Dr Rob Wicks recounts how revisiting the guidelines four years on prompted his practice to re-examine their antibiotic prescribing


   

Dr Lockyer's article on which guidelines to adopt ('Applying guidelines to general practice', October) reminded me that, at the Seaside Practice, we had taken the local antibiotic guidelines quite seriously – when they were published. This turned out to be four years ago, and I have them safe in the bottom drawer of my desk – gone, but not forgotten.

Potential savings

Our initial enthusiasm was borne on the back of a severe cash-flow problem. The carrot being waved at the time was that if we could reduce our spending on prescribing, we could use the savings made for patient care on new equipment for the surgery (bulbs for our ophthalmoscopes, for instance).

The guidelines seemed quite straightforward and well thought out. A brief discussion over coffee suggested that they even mirrored our prescribing.

Differences highlighted

We were about to congratulate ourselves and carry on as usual, when I noticed one surprising difference between my prescribing and the guidelines.

I had always used doxycycline as first-line treatment for sinusitis – I'm not sure why. The guidelines, however, suggested I should be using amoxycillin on the grounds of both efficacy and cost (Table 1).

Table 1: East Sussex FHSA prescribing guidelines 1994

Acute bacterial sinusitis

First line
Amoxycillin 250-500 mg three times a day for 5 days
or  
Erythromycin

250-500 mg four times a day for 5 days

Second line

Co-amoxiclav

375-750 mg three times a day for 5 days

Worse was to come. My partners were all doing the same thing – except for one, who famously remarked that he only used Vibramycin – so much for generics. We decided to look at the problem more closely, using our PACT data (Table 2).

Table 2: PACT data on antibiotic use

Antibiotic
Costs (as % of total)
Penicillins
26.90%
Cephalosporins
6.40%
Tetracyclines
29.97%
Macrolides
11.16%
Quinolones

13.29%

PACT data revelations

We couldn't believe what we found. Thirty per cent of our antibiotic prescribing costs were for tetracyclines. Not only were we not following the guidelines, but we were also spending lots of money on acne.

Closer examination revealed that these costs were incurred for only 10% of the total items prescribed, the majority being for doxycycline. This was mirrored in the FHSA figures and the Audit Commission suggested 'benchmark' for 1991 (Table 3).

Table 3: Antibiotic prescribing in the Seaside Practice compared with EAst Sussex FHSA and the benchmark figures suggested by the Audit Commission
Antibiotic
Audit Commission 1991
FHSA 1993/4
Seaside 1993/4
Seaside 1997/8
Penicillins
51.0%
48.0%
52.0%
61.0%
Cephalosporins
8.6%
10.0%
4.7%
5.9%
Tetracyclines
9.8%
10.2%
10.0%

10.0%

Macrolides
13.7%
13.2%
10.9%
17.0%
Quinolones
4.6%
4.9%
3.6%

In most areas, we seemed to be on a par with our peers. However, at the time we all resolved to adhere to the guidelines – particularly for sinusitis.

How did we get on?

The FHSA were able to furnish me with up-to-date figures within a week. The results were only partially encouraging.

We have successfully stopped using doxycycline, as can be seen by a 9% jump in penicillin usage.

However, we still use a lot of tetracyclines – 10% of total antibiotics prescribed. The cost of tetracycline has fallen to 18% of the total.

The remainder of the costs is entirely down to long-acting minocycline preparations. This is bad for two reasons: first, the guidelines suggested erythromycin or oxytetracycline and, second, minocycline is expensive. Happily, as it turns out, this is not our fault! And here the guidelines fall down.

Drawbacks of following guidelines

We refer our difficult acne patients to the local hospital outpatients. The first thing that happens is that they are put on to long-acting minocycline – with instant improvement.

They come back delighted, with a darkly critical look in their eyes. No-one has yet asked "Why couldn't you have done that?", but I am sure that has more to do with teenage reluctance to engage in conversation, than with satisfaction with their GP's performance!

Outside pressure is blowing the guidelines out of the water. Either they are wrong or compliance is a factor – the once-a-day preparations being easier to remember.

The other categories of antibiotic prescribing remain unchanged, apart from a massive increase in macrolides. The majority of this is erythromycin, but 24% was for azithromycin.

External influences

Azithromycin is very effective across a wide range of infections, but that is not why we use it. And it is not mentioned in the guidelines.

The main reason we use it is that we all have young families and know how difficult it is to administer three or four teaspoons of mixture to young children when they are ill.

Not only is azithromycin given once a day, but also the course is only three days long. The final seal of approval is that it is said to work for 10 days!

None of these are good reasons for using antibiotics, but I have to admit to a pang of guilt when I dish out amoxycillin to my patients but prescribe azithromycin for my own family.

The reason for citing this example is to reiterate that guidelines are just that. Other, external influences can come to bear on antibiotic prescribing.

The most rational guideline

The recent Department of Health advice not to prescribe if at all possible is surely the most rational guideline we have been given for a long time.

Somehow my prescribing needed some outside support. It is now much easier not to prescribe than previously.

Were the guidelines useful?

I think so. They made us look at one aspect of our prescribing more closely, and we now stop and think before pushing that prescribing button. Certainly our antibiotic usage is more rational.

What our experience does illustrate is that looking at the guidelines once is no good. Revisiting them four years on has shown that we have slipped in some areas and that religious adherence to guidelines is impractical.

Guidelines in Practice, December 1998, Volume 1
© 1998 MGP Ltd
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