1. An audit of the use of antibiotics in the treatment of upper respiratory tract infections (URTIs) in children aged between 0- 10 years in a GP surgery in Newbridge, Co. Kildare, Ireland. Dr JJ Flynn, Dr M McDonnell, Dr M O’Doherty Newbridge family practice. TCD / HSE Specialist Training Programme in General Practice. Introduction  URTIs are common presentations in general practice. According to the WHO for every 100 respiratory infections, only 20% require antibiotic treatment (1).  URTIs create difficult clinical situations, are associated with considerable maternal anxiety and occasionally the belief that an antibiotic is required to treat what is in effect a self-limiting illness.  Over-prescribing of antibiotics is common and associated with increasing resistance to antibiotics ; 50% of antibiotic use is by humans (of which 80% occurs outside of hospitals), and 20-50% of this is unnecessary (2).  NICE guidelines for prescribing antibiotics for self limiting infections in children suggest a no antibiotic or delayed antibiotic strategy for patients with URTI, unless there is a risk of developing complications when antibiotics should be prescribed immediately (3).  A recent Cochrane report showed there was no difference in clinical outcome between delayed, immediate and no antibiotic policies for respiratory infections (4).  Concern was raised during a practice meeting about over-prescribing of antibiotics in the surgery, especially in the treatment of URTI in children. There was no practice formulary and it became obvious through this discussion that different doctors were managing URTI differently leading to some variability in treatment that may or may not have been evidence based. Therefore it was decided to perform an audit of the treatment of URTI in children. Audit method  Cycle 1; a retrospective review of the practice database; patients aged between 0-10 years who attended between 1st Oct 2008-28th Feb 2009 with a diagnosis of viral URTI or tonsillitis. The diagnosis and treatment plan (immediate, delayed or no antibiotic) was recorded.  Compare current practice with gold standard.  Introduce and implement change A practice guideline for treating URTIs was created using the clinical guidelines published by NICE, The Royal Children’s hospital Melbourne and Our Lady’s Hospital Sick Children Crumlin (Figure 1). Parental education about the aetiology and natural history of URTIs, and the role of antibiotics in the management of viral illnesses.  Cycle 2: The search of the database was repeated to identify patients with a diagnosis of viral URTI or tonsillitis who attended between 1st Oct 2009-28th Feb 2010 to determine if prescribing attitudes had changed. Acknowledgements Many thanks to Dr. Michael McDonnell, Dr. Mary O’Doherty, Dr. Catherine Darker, Dr. Brendan O’Shea and Lisa O’Leary for their help throughout this audit. Conclusions  This audit highlights the benefits of reviewing current literature, assessing current practice and implementing appropriate changes in line with best practice. Cycle 1Cycle 2 No patients4588 Female2540 Male2048 Treatment No antibiotics07 (8.6%) Reserve prescription2 (4%)39 (48%) Antibiotics45 (100%)81 (92%) Phenoxymethylpenicillin3 (7%)61 (75.3%) Cefaclor19 (42%)12 (14.8%) Co-amoxiclav21 (41%)6 (7.4%) Amoxicillin1 (2%)1 (1.2%) Clarithromycin1 (2%)1 (1.2%) Table 2; Results of audit on treatment of tonsillitis in children. Cycle 1Cycle 2 No. patients68/17086/302 Female3539 Male3447 Findings on exam Normal exam36 (53%)43 (50%) Pyrexial3 (4.4%)9 (10%) Tonsils enlarged erythematous 14 (21%)28 (33%) Acute otitis media3 (4.4%)4 (5%) Rash3 (4.4%)0 Pharyngitis11 (16%)15 (17%) Treatment No antibiotics30 (44%)55 (64%) Reserve prescription18 (26%)27 (31%) Antibiotics20 (29%)4 (5%) Table 1. Results of audit for the treatment of URTI. Diagnose bacterial tonsillitis Plan; Immediate antibiotics (Kopen as per BNF, tastes nicer!) Supportive management Counsel Review if deteriorates Diagnose EBV infection Diagnose Viral URTI; incl viral tonsillitis History; Presenting symptoms Duration of illness Background Relevant comorbitities Examination Features of URTI Hx and Ex suggest EBV infection (ie may be assoc with fever, malaise, lymphadenopathy History; Short duration of symptoms Otherwise well Eating and drinking normally Examination; Normal Hx and Ex suggests bacterial tonsillitis (Features of Group A strep infection; fever, Pharyngo-tonsillitis, tender tonsillar LN) Supportive management Counsel and reassure antibiotic not required Review if deteriorates, no improvement or parental concerns Hx and Ex suggest uncomplicated AOM, systemically well Hx and Ex suggest complicated AOM, ( i.e. systemically unwell; underlying condition; <6/12 age; 6/12 to 2 years with severe symptoms) Supportive management Counsel and reassure antibiotic not required Topical analgesia, eardrops Review if deteriorates, no improvement or parental concerns Supportive management Topical analgesia Immediate antibiotic amoxicillin 15 mg/kg/dose TDS or co-amoxiclav 15 mg/kg/dose Review 48 hours, if no improvement switch to co-amoxiclav Figure 1; Protocol for the treatment of URTI from Oct 1 st 2009- Feb 28 th 2010 References 1)WHO website 2)Antimicrobial resistance, Wise et al., 1998, BMJ 1998, vol 317, pg 609-610 3) NICE clinical guideline 69 Respiratory tract infections- antibiotic prescribing. (July 2008) 4)Delayed antibiotics for respiratory infections. Spurling et al., Cochrane database of systematic reviews 2007. Results 170 patients were identified with a diagnosis of viral URTI in cycle 1 compared to 302 in cycle 2. These results are presented in table 1 and illustrated in figure 2. Similarly more patients were identified with a diagnosis of tonsillitis in cycle 2 (table 2, figure 3). Figure 2; Comparison of the treatment of URTI between cycle 1 and cycle 2. (Abx =antibiotic). Figure 3; Comparison of the antibiotics used in the treatment of tonsillitis between cycle 1 and cycle 2. Discussion  The clinical presentation of URTI was similar in both audit cycles (Table 1)  The increase in attendances may have been due to the outbreak of H1N1, an especially cold winter in Ireland or an increased awareness of the Doctors when recording the diagnosis.  Changes in prescribing patterns were evident after cycle 2.  Fewer antibiotics were used for the treatment of URTIs. 95% of patients received no antibiotics or delayed antibiotics (Table 1). There was an extensive national health promotion campaign in Ireland highlighting the natural history of viral illnesses and the role of antibiotics. Parents were more aware of viruses, their effects and treatment, and possibly more accepting of the wait and see approach.  There remained variance between doctors as cefaclor, amoxicillin and co-amoxiclav were used as reserve prescriptions for URTIs (unshown data)  Cefaclor use for the treatment of tonsillitis was reduced  The use of documented reserve prescriptions for tonsillitis increased from 4% to 48%.  Phenoxymethylpenicillin was used more to treat tonsillitis whereas co-amoxiclav was used less as per guidelines (Table 2). % antibiotic use Antibiotic used Treatment option