Are insect bites responsible for the rise in summer flucloxacillin prescribing in United Kingdom general practices?

BACKGROUND: Insect bite inflammation may mimic cellulitis and promote unnecessary antibiotic usage, contributing to antimicrobial resistance in primary care. We wondered how general practice clinicians assess and manage insect bites, diagnose cellulitis, and prescribe antibiotics. METHOD: This is a Quality Improvement study in which 10 general practices in England and Wales investigated patients attending for the first time with insect bites between April and September 2021 to their practices. Mode of consultation, presentation, management plan, and reattendance or referral were noted. Total practice flucloxacillin prescribing was compared to that for insect bites. RESULTS: A combined list size of 161,346 yielded 355 insect bite consultations. Nearly two-thirds were female, ages 3-89 years old, with July as the peak month and a mean weekly incidence of 8 per 100,000. GPs still undertook most consultations; most were phone consultations, with photo support for over half. Over 40% presented between days 1 and 3 and common symptoms were redness, itchness, pain, and heat. Vital sign recording was not common, and only 22% of patients were already taking an antihistamine despite 45% complaining of itch. Antibiotics were prescribed to nearly three-quarters of the patients, mainly orally and mostly as flucloxacillin. Reattendance occurred for 12% and referral to hospital for 2%. Flucloxacillin for insect bites contributed a mean of 5.1% of total practice flucloxacillin prescriptions, with a peak of 10.7% in July. CONCLUSIONS: Antibiotics are likely to be overused in our insect bite practice and patients could make more use of antihistamines for itch before consulting.

It can be difficult to know if redness, heat, swelling, and pain from insect bites are due to inflammation or infection. Prescribing unnecessary antibiotics may result in germs becoming resistant to antibiotics when needed. Ten general practices in England and Wales investigated their management of insect bites in the 6 months of April to September 2021 inclusive. There were 355 bites; women presented more often than men, and ages were from 3 to 89 years old, half of them were 30­69 years old. People mainly consulted their GP by phone with photos of their bites. Key symptoms were redness, itchness, heat, and pain. More people had itch than were taking antihistamines or using steroid cream. Most people (nearly 7 out of 10) were prescribed an oral antibiotic, usually flucloxacillin, which accounted for about 5% of total flucloxacillin prescribed in the practices. Only 2 in 100 people needed further hospital care. It is likely that general practice clinicians are over-using antibiotics for insect bites and that home management before seeking medical help with painkillers, antihistamines, and steroid creams could be used more. Now that we have baseline data, there is a need to set up studies to prove that these reduce antibiotic usage.

Broad spectrum antibiotic stewardship by quality improvement methods.

BACKGROUND: With the majority of antibiotics being prescribed in primary care it is of utmost importance that antimicrobial stewardship principles are adhered to in order to slow down the incidence of antimicrobial resistance. OBJECTIVE: Broad spectrum antibiotic prescribing is often seen as a proxy marker of increasing resistance within a population and so it is important that they are used sparingly, to avoid drug-resistant bacteria developing. METHOD: In Tameside and Glossop a novel approach, using quality improvement methods, was employed to allow the behaviour change to be sustained for a longer period. Practices submitted monthly broad spectrum usage data, and if over a set target they were required to submit a "deep dive". RESULTS: A 10.6% reduction of broad spectrum antibiotic usage was seen over the 2019-20 financial year. CONCLUSION: Over time the number of practices submitting a deep dive reduced and clinicians saw the deep dive as method to peer review their prescribing. Putting the practice staff in control of their own prescribing, allowed for a better method to sustain the improvement.

Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing.

BACKGROUND: There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians. METHODS: Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012-2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk-based prescribing. Poisson regression models with random effect for clinicians were fitted. RESULTS: 6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection-related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk-based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year. CONCLUSIONS: The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing.

Increasing the uptake of cervical screening at cornerstone medical practice.

BACKGROUND: Nationally, cervical screening uptake is suboptimal, even though research shows that the programme is highly effective at preventing cervical cancer. LOCAL PROBLEM: Cornerstone is a small practice located in Salford in the North West of England. Historically, screening uptake here has been lower than average. There were 656 eligible women on our practice list and 177 of them were unscreened at the start of the project. The largest group of non-white British or Irish people on our list (13) spoke Polish as their first language. METHODS: We used quality improvement methods: the model for improvement, a driver diagram and Plan, Do, Study, Act cycles. Specifically, we targeted 177 women who were previously non-responders, as well as keeping up the regular screening service. We managed to contact 120 women during the project. INTERVENTIONS: We tested different methods of inviting women to attend cervical screening: telephone calls, text messages and letters. Later, a video link was also included in the text invitation. Information leaflets about the tests were added to letters. The letter was also translated into Polish. RESULTS: Uptake improved and the aim was reached. Telephone calls from the nurse increased uptake but took time away from other work, so was not a sustainable change for our practice. A letter stating evidence basis for the test, and a letter translated into Polish showed limited improvement. Sending letters with information leaflets and text messages with video links achieved similar response rates with no statistical significance when we analysed the data. Offering extended hours and flexible appointment times showed very positive results. CONCLUSIONS: The text message with a video attached was adopted as an effective method for targeting persistent non-responders.The project in its second year is being scaled up across the Primary Care Network.