ANTIBIOTICS


in 2014. This was the third successive annual reduction and was 374, 500 fewer items and 9.5 per cent lower than the highest rate of prescribing observed in 2012. Only once in the last 20 years (2004) has the prescribing rate been lower than in 2015.


The proportion of the Scottish population who received at least one antibiotic item was 29.6 per cent in 2015 and is the lowest proportion on record since 2010, when data was first available.


Despite the progress that has been made, SAPG has, however, pointed out that considerable variation still exists in antibiotic prescribing rates between GP practices and has urged practices to reduce their rates of unnecessary prescribing - particularly those which have higher rates of antibiotic use. (In 2015, GPs accounted for 86.6 per cent of antibiotic use in primary care.)


In order to assist GP practices with this objective, in April of this year, SAPG launched a phased programme of providing GP practices with personalised feedback on their own antibiotic prescribing data. As a result, some practices now receive quarterly reports containing their rates of antibiotic prescribing compared to local and national benchmarks.


In addition to the prescribing reports, during the winter of 2015/16, SAPG also tested the feasibility of using C-reactive protein near patient testing as a diagnostic aid to support clinicians to reduce antibiotic prescribing in lower respiratory tract infections. This initiative demonstrated the benefits of using this test in supporting appropriate prescribing, and also showed that it could be integrated into current GP consultation processes. Patients, SAPG found, were reassured by use of the test.


SO WHICH ANTIBIOTICS ARE BEING USED?


SAPG’s second key strategic objective is to reduce the inappropriate use of broad spectrum antibiotics.


The initial focus on reducing broad spectrum antibiotic use was intended to support the reduction of Clostridium difficile infection (CDI), as the use of particular broad spectrum antibiotics (including cephalosporins,


co-amoxiclav and fluoroquinolones) is associated with a higher risk of CDI.


It is increasingly recognised that it is equally important to reduce inappropriate use of broad spectrum antibiotics to preserve their effectiveness and slow the development of AMR.


In 2015, there were reductions in the use of co-amoxiclav (4.9 per cent), fluoroquinolones (5.8 per cent) and cephalosporins (6.0 per cent). These broad spectrum antibiotics together accounted for 8.0 per cent of total antibiotic use in primary care, the lowest proportion on record.


SAPG has supported development of antibiotic prescribing policies in primary care using an evidenced based template which has had a considerable impact on the choice of antibiotic used with a 64.0 per cent reduction in the use of broad spectrum antibiotics since 2008. There has also been an increase in the antibiotics recommended in prescribing policies for the first line empirical treatment of infections commonly encountered in primary care.


According to William Malcolm, Pharmaceutical Adviser at Health Protection Scotland, the findings of the report are welcome, but, says William, there’s still a lot of work to be done.


‘There’s no doubt that antibiotics revolutionised medical practice during the 20th century. Antibiotics are vitally important for fighting serious infections such as pneumonia and meningitis, and they have become the cornerstone of modern healthcare. Indeed, surgical operations are much safer and in some cases only possible because antibiotics can prevent or treat post-surgery infections and those caused by powerful chemotherapy treatments. If antibiotics lose their effectiveness, key medical procedures (such as gut surgery, caesarean sections, joint replacements, and treatments that depress the immune system, such as chemotherapy) could become much more dangerous to perform. In short, antibiotics are central to how we deliver healthcare across the country.


‘Having said that, it’s clear that through overuse and inappropriate use across the world, we are now witnessing the increasing development


of resistance to antibiotics and so healthcare professionals and the public need to work together in ways in which can preserve antibiotics to ensure that they continue to work.


‘The warnings regarding antimicrobial resistance are both ominous and alarming. In his May 2016 Review on Antimicrobial Resistance, for example, the author, Professor Jim O’Neill, states that, if we don’t find proactive solutions now to slow down the rise of antibiotic resistance, by 2050, ten million lives a year and a cumulative 100 trillion USD of economic output are at risk. Even today, 700,000 people die every year of resistant infections across the world.


‘Our report shows that some progress is being made in reducing the use of antibiotics in primary care in Scotland, which is to be welcomed. I’m well aware of the great work that’s being done by both the Scottish Antimicrobial Prescribing Group and by clinicians working across the NHS. Everyone is focussed on reducing prescribing antibiotics in primary care and it’s clear that the good work appears to be paying off. We do, however, need to do more and to remain forward looking.


‘I firmly believe that community pharmacists can make a major contribution in this area. One of the main reasons for antibiotics being prescribed in primary care, for example, is for respiratory tract conditions such as sinusitis, middle ear infections and coughs. There is now, however, good evidence that in many of these infections antibiotics are not required and so community pharmacist can play an important role in supporting patients to self manage these conditions. SAPG developed a Community Pharmacy version of the RCGP self-care leaflet which is available on their website. This can be customised by the Pharmacy team to provide detailed advice for patients on self care, symptom duration and signs that may indicate serious infection requiring medical advice. Community Pharmacists can also help to highlight the problems of antimicrobial resistance through activities for European Antibiotic Awareness Day held annually in November. This year the Public Health campaign for October – November will feature an antibiotic resistance poster giving pharmacists the opportunity to discuss the issues with patients and the public.’ •


ANTIBIOTIC USE AMONG CARE HOME RESIDENTS


The report’s findings clearly indicate the problems faced by care home residents: a vulnerable patient population which may be more susceptible to infection as a result of increasing age and co-morbidities.


The fact that these residents live in close proximity to other older people indicates that there is an increased risk of transmission of infection, and so the care home setting plays an important role in the epidemiology of AMR and may become a reservoir for resistant strains of bacteria.


The report contains data on antibiotic use among this section of the population thanks to the fact that, when an individual becomes a care home resident, their CHI number is linked with a marker which designates them as living within a care home. As CHI numbers are captured on NHS prescriptions, anonymised analysis of antibiotic use among care home residents becomes possible.


In 2015, there were 90, 530 antibiotic items dispensed to people known to be care home residents, accounting for 2.3 per cent of total antibiotic use in primary care in Scotland. The rate of antibiotic prescribing in care home residents ≥65 years was 5.6 items/1000/day which is 83.1 per cent higher than observed in all individuals aged ≥65 years (3.1 items/1000/day).


However since 2012, there has been a more pronounced reduction in the antibiotic prescribing rate in care home residents aged ≥65 years (7.8 per cent) compared to all individuals aged ≥65 years (5.1 per cent). This may be due to increased awareness amongst GPs and care home staff about prudent use of antibiotics which has featured in SAPG guidance specifically aimed at older people.


SCOTTISH PHARMACIST - 27


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