to promote an effective collaboration among the collaborators; to develop links with researchers interested in this field from other universities, institutions and organisations within and outside the UK; to identify gaps in the current evidence base and highlight research questions.

Expected outcomes: a wider collaboration within and outside the UK and the generation of further specific research ideas.

 

Collaborators

Dr Jeremy Hawker is a Consultant in Public Health who specializes in Communicable Disease Epidemiology. He is Head of Public Health Development for the HPA. He is Registrar of the Faculty of Public Health, Member of the Public Health Register Board, National Institute for Health and Clinical Excellence (NICE) public health committee; CMO's Expert Advisory Group on AIDS and Scotland's Health Protection Advisory Group. He also writes the Communicable Disease Control Handbook.

Dr Babatunde Olowokure is a Consultant Regional Epidemiologist with the HPA West Midlands since 2004 and is the regional lead for R&D. He has a strong interest in epidemiological methods, infectious diseases, translational research and inequalities in health.

Dr Gillian Smith is Head of the HPA Syndromic surveillance team and Consultant Regional Epidemiologist in the West Midlands. She has introduced two new syndromic surveillance systems using data generated in primary care that are now used in routine surveillance and have generated many research papers.

Dr James Bashford is Academic General Practitioner at Medicines Management, School of Pharmacy, Keele University. He is a practising GP with an interest in therapeutics. He also undertakes teaching activities for a range of postgraduate programmes in medicines management for pharmacists and health care professionals and for undergraduates at the School of Medicine.

Dr Andrew Hayward is Senior Lecturer in Infectious Disease Epidemiology at the UCL Research Department of Infections and Population Health.  His work focus includes influenza, antibacterial prescribing and resistance in primary care, health care associated infections and tuberculosis.  He is scientific co-director of the Infectious Disease Research Network.  He was a member of the Specialist Advisory Committee on Antimicrobial Resistance Surveillance Subgroup. 

Dr Chris Hyde is a Reader in Evidence Synthesis in Health at the University of Birmingham. He is also Director of the West Midlands Health Technology Assessment Collaboration (WMHTAC) which produces systematic reviews, health technology assessments, and economic evaluations, and disseminates their results. In particular it provides support for NICE in developing guidance on new technologies and public health. He has a longstanding interest in systematically reviewing evidence on behaviour change and is an active member of the Effective Practice and Organisation of Care (EPOC) group of the Cochrane Collaboration.

Dr Alan Johnson is Clinical Scientist at the Department of Healthcare Associated Infection and Antimicrobial Resistance (HCAI & AMR) at the HPA Centre for Infections. He is editor in chief of the Journal of Antimicrobial Chemotherapy. He was a member of the prescribing subgroup of SACAR and is a member of the Improving Children's Antibiotic Prescribing Group.

Dr Cliodna McNulty heads the HPA Primary Care Unit.  The Unit aims to improve the management of infectious diseases and use of antibiotics in the community, through research, guidance development and education.  She sits on the following: EU Antibiotic day 2008, advisory committee; NICE Advisory Committee for short RTI guidance for primary care; Advisory Committee on Antimicrobial Resistance & Healthcare-Associated Infections; ARHAI Public Education Sub-group; SACAR Public Education Sub group.

Last reviewed: 4 May 2010