Dr Cliodna McNulty, PHLS Primary Care Coordinator and Dr Gillian Smith, Consultant Epidemiologist

The Public Health Laboratory Service (PHLS) consists of a network of microbiology laboratories and regional epidemiology centres servicing primary and secondary care across England and Wales. The PHLS network is organised into eight regional groups, a Central Public Health Laboratory, which houses many of the reference laboratories, and the Communicable Disease Surveillance Centre.

The PHLS provides GPs with a diagnostic microbiology service; advice on antibiotic prescribing and the prevention and control of infections; and feedback on surveillance through the Communicable Disease Report Weekly.

Fifty per cent of the specimens handled by the PHLS originate from primary care (personal communication). The fourth national study of morbidity in general practice 1991/21 found that 14% of people in the UK sought at least one consultation for a disease listed in the International Classification of Disease chapter of Infections and Parasitic Diseases. It is estimated that infection is the fifth most common reason for consultation.

The main role of the PHLS is 'Protecting the population from infection'. It achieves this by providing evidence for action to prevent and control infectious disease threats to individuals and populations. The evidence comes from expert analysis and assessment of data generated from the PHLS' own microbiological and epidemiological investigations and other sources. The unique strength of the PHLS lies in the integration of microbiology and epidemiology at every level within the national network.

The PHLS Primary Care Initiative

In recognition of the importance of working in partnership with primary care, in 1998 a consultant microbiologist (Cliodna McNulty) was released from clinical work to develop the PHLS Primary Care Initiative (PCI). Her role as PHLS primary care coordinator was to develop an inventory of current PHLS activities, establish links with potential collaborators and prioritise future primary care service developments and research and development. At the same time a regional epidemiologist (Gillian Smith) was appointed to take a particular interest in communicable disease surveillance in primary care.

A representative from each PHLS group was nominated to attend a quarterly PHLS Primary Care Forum. In March 2001 the posts attained permanent funding and a PHLS Primary Care Advisory Committee was established with a broad membership including GPs, a community infection control nurse, community pharmacists, epidemiologists and microbiologists. The Primary Care Forum and then the Advisory Committee advised on the strategic direction taken by the primary care coordinator and epidemiologist.

A wide range of primary care professionals including chairs of PCGs, GPs and nurses in research networks were surveyed for their opinion on PCI priorities. Workshops were also held with primary care to discuss research and development priorities for, and communication with, the PHLS.2,3

GPs indicated that they wanted more guidance on the diagnosis and treatment of infectious diseases, especially respiratory tract infections, genital chlamydial infections, chronic fatigue, vaginal discharge, antibiotic resistance, leg ulcers and Helicobacter pylori.

Infectious disease guidelines

The importance of local and national infectious disease guidelines was emphasised in the report of the Department of Health's Standing Medical Advisory Committee, The Path of Least Resistance.4 Many microbiologists have produced antibiotic guidance for GPs, but this has been very diverse with no set format.4

As part of the PCI on antibiotic guidance a template was developed in consultation with colleagues in primary and secondary care. This has been posted on the PHLS website (www.phls.co.uk) for use by PCG/Ts across the country (Figure 1). The template can be downloaded and modified locally to take account of local guidance and susceptibility data.

Figure 1: First part of the template guideline for antibiotic use, available on the PHLS website

This antibiotic guidance accords with current guidance from national societies (for example, the British Society for Antimicrobial Chemotherapy, British Thoracic Society and the Association of Genitourinary Medicine) and PRODIGY (Prescribing RatiOnally with Decision support In General practice studY) guidance.5

One of the aims of the guidance is to reduce the development of antibiotic resistance by the rational use of antibiotics. Therefore the authors have collaborated closely with the Clinical Prescribing Subgroup of the Department of Health Standing Interdepartmental Steering Group on Resistance to Antibiotics and Antimicrobial Agents, and the newly formed Publicity Subgroup.

Users of the guidance are encouraged to comment on its format and content, which is updated 6-monthly to take account of new trial and antibiotic susceptibility data. For example, in January 2002 PHLS surveillance data showed that fusidic acid resistance was increasing. The guidance was modified to stress the increasing problem of fusidic acid resistance and the importance of reducing and avoiding the use of topical fusidic acid.

The importance of the GPs' request for guidance on when to use the laboratory for the diagnosis of infection is emphasised by the great variation in use of the service.6,7 A series of qualitative studies with primary care is planned in order to enable the PCI to produce meaningful guidance for GPs. These studies will provide an insight into the diagnostic strategies used and determine reasons for the variation in laboratory use.

For example, development of guidance for the management of urinary symptoms is complicated by variation between practices in laboratory-confirmed bacteriuria in urine specimens submitted. A qualitative study undertaken by the PCI has determined that this variation in urine positivity is due to the differing use of near patient tests.

The guidance for GPs' use of laboratory urine testing aims to reduce the use of antibiotics in treating urinary symptoms and to concentrate the use of the laboratory on complicated urinary tract infection (UTI). The guidance, developed in consultation with GPs, can be found on the PHLS website and has been incorporated into the UK PRODIGY project guidance (Figure 2).5,8

Figure 2: First part of the guidance on urinary tract infection on the PHLS website

Evidence-based guidance on the laboratory diagnosis of Chlamydia has also been produced and other guidance is planned. The PCI is now working closely with the PRODIGY team to ensure that guidance for laboratory use is consistent across the PHLS and PRODIGY. This close collaboration will also prevent duplication of effort and broaden the expertise of the PHLS and PRODIGY teams.

Surveillance of infectious disease

Much of the evidence for action produced by the PHLS comes from surveillance of infectious disease in primary care. Increasing collaboration between the PCI and primary care colleagues involved in surveillance has resulted in close liaison with the Birmingham Research Unit of the RCGP.

The unit's director runs the Weekly Returns Service, a well established scheme of 'spotter' general practices that provides timely information on rates of consultations in general practice by clinical diagnosis.9 One result of this collaboration has been a more detailed analysis of the total burden of morbidity from infection in primary care.

NHS Direct has afforded new opportunities for communicable disease surveillance. Calls to the service can provide data on patients' reported symptoms and countrywide population coverage in real time. The Communicable Disease Surveillance Centre has collaborated with NHS Direct and produces regular bulletins on cold/flu calls. It is developing this monitoring to include a variety of algorithms that may be suggestive of infection in the callers.10,11

The evidence base

For many infections seen in primary care there are deficiencies in the evidence base needed for the development of guidance on management. Areas where evidence is lacking include the impact on clinical and microbiological outcomes of diagnostic tests, antimicrobial treatment, and resistance. One of the priorities of the Advisory Committee is to identify the evidence gaps and facilitate research in these areas.

To this end, the PCI is concentrating on developing closer links with university primary care departments with an interest in the priority research areas, namely antibiotic resistance, respiratory tract infections, H. pylori, STDs and chronic fatigue.

Antibiotic resistance

Concerns over the increasing prevalence of antimicrobial resistant, especially multi-resistant, microorganisms have been highlighted in documents published worldwide by parliamentary and other expert groups4,12 to which the PHLS has contributed.

There is evidence that increased use of antimicrobials in the community may be related to increasing resistance. Thus the PHLS, through its relationships with primary care, needs to rationalise antibiotic use. The PHLS has facilitated this process through publication of antimicrobial resistance surveillance data,13,14 antibiotic guidance, membership of the DoH committees and by modifying patient expectations.

The PCI has been pivotal in the development of school-based antibiotic workshops aimed at 9-12 year olds and has published evidence that these workshops improve children's knowledge of antibiotics and their appropriate use in severe infections rather than in coughs and colds. These school workshops have now been developed into a school educational package funded by the DoH and supported by the DfEE.15

The PCI is also involved with studies to measure the effectiveness of different educational techniques combined with patient leaflets to modify practice prescribing.

The future of the PHLS in primary care

The Chief Medical Officer's report Getting Ahead of the Curve, a strategy for combating infectious disease,16 proposed a new Health Protection Agency combining the existing functions of the PHLS, the National Radiological Protection Board, the Centre for Applied Microbiology & Research and the National Focus for Chemical Incidents.

The agency will provide an integrated approach to protecting the health of the public against infectious disease and will have a strengthened and expanded system of infectious disease surveillance. There will be new action plans to address infectious disease priorities, including antimicrobial resistance, hospital-acquired infection and chronic diseases caused by microorganisms. Standards for diagnosis of infection will be expanded. These action plans will open up new opportunities for the PCI, while it will continue to produce evidence for action.

THE PHLS PRIMARY CARE INITIATIVE
Set up: 1998
Objectives:
  • To act as a focal point for primary care issues within the PHLS
  • To take a lead in the development and ongoing monitoring of antibiotic guidelines and infectious disease diagnostic and management algorithms for primary care
  • To identify research and development activities currently taking place and needs and priorities for the future
  • To identify key organisations and individuals with an interest in developing effective partnerships with the PHLS, which will enhance the development of public health microbiology and communicable disease surveillance in primary care
Funding: PHLS
Key personnel: PHLS Primary Care Coordinator: Dr Cliodna McNulty
Consultant Epidemiologist: Dr Gillian Smith
Contact details:

 

Address: Public Health Laboratory,
Gloucestershire Royal Hospital,
Great Western Road,
Gloucester GL1 3NN
Telephone: 01452 305334/332316
Email: cmcnulty@phls.org.uk and gesmith@phls.org.uk
Website: www.phls.co.uk

References

  1. RCGP, OPCS, DH. Morbidity statistics from general practice 1991-1992. Service MBS No. 3 London: HMSO, 1995.
  2. McNulty CAM, Smith GE, Graham C on behalf of the PHLS primary care coordinators. PHLS primary care consultation – infectious disease and primary care research and service development priorities. Commun Dis Public Health 2001; 4: 18-26.
  3. McNulty CAM, Kane A. Foy CJW et al. Primary care workshops can reduce and rationalise antibiotic prescribing. J Antimicrob Chemother 2000; 46: 493-9.
  4. Department of Health Standing Medical Advisory Committee Sub-group on Antimicrobial Resistance. The path of least resistance. Occasional Report 1998.
  5. Eddy D, Purves IN. PRODIGY. Implementing clinical guidance using computers. Br J Gen Pract 1998; 48: 1552-3.
  6. McNulty CAM, Freeman E, Nichols T, Kalima P. Microbiological investigation of urinary symptoms: different management strategies in primary care. Submitted to Br J Gen Pract.
  7. Smellie WSA, Galloway MJ, Chinn D. Benchmarking general practice use of pathology services – a model for monitoring change. J Clin Pathol 2000; 53: 476-80.
  8. Watson N. Improved PRODIGY will include chronic disease management. Guidelines in Practice 2001; 4: 96-101.
  9. Fleming DM. Weekly Returns Service of the Royal College of General Practitioners. Commun Dis Public Health 1999; 2: 96-100.
  10. Department of Health. Saving lives: our healthier nation. London: Stationery Office, 1999 (Cm 4386).
  11. Harcourt SE, Smith GE, Hollyoak V et al. Can calls to NHS Direct be used for syndromic surveillance? Commun Dis Public Health 2001; 4: 178-88.
  12. World Health Assembly Resolution. Emerging and other communicable diseases. Antimicrob Res 1998; 51: 16.
  13. Magee JT, Pritchard EL, Fitzgerald KA et al on behalf of the Welsh Antibiotic Study Group. Antimicrobial prescribing and antibiotic resistance in community practice: retrospective study, 1996-8. Br Med J 1999; 319: 1239-40.
  14. Priest P, Yudkin P, McNulty C, Mant D. antibacterial prescribing and antibacterial resistance in English general practice; a cross-sectional study. Br Med J 2001; 323: 1037-41.
  15. McNulty CAM, Swan AV, Boland D. Schools antimicrobial resistance NAP campaign – a pilot study. Health Education 2001; 101(5): 235-42
  16. Department of Health. Getting Ahead of the Curve: a strategy for combating infectious disease. Chief Medical Officer's report. London: DoH, 2002.

Guidelines in Practice, June 2002, Volume 5(6)
© 2002 MGP Ltd
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