The effectiveness of a simple antimicrobial stewardship intervention in general practice in Australia: a pilot study

Antimicrobial resistance is a global threat to human health [1]. Excessive and inappropriate antimicrobial prescribing is a major contributor to this problem [1]. Australia has a higher rate of antimicrobial prescribing compared to the average of countries in the Organisation for Economic Co-operation and Development [2]. In 2017, 41.5% of Australians were prescribed at least one antimicrobial through the Australian Pharmaceutical Benefits Scheme (PBS) [3] and many of these prescriptions were inconsistent with Australian prescribing guidelines [4]. General practitioners (GPs) provide the majority of primary healthcare in the community setting and write up to three quarters of annual antimicrobial prescriptions in the primary care setting [3, 4]. Despite this, national Antimicrobial Stewardship (AMS) programs have been mainly directed at hospitals and incorporated into accreditation standards to enforce monitoring of antimicrobial usage, appropriateness of prescribing and adherence to guidelines [5, 6]. In contrast, AMS is not a clinical requirement for general practice in Australia, however, the Royal Australian College of General Practitioners has committed to adopt antimicrobial resistance (AMR) education programs and AMS principles have been implemented in 2017 [7].

Recent research has explored factors that contribute to inappropriate antibiotic prescribing in general practice. These include automatic repeat prescriptions, inappropriate durations and quantities and the extended period of time during which a prescription may be filled (12 months after issuing) [5, 8‐11]. Some prescriptions are dispensed more than 60 days after the prescription date [4], suggesting likely usage for an alternate indication to that intended by the prescriber [8, 9]. Perceived patient expectation has been identified as significantly influencing GPs to prescribe broad spectrum antimicrobials [12, 13], although this may be countered by interventions promoting shared decision-making with patients [13, 14]. Delayed prescription provision (where a prescription is provided only to be used in the event of clinical deterioration) is another useful collaborative tool [15‐17] .

Interventions designed to improve antimicrobial prescribing have shown success amongst GP trainees and supervisors [18‐22]. Additionally, international interventions focussing on factors influencing inappropriate prescribing have been shown to improve antibiotic prescribing over time [15, 23‐26], particularly for respiratory tract infections [27‐30]. These interventions include educational sessions [31, 32] and support material for GPs [33, 34]. In Australia, effective educational interventions have been multi-faceted, encompassing online modules [26, 35] and academic detailing (face to face education provided by qualified professionals) [10, 36].

We sought to establish a simple educational intervention for GPs using these evidence-based techniques, targeted towards bacterial resistance, relevant microbiological tests, empirical therapy and duration of therapy. This approach is recommended to improve antimicrobial prescribing among GPs [37]. This study sought to assess the effectiveness of this carefully designed educational intervention on baseline antibiotic prescribing habits in general practice, focusing on compliance with national guidelines and antibiotic appropriateness.

This study measured baseline GP antimicrobial prescribing habits; identifying common errors and areas for improvement. This information was subsequently used to provide feedback to GPs as part of an educational intervention designed to improve antimicrobial prescribing. The success of the intervention was demonstrated by significant improvement across all major outcome measures including: concordance with guidelines, appropriate antibiotic selection and course duration.

Analysis of baseline prescribing data and discussion with GPs in the educational session revealed some key issues. Some prescriptions followed superseded guidelines or manufacturers product information, indicating lack of awareness of current guideline recommendations [39]. GPs acknowledged their infrequent referral to current guidelines. In this study, GPs experienced restricted access to an electronic guideline as the clinic had only one shared account. Where clinical guidelines are electronically available, individual access is an important consideration. Utilisation of outdated guidelines may be more widespread as evidenced by the fact that roxithromycin and cefaclor are among the top 10 PBS-dispensed antibiotics in Australia, despite having become largely superseded in current Therapeutic guidelines [3, 4]. To remedy this issue, GPs were provided with individual hard copies of the Therapeutic Guidelines which was well received by the participants due to the difficulty accessing the clinic’s online version. Following the intervention there was a substantial reduction in roxithromycin and cefaclor prescriptions and the use of prescribing guidelines was documented in clinical notes. More broadly, antimicrobial prescribing in primary care would benefit from improved access to electronic guidelines (where available) and linking prescribing software to guideline recommendations.

Prescriptions are deemed compliant with guidelines when drug, dose, frequency and duration are correct. Whilst there was improvement in this measure post intervention, the overall rate of prescriptions compliant with guidelines remained relatively low at 59%, mirroring that observed in Australian hospitals (54% in 2017) [40]. Appropriate antibiotic selection also occurs more often than complete prescription compliance in Australian hospitals (73% in 2017) [40]. Ongoing auditing and education may improve GP compliance with guidelines. Further research to review the effectiveness of integrating guidelines into prescription software would be beneficial.

Following the intervention there was improvement in appropriate antibiotic duration with better documentation on the prescription and in the clinical notes. One such example was trimethoprim for cystitis in non-pregnant women, which is often prescribed as a full pack, with 7 days of therapy, rather than the guideline recommended 3 days [38]. Following intervention, guideline compliance for trimethoprim almost doubled. This highlights a broader challenge for AMS in primary healthcare as Australian antibiotic pack sizes rarely align with recommended treatment protocols. Without clear duration directions, patients may consume excess doses which may contribute to adverse effects or antimicrobial resistance [11]. Prescribing the exact duration of therapy is ideal and is possible for most solid preparations, regardless of the number of doses in the original manufacturers’ pack. A perceived reluctance to break packs by pharmacies is commonly theorised, though not substantiated [10, 11]. However, this strategy requires further consideration to ensure patients are not financially burdened by this practice due to discordance with the Australian PBS.

GPs occasionally used delayed prescribing tactics; most often through the provision of a prescription with advice to delay therapy for a specified duration, until microbiology results are communicated or if deterioration occurs. The increased use of these tactics post intervention demonstrates GP acceptance of this method to curb unnecessary antimicrobial usage. The study did not ascertain the outcomes of delayed prescribing on the percentage of delayed scripts that were dispensed, though previous work has demonstrated overall reduced antibiotic use [16].

Repeat prescriptions are ordered with most antibiotic prescriptions in Australia [4] and often provide a duration of therapy that exceeds guidelines [38]. Furthermore, patients often don’t receive clear instructions about when to fill a repeat prescription [8] and may inappropriately extend their antimicrobial [9]. GP prescribing software may contribute to unnecessary repeat provision with the default setting providing a repeat prescription [3, 9, 10]. The significant reduction of inappropriate repeat prescriptions in this study indicates the success of this antimicrobial stewardship intervention. Additionally, up to 20% of antibiotic repeats are dispensed several months after the original prescription date [3, 4]. To address this issue, one GP issued three prescriptions with a documented arbitrary expiry date. Though not recognised legally, this strategy may be effective in preventing the dispensing of antimicrobial prescriptions beyond the immediate acute illness and may be worth considering in future AMS interventions. Widespread uptake would require legislative change. Limiting antimicrobial courses to their appropriate duration is a pivotal aspect of AMS programs to limit adverse effects for patients and avoid the development of resistance [6, 41]. In 2020, access to repeats for common antimicrobials was restricted on the PBS to reduce inappropriate prescribing [42].

The majority of antibiotic prescriptions in Australia are written in primary care but AMS is not well established in this setting. This study demonstrated the value of a simple AMS intervention comprising prescription auditing, feedback and an educational intervention, which together, led to highly significant improvements in antimicrobial prescribing.

This study contributes evidence that clinic-level AMS interventions improve antimicrobial prescribing and should be utilised on a larger scale. This intervention, was well received, highly effective and inexpensive. Future research to investigate the sustainability of these improvements is required to determine the ongoing benefit of auditing and educational intervention.