1. Facilitator Notes
This session starts with a general overview outlining why there is still a need to reduce unnecessary prescribing.
Part 1 then explores the groups current understanding of using antibiotics in common RTIs before providing them with the actual evidence of benefit (or lack of). Decision support scoring is also highlighted where available to support risk assessment.
Part 2 looks at strategies to reduce prescribing such as delayed prescribing, patient education resources, and CRP testing.
Ideally part 1 and 2 are expected to be delivered together. If there are time restraints they can, however, be delivered independently.
For a full list of the ScRAP sessions available please see resource pack.
Aims and objectives are outlined on the next page.

2. Facilitators Notes
Aim and objectives as per slide

3. Facilitators Notes
It is important to recognise that this is not about restricting the use of antibiotics in all patients, as there are some for whom antibiotic use is clinically indicated.
This useful quote from a paper in the BJGP in 2009 accurately reflects the purposes of this educational resource in that it is not intended that we should prescribe as few antibiotics as possible.
Our focus should be on identifying the group of patients who really need antibiotics and to explain, reassure and educate the large group of patients who don’t.

4. Facilitator Notes
The following six slides look at the evidence that suggests there is still unnecessary use of antibiotics.
This includes reflecting on your own prescribing volumes and how they compare to your peers.

5. Facilitator Notes
Answer Q1 (skip if you have already answered this in ScRAP session on Resistance and HAI)
At least 30% of all antibiotics are unnecessary according to data published in the Journal of the American Medical Association (JAMA) by the Centre for Disease Control and Prevention (CDC) in the US. The study looked at antibiotic use in GP practices and emergency departments (ambulatory care) during and found that most of these unnecessary antibiotics were prescribed for self-limiting RTIs – including common colds, viral sore throats, bronchitis, and sinus and ear infections.
When prescribing for respiratory tract infection alone was looked at, 50% of these deemed to have been prescribed unnecessarily.
These excess prescriptions each year put patients at needless risk of side-effects, allergy, HAI e.g. Clostridium difficile, and add to antibiotic resistance. (JAMA. 2016;315(17):
Although this data relates to the US we also still have scope in the UK to reduce prescribing for self-limiting infections. As a result, government targets to reduce total volumes in primary care continue.
Answer Q2 and 3
A 2014 UK poll of 1000 GPs found that:
28% prescribe antibiotics several times a week when they are not sure medically indicated
45% have prescribed even when they think it is a virus (55% if you qualified before 1980….)
90% do so because of patient pressure (this is covered in the session on patient expectations and understanding)
70% do so as unsure if virus/ bacteria
24% say it is because of lack of availability of diagnostic tools
NESTA survey
This session will focus on supporting you to make a decision on the risk/ benefits of prescribing and explores some tools that can help assessment and safety netting. You may also find it helpful to undertake the session on Public Understanding and Expectations if this has been mentioned as a reason for prescribing unnecessarily.

6. Facilitators Notes
This graph illustrates that although use is highest in the elderly (40-50% of 65-85yr olds had an antibiotic in 2015) there is notable level of prescribing of around 30% for those yrs – many of whom are unlikely to have other risk factors such as co-morbidity. In particular there is a steep increase in the age range years old.
It is worth thinking about risk benefit in these different groups and whether there is scope for you to reduce unnecessary prescribing.

7. Facilitator to have practice level information on total volume of antibiotic prescribing compared to relevant practices *NOTE you can omit this slide if already discussed in another session*
Facilitator Notes
This graph demonstrates that across NHS Scotland there is still considerable variation between GP practices in antibiotic prescribing rates. Opportunities therefore remain to reduce unnecessary prescribing. Higher comparative prescribing rates in some practices can indicate a lower threshold for giving antibiotics to patients. In the next slides we will explore information and tools to support risk assessment and management.
How do you compare?
Use the practices own prescribing data compared to peers where available. Ask them – ‘what are your thoughts on how you compare?’ to find out if this is where they expected to be.

8. Facilitator Notes
The case to change – consequences of prescribing ‘just in case’.
Although dates back to 1997, the study by Little et all showed that current and previous (12 months prior) antibiotic prescribing increased likelihood of future consultation (hazard ratio 1.39 times for current prescribing and 1.69 for additional). The same study showed that where delayed/ no prescribing was utilised early return consultations and complications were rare. Delayed prescribing is discussed further later on.
The more recent study (2014) by Little et al showed that where patients were given immediate antibiotics, 97% took them and 93% strongly believed in them. This compares to 66-74% in the no/delayed prescribing groups. So giving a prescription for antibiotics when they are not indicated will reinforce the health belief the are needed.
Adopting a common approach to making self-management and patient education the preferred treatment strategy for patients with self-limiting illness is extremely important. If one prescriber takes the time to educate a patient/ carer and another prescriber (within or outwith hours) gives them an antibiotics even when unnecessary, this can severely undermine the doctor patient relationship/ trust.
It can be easy to think that you are doing the best for a patient by giving them antibiotics, particularly if that’s what you think they want, but in cases where the infection is likely to get better on it’s own and the risk of deterioration is low, you may actually be causing them harm. The next slide illustrates this harm.

9. Facilitator Notes
This slide gives a visual representation of adverse effects for otitis media (7%) and rhinosinusitis (13%). Given that 30% of the population receive at least one antibiotic a year this could be extrapolated to significant numbers of patients. Also it is important to remember this is only the visible harm that antibiotic exposure causes and not other aspects such as resistance.
Remember: Antibiotics are the only medicine we give to one patient that can directly affect another (through transfer of resistant organisms) but do we always treat them with the care they deserve? You also put the patient at risk of healthcare associated infections (HAI) such as Clostridium difficile infection– of which community associated cases now account for a notable proportion (29% in 2015).
There are also some less common severe adverse effects linked to specific classes of antibiotics
In July 2016, the FDA issued a safety warning relating to fluoroquinolones. This followed a safety review which showed that fluoroquinolones when used systemically (i.e. tablets, capsules, and injectable) may be associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system. As a result drug labels and Medication Guides for all fluoroquinolone antibacterial drugs were updated. They have called on fluoroquinolones to be used only when there are no alternative treatment options.
A Danish study published in the BMJ in 2014 found a significantly increased risk of sudden death due to clarithromycin. In practice this has lead to a heightened awareness of the risk of QT prolongation and the importance of recognising drug interactions which increase the risk.

10. Facilitator Notes
The infection intelligence platform (IIP) supports the infection community in Scotland by providing integrated information on infection (for example, by combining risk factors, demographics, healthcare activity, medicines usage and clinical data) and enabling better analysis of infection information to improve patient outcomes and reduce harm from infection.
By bringing information together in this way, IIP can be used to measure the intended and unintended consequences of antimicrobial stewardship interventions. IIP is an innovative approach to enhancing and linking infection data held within NHSScotland in a single secure platform. IIP improves the utility of existing datasets, through a 'collect once, use often' approach.
An example of their work is ‘Measuring Potential Unintended Consequences of Interventions to Reduce Primary Care Antibiotic Use’ which sought to determine if the reduced rate of total antibiotic prescribing seen over the past few years had resulted in an increased rate of serious bacterial infections as potential complications of undertreatment. No association was found which helps reassure us.
This failure to observe negative consequences is also backed up by Swedish data. Between 1995 and 2004, antibiotic use for outpatients decreased from 15·7 to 12·6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5–14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Sweden subsequently set a further reduction target due to ongoing concerns about resistance, despite having significantly lower prescribing rates than the UK.

11. Facilitators Notes
The following slides cover the acute conditions listed above

12. Facilitators Notes
We first focus on the risk benefit of antibiotic prescribing for upper RTI infections i.e. sore throat, rhinosinusitis, otitis media

13. Facilitator Notes
Ask the participants the questions on the slide.
Answer
1. They should mention both symptom history (duration of symptoms, fever, whether there is cough) as well as physical examination of tonsils for inflammation and exudate. How these translate to action will depend on the severity. Use of scoring to support this is discussed on the next slides.
2. Without antibiotics 40% will resolve after 3 days and 90% after 7 days (so basically most patients will get better themselves in around a week)
3. Antibiotics reduce duration of pain symptoms by about 1 day. The number needed to treat for benefit = 6 at day 3 and 21 at day 7 to prevent one sore throat.
4. Antibiotics can reduce the chance of rheumatic fever by more than two-thirds in communities where this complication is common (not the case in UK). Other complications associated with sore throat are also reduced through antibiotic use. However it should be noted though that protecting sore throat sufferers against complications in high-income countries requires treating many patients with antibiotics for one patient to benefit. Spinks et al. Antibiotics for sore throat. Cochrane database for systematic review published 5 November 2013
So analgesia and self-management should be utilised where appropriate to manage the symptoms and the patient educated and reassured on the expected duration of symptoms and the self-limiting nature of the condition.
In relation to risk of not treating the following slide has some statistics that may help provide reassurance.

14. Facilitator Notes
As per slide

15. Facilitators Notes
This score has recently been adopted in the Public Health England primary care infection management guidance. It is thought to be more sensitive at identifying low risk cases not requiring antibiotics than CENTOR scoring which you may be more familiar with. With CENTOR if you had 3 or more of tonsillar exudate, tender anterior cervical lymphadenopathy, history of fever, absence of cough – you would be more likely to need an antibiotic .
FeverPAIN score results in patients being in one of three risk bands depending on the likelihood of streptococcal infection, and gives proposed actions. It is intended to be used alongside clinical assessment to help support rationale decision making on the need for an antibiotics. It can also be used in discussion with patients to reassure them on your decision.
The study below which used the score results in 29% reduction in antibiotic use, and faster symptom resolution. If you would like to know more of the detail of this study – see below.
Signposting Reference
‘A UK study in the BMJ in 2013 involving 631 patients with acute sore throat 3 yrs or older found that compared to delayed prescribing (control) using the feverPAIN score to target prescribing reduced antibiotics by 29%. Rapid antigen testing (in practice) reduced antibiotic use by a similar amount -27% - suggesting this was not any better at targeting prescribing than using the scoring. Patients in the scoring arm also had a quicker resolution of symptoms than in the delayed arm. This showed that using clinical scoring can support targeting of prescribing and help GPs reassure patients when antibiotics are not needed.’

16. Facilitator Notes
Using the feverPAIN score 62% of those that scored 4+ (immediate antibiotics recommended) were found to have Streptococcus
Using CENTOR 48% of those had a score 3+ (antibiotics recommended) were found to have Streptococcus – so more patients may end up treated unnecessarily is using CENTOR
FeverPAIN appears to be more sensitive to identifying patients likely to have Streptococcus

17. Facilitator notes
It may help to identify a case in advance which will help illustrate how the score can help reduce unnecessary use in practice.
You can always do this as a follow up exercise if no case ready to hand.
It would be helpful to still have the discussion about how they may see it being used in their practice though.

18. Facilitator Notes
Ask participants questions on the slides
Answers
There is a limited role for antibiotics in acute rhinosinusitis which is usually caused by a viral upper respiratory tract infection of which only 0.5% to 2% of cases are estimated to be complicated by a bacterial rhinosinusitis (i.e % viral). If there is purulent nasal discharge an antibiotic could be considered or delayed for a further 7 days. Consider ENT referral for patients with persistent infection.
80% resolve in 14 days with no antibiotics.
Antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster after 7 to 14 days if they receive antibiotics instead of placebo, or 18 participants will need to be treated with antibiotics for one extra patient to be cured more quickly. However, for every eight patients treated with antibiotics one patient experiences an adverse event caused by the treatment. The rate of serious complications was very low in both the placebo and antibiotic treatment groups.
There was no additional benefit of antibiotics in older patients, more severe pain or longer duration of symptoms
This would suggest a role for simple analgesia and self management. Topical decongestant sprays may also help e.g. xylometazoline.
References
Lemiengre MB et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane database for systematic reviews. Published Oct 2012

19. Facilitators Notes
As per slide
Summary slide of previous slides discussion

20. Facilitators Notes
Ask the participants the questions on the slide
Answers
a. Bilateral acute otitis media in children younger than two years (NNT 4)
b. Bulging membrane with 4 or more marked symptoms
c. All ages with otorrhoea (NNT3)
Important to optimise symptomatic relief as first step.
Above reasons make antibiotic treatment more likely to be required but depending on the severity prescribing could still be delayed by 2 to 3 days.
See ‘public understanding and expectations’ session for materials that can be used with a parent/ carer during a consultation.
% cases resolve spontaneously. 60% of children are better within 24 hours and antibiotics have no effect on symptoms and 90% of children are better in 2 to 7 days
3. Antibiotics have only a small effect on reducing pain by 16 hours (NNT =15). Antibiotics do not prevent deafness. Antibiotics to prevent Mastoiditis NNT > As the main impact is on pain this would suggest a role for simple analgesia and self management.
Reference
Venekamp RP et al. Cochrane Review Antibiotic for ear infection (acute otitis media) in Children. January 2013
Sanders et al. Antibiotics for acute otitis media in children. Cochrane database for systematic reviews issue

21. Facilitators Notes
The most important treatment is pain relief. Even if antibiotics are indicated they do not relieve pain in the first hours.
In addition, children prescribed amoxicillin for acute otitis media (AOM) are about 50% more likely to have recurrence of this over the following three years, compared with those given placebo. For every 5 children treated with amoxicillin, one had a recurrence of AOM who would not otherwise have done so.
There were no significant effects on rates of related referrals or ENT surgery.

22. Facilitator Notes
This section now looks at the risk benefit of prescribing in lower respiratory tract infection

23. Facilitators Notes
Ask the participants the questions on the slide
Answers
Will depend on medical history and co-morbidities. In healthy communities, there is little evidence of bacterial infection in people with bronchitis. If no co-morbidity advice could be given and an antibiotic delayed for a further 7 days to see if the patient improves on their own.
Symptoms generally last for two weeks but the associated cough can last for up to eight weeks. Often a duration of 3 weeks is suggested in patient educational resources. NICE guideline can be used to quantify risk due to co-morbidity (see next slide). Patients often underestimate how long a cough will naturally last.
3. Antibiotics reduced symptoms by only one day in an illness lasting up to 3 weeks. The available evidence suggests that there is no benefit in using antibiotics for acute bronchitis in otherwise healthy individuals (though more research is needed on the effect in frail, elderly people with multi-morbidities who may not have been included in the existing trials). The use of antibiotics needs to be considered in the context of the potential side effects, medicalisation for a self-limiting condition and costs of antibiotic use, particularly the potential harms at population level associated with increasing antibiotic resistance.
Reference
Smith SM et al. Antibiotic treatment for people with a clinical diagnosis of acute bronchitis Cochrane database for systematic reviews. Published March 2014

24. Facilitator Notes
As per slide
There is a large body of evidence including meta-analyses and systematic reviews that does not support routine antibiotic use.

25. Facilitators Notes
As per slide
Facilitators may wish to give prescribers a copy of the flowchart from NICE CG69 – available within the full guidance
Note that this is only a pragmatic approach to risk and decision making. Most of the trials mentioned in the Cochrane slide earlier excluded higher risk patients including elderly.

26. Facilitator Notes
The above STARWAVe scoring system to determine a child’s risk of hospitalisation was published in 2016.
It is based on research done by the University of Bristol to identify factors correlating to hospitalisation risk.
Reasons for development of the tool included earlier research suggesting that there is a low threshold to prescribing in children and antibiotics are often prescribed ‘just in case’.
As it has just been published at the time of writing, more experience in practice is likely to be required.
The authors hope that it can help reduce prescribing in low risk groups.
The next slide illustrates some additional factors that can limit infection occurring in the first place in children

27. Facilitators Notes Vaccination
Childhood mortality from infection has reduced dramatically over the last years and now sits at low levels
Preventing infection from occurring is the easiest way to avoid prescribing antibiotics
UK vaccination schedules have had great success in this respect. Ensuring all those relevant for vaccination, including those entering the country is extremely important
Even prior to vaccination risk of pneumonia of children treated with antibiotics for URTI was 5.7 per 10,000 vs 8.8 per 10,000 for those not treated i.e. Not prescribing antibiotics for those presenting with URTI’s would result in additional 3.1 cases of pneumonia per 10,000 (BMJ 2007; 335:982)
Breastfeeding
Another factor that can reduce the incidence of infection is breastfeeding – particularly where this is exclusive and prolonged. A study in 2007 found that an estimated 53% of diarrheal hospitalizations could have been prevented each month by exclusive breastfeeding and 31% by partial breastfeeding. Similarly, 27% of lower respiratory tract infection hospitalizations could have been prevented each month by exclusive breastfeeding and 25% by partial breastfeeding.
Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Paediatrics 2007
In 2015/ at 10 days across all of Scotland 49.3% of all mothers breastfeeding – this includes 35.6% exclusive breastfeeding (EBF) and 13.7% mixed breastfeeding (MBF). At the 6-8 week visit/baby check: across all of Scotland 38.9% giving some breastmilk (either EBF or MBF)
At 10 days, there is considerable variation across health boards with the lowest being 23.7%. There has been very little change over the past 10 years – slight increase in the numbers breastfeeding, but an increase in the number mixed breastfeeding.

28. Facilitators Notes
It is really important that patients understand the natural duration of self-limiting respiratory tract infections.
Evidence suggests that this is often poorly understood, in particular in relation to cough, where symptoms may be expected to last 2-3 weeks (but cough may last up to 8 weeks if post viral cough).
Reference
Ebell MH et al. How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature. Ann Fam Med January/February :5-13; doi: /afm.1430

29. Facilitators Notes
Immediate antibiotics or further investigation would be justified in the above situations.

30. Facilitator Notes
If you are moving straight on to delivering part 2 – you may wish to wait until the end to have this discussion

31. Facilitators Notes
We have already discussed the evidence base and infection specific scoring systems and how these can help support quantification of risk.
This last part of the session looks at general strategies that can be adopted to support a reduction in unnecessary antibiotic prescribing.

32. Facilitator Notes
This review looked at 10 studies, involving 3157 participants, looking at prescribing strategies for respiratory infections
Whilst there is an argument that antibiotics are either indicated or not, delayed back-up prescribing can be used to reduce the risk of disease progression and complications and potentially reduce re-attendance.
Much of the work around this, has been undertaken in UK populations.
It is important that delayed prescriptions are used in the correct circumstances and not just to placate inappropriate patient demand.

33. Facilitator Notes
The above slide demonstrates that the risk or likely complications are rare.
Evidence from DESCARTE study in > 13,000 patients showed that delayed antibiotics reduced the risk of complications occurring by 45% - similar to giving antibiotics immediately.
This study also found that patients reconsulted less in this group.
15-20% of patients will normally reconsult for RTIs, and with immediate antibiotics this reduces by 25%, but with delayed it reduces by 40%.
So delayed prescribing is just as effective as immediate antibiotics in relation to avoiding complications, but will reduce workload by reducing reconsultations.
Reference

34. Facilitator Notes
In summary the evidence for delayed prescribing suggests that it is acceptable to patients, reduces complications, repeat consultations, and antibiotic use.
It is a relatively easy intervention to adopt, but only works if used appropriately.
‘Appropriately’ includes only using it when it is necessary i.e. in the 20-30% you are unsure about.
It also includes making sure your discussion with the patient is adequate to ensure they have realistic expectations and understanding about this approach.
Paul Little ( GP and Professor of primary care research, Southampton University) suggests a 6 ‘R’ approach to discussing with patients to make sure all the necessary information is covered.

35. Facilitator Notes
This study compared four different types of delayed prescribing with no prescribing and immediate antibiotics. There was little to choose between the strategies in terms of benefit – suggesting it doesn’t matter too much how this is implemented. It found (similar to Cochrane) that fewer than 40% people use antibiotics when delayed prescriptions are used. It also found patients had similar symptom outcomes to immediate antibiotics when delayed strategies were used. Interestingly those not given immediate antibiotics had less strong beliefs in antibiotics. Giving immediate antibiotics may therefore reinforce the patient belief that these were necessary and may result in them expecting the same next time they have symptoms.
This is similar to a Canadian study which compared a prescription issued with advice to delay; compared with a post-date prescription that could not be redeemed until the allotted date. No difference was found. Approximately 45% of patients redeemed their prescriptions.
Pooled data from 5 trials, indicates that the rates of redemption of a delayed prescription is around 24% for acute otitis media and 54% in the case of a cold. Three of the trials involved the patients having to return to surgery, while the remaining 2 provided a prescription immediately to be redeemed at a later date. Subgroup analysis suggested that the barrier of returning to the surgery resulted in a lower uptake of prescriptions.
So basically although some patients will still redeem their prescriptions a significant proportion will not, and so where no prescribing is not an option, it may still help to reduce overall prescribing rates. It is noted that making the patient have to return to the surgery (rather than hand them it there and then) may help prevent inappropriate use, although this has not consistently been found.
PHE/ DOH - Behavioural Change and antibiotic prescribing in healthcare settings: Literature Review and behavioural analysis February 2015

36. Facilitator Notes
TARGET patient information leaflet
The leaflet is available in 17 languages and there is a version for community pharmacy and out of hours services in addition to this one for GP/ nurse use. It also has a section at the bottom to use for delayed (back up) prescribing if necessary.
It has also recently been reformatted into a pictorial version which may be useful for those with lower health literacy/ communication barriers

37. Facilitators notes
When should I worry
When Should I Worry (developed by Cardiff university) was tested in a RCT involving 61 GP practices, 528 children across England and Wales. The amount of antibiotics prescribed was significantly lower in the intervention group (where leaflet was used during consultation and then taken home) at 19.5% versus 40.8% in the control (p<0.001).
There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness (odds ratio 0.34; 0.20 to 0.57). Satisfaction, reassurance, and parental enablement scores were not significantly different between the two groups. The leaflet contains information on common RTIs (cough, cold, sore throat, earache) and uses cates plots (smiley faces) to try and provide reassurance about the usual symptom duration.
It also contains information on self-management and signs of deterioration and what to do (safety-netting).
The ScRAP session on Public Understanding and Expectations contains more information on what people think, and the evidence to support education/ information provision.

38. Facilitators Notes
A Cochrane review in 2014 concluded that use of C-reactive protein (CRP) testing could reduce antibiotic use, but they were unable to quantify the effect due to the variability of the studies reviewed. Patient time to recovery was not adversely affected. Further evidence is needed in relation to any impact on hospital admission.
In the UK the role and use of CRP has yet to be established but the recent NICE Clinical Guideline on Pneumonia recommended that a CRP test should be considered if after clinical assessment it is not clear whether antibiotics should be prescribed.
Furthermore, in the updated Public Health England (PHE) primary care guidance (May 2016) for acute cough and bronchitis CRP testing is recommended.
In Scotland a feasibility study of using the test within a GP setting was undertaken in 2015/16. The outcomes of this have been fed back nationally. No further information is available at the time of writing.
Signposting Reference
Aabenhus R, Use of rapid point-of-care testing for infection to guide doctors prescribing antibiotics for acute respiratory infections in primary care settings. Cochrane 2014.

39. Facilitator Notes
Often prescribers do not trust patients to use back up (delayed) prescriptions appropriately. Hopefully some of the statistics from the trials quoted earlier can provide some reassurance that this can reduce use overall.
The method used may not matter too much as long as it is used in the correct patients when there is a need to provide this for safety – netting.
It may depend on the prescriber/ practice preference how this is done.
It should be remembered that the method does not always need to involve giving the patient the prescription there and then, but it can be more about safety netting advice to come back after x days etc.

40. Facilitator Notes
Summary as per slide
To learn more about Resistance and HAI, or Public Understanding and Expectations consider undertaking these additional ScRAP sessions.

41. Facilitator Notes
It is important to get participants to follow through any identified improvements by formulating an action plan and identifying who is doing what and by when
If this is not done on the day it is really important to revisit within a few weeks of this session e.g. at the next practice/ group meeting.
Further learning
There is a 2 hour e-learning module on managing acute respiratory tract infections through RCGP if participants wish to undertake self-directed learning