Summary
An enhanced stewardship approach for UTIs was initiated with new local management guidelines, new laboratory testing methods, new antibiotics and a rapid 24-hour turnaround time to report urine sensitivities. As a result of this stewardship initiative, there has been a dramatic reduction in inappropriate prescribing for UTIs in Nottinghamshire.
Background
An enhanced stewardship approach for UTIs was initiated in early 2015 in the face of rising antimicrobial resistance in urinary tract isolates in Nottinghamshire, which were the second most common cause for antibiotic prescriptions in the county.
What was involved?
New local management guidelines were developed following research into the local resistance and prescribing trends. New laboratory testing methods and a rapid 24-hour turnaround time to reporting of urine sensitivities enabled the addition of new antibiotics to the local formulary for routine use. These new guidelines were approved by the area prescribing committee, recognising the potential for patient benefit in reducing treatment failures and further rises in resistance rates.
An education programme was implemented to support initial guideline introduction, to cover the 4 local CCGs, with presentations and question and answer sessions with GPs and prescribing advisers. These were designed to be local evidence based, with research indicating that local resistance data is highly valued by GPs.
The initial education programme was subsequently extended to other prescribing groups, who at that time did not receive any training on appropriate use of antibiotics:
- GP registrars
- urgent care practitioners
- community matrons
- community hospital nurse practitioners
Tailored sessions to each group were designed and feedback received with the aim of improving and embedding these sessions into regular training cycles.
Non-prescribing professionals were also recognised to play a vital role in antimicrobial stewardship, so sessions were introduced to cover the following community nursing groups:
- continence specialist nurses
- district nurses
- practice nurses
A resource pack for local patient participation groups was developed by the Committee’s patient representative, with the aim of presentations and resources being disseminated into GP practices through active patient groups.
As a result of this stewardship initiative, there has been a dramatic reduction in inappropriate prescribing for UTIs in Nottinghamshire, and a subsequent drop in local resistance rates in UTI organisms, demonstrating the direct and impressive effects that promoting the safe and responsible use of antibiotics in the community can have on a local population.
Following the introduction of the new UTI guidelines and education campaign, the uptake in nitrofurantoin use as the first-line choice for urinary tract infections has been dramatic, with trimethoprim usage falling significantly. Prior to introduction of the guidelines and education campaign, the 4 South Nottinghamshire CCGs had an average trimethoprim: nitrofurantoin prescribing proportion of 61%. This was in line with the national average. This has since fallen to 23%, with the Nottinghamshire CCGs now having the lowest prescribing ratios in England. This has been achieved whilst continuing to reduce prescribing of broad-spectrum antibiotics (e.g. co-amoxiclav, cefalexin and ciprofloxacin).
With this dramatic reduction in trimethoprim use, the resistance rate for urinary tract E.coli isolates from community patients has fallen significantly. Prior to the guideline introduction and education campaign, the trimethoprim resistance rate for E.coli in community urine samples was 35%; this has now fallen to 23%. This means it is a suitable treatment option for more patients and is likely to be due to the reduction in selective pressure from prescribing in the local community.
By reducing selective pressure through stewardship interventions, we are protecting this useful and effective antibiotic for use in certain groups now, and potentially more widespread use again in the future (using the rationale of cycling the antibiotic formulary). This effect has also been seen in local community-onset bloodstream infection E.coli isolates, with resistance rates falling from 43% to 31%. This means it can be used as a narrow-spectrum intravenous to oral step-down antibiotic option in more patients than previously due to high resistance rates.
Production of new local guidelines on the management of recurrent UTIs has supported local GPs in avoiding starting long-term antibiotic prophylaxis, identifying patients on long-term antibiotics for review, and supporting them in stopping long-term antibiotics where appropriate. This will support the achievement of the Quality Premium in reducing trimethoprim items prescribed to over 70-year-olds, and be added to local CCG Quality, Innovation, Productivity and Prevention (QIPP) plans for 2017 to 2018.
What works well?
- engagement from the start of the initiative with CCG prescribing advisers and GPs, in the development and launch of new guidelines, ensured their buy-in
- education sessions designed and delivered to both prescribing and non-prescribing groups increased the local awareness of antimicrobial resistance, and empowered local healthcare professionals to disseminate good practice and improve antibiotic use in their own areas of practice
Next steps
The introduction of fosfomycin into local community antibiotic guidelines is imminent, supported by a laboratory evaluation and introduction of routine testing of all urine samples sent to the laboratory at Nottingham University Hospitals. This will further improve treatment options for community patients, especially for those with resistant organisms, allergies, or renal impairment. The wider use of fosfomycin for UTIs within the local health economy is currently being planned.
Regular practice-based audit across Nottinghamshire GPs on the use of prophylactic antibiotics over 6 months commenced in April 2017, with practice pharmacists or prescribing advisers flagging patients for review by clinicians using the new local guidelines on management of recurrent urinary tract infections.
Contact: Amelia Joseph, Microbiology Specialty Registrar, Integrated Antimicrobial Stewardship Fellow (Health Education England East Midlands)
This project was the winner of the Antibiotic Guardian Award for Prescribing & Stewardship 2017.
