Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care.

Objectives: To assess the appropriateness of prescribing systemic antibiotics for different clinical conditions in primary care, and to quantify 'ideal' antibiotic prescribing proportions in conditions for which antibiotic treatment is sometimes but not always indicated. Methods: Prescribing guidelines were consulted to define the appropriateness of antibiotic therapy for the conditions that resulted in antibiotic prescriptions between 2013 and 2015 in The Health Improvement Network (THIN) primary care database. The opinions of subject experts were then formally elicited to quantify ideal antibiotic prescribing proportions for 10 common conditions. Results: Of the antibiotic prescriptions in THIN, 52.5% were for conditions that could be assessed using prescribing guidelines. Among these, the vast majority of prescriptions (91.4%) were for conditions where antibiotic appropriateness is conditional on patient-specific indicators. Experts estimated low ideal prescribing proportions in acute, non-comorbid presentations of many of these conditions, such as cough (10% of patients), rhinosinusitis (11%), bronchitis (13%) and sore throat (13%). Conversely, antibiotics were believed to be appropriate in 75% of non-pregnant women with non-recurrent urinary tract infection. In impetigo and acute exacerbation of chronic obstructive pulmonary disease, experts clustered into distinct groups that believed in either high or low prescribing. Conclusions: In English primary care, most antibiotics are prescribed for conditions that only sometimes require antibiotic treatment, depending on patient-specific indicators. Experts estimated low ideal prescribing proportions in many of these conditions. Incomplete prescribing guidelines and disagreement about prescribing in some conditions highlight further research needs.

Reducing diazepam prescribing for illicit drug users: a randomised control study.

Illicit drug users undergoing mandatory reductions in prescribed diazepam were randomly allocated to one of two methods of delivering psychological support to help reduce their prescription: a) an enhanced intervention consisting of skills training and reinforcement, and b) a limited intervention where patients initially received skills training and thereafter only advice. Outcome measures at baseline and six-months consisted of daily diazepam dose; reported illicit drug use; Severity of Dependence Scale; Hospital Anxiety and Depression Scale (HADS); Pittsburgh Sleep Quality Index. Fifty-three of 119 eligible patients agreed to be randomly allocated to the interventions. Those in the enhanced intervention reduced their daily dose of prescribed diazepam from a mean of 27.8 mgs to 19.9 mgs at six months (5.3% per month) compared with 29.8 mgs to 17.6 mgs at six months (7.5%) among those in the limited intervention group. However, there was no statistically significant difference in the reduction rate between the intervention groups. Approximately 75% of patients in each group suspended their reduction programme. The enhanced intervention group reported a statistically and clinically greater reduction in the mean HADS depression score (10.6 at baseline and 7.7 at follow-up), compared with a rise from 8.9 to 11.2 in the limited intervention group. In conclusion, it is possible to reduce prescribed diazepam among illicit drug users but not at the rate of 10% per month set by the study. The difficulties of working with this population necessitate a flexible and possibly long-term approach to reducing prescribed benzodiazepines.