Strength in numbers: Reviewing UTI antibiotic prophylaxis across a GP cluster

Context

Continuing antibiotics for prophylaxis of urinary tract infections (UTIs) after six months has limited benefit. Ongoing prescribing increases the risks of adverse drug reactions and contributes to the wider antimicrobial resistance dilemma. A reassessment of treatment is recommended at least every six months. A previous project identified that reviews result in a significant reduction of antibiotic prescriptions per year, and has been adopted nationally.

Problem

The GP clusters are tasked with adopting joint projects that can address national targets. Reviewing antibiotics used for recurrent UTIs as a cluster, could achieve both. The scale of the problem needed to be defined, by identifying patients taking antibiotics for UTI prophylaxis for longer than six months. Between 1 April and 30 September 2022, searches of clinical systems were carried out in all seven GP practices to identify patients meeting the inclusion criteria of nitrofurantoin 50mg/100mg nocte or trimethoprim 100mg nocte or cefalexin 125mg nocte (second line) on repeat for over six months. Patients were excluded if deemed complex (under specialist review or previous complications), in hospital or had not collected a prescription for the last six months.

Strategy for change

Utilising the skill-set of pharmacists could reduce prescribing of antibiotics; a cluster approach could improve success even further due to consistent messages. Eligible patients identified in the searches were invited for a review with a pharmacist and followed up two months later. Supportive lifestyle advice was provided with options of a stand-by antibiotic prescription. Protocols were created to ensure ongoing patients receive a review at six months following initiation and, if continuing, at least every six months thereafter (to include relevant blood monitoring). GP staff within the practices were updated on project progress to sustain change. Data was analysed via Microsoft Excel.

Effects of change

117 patients were identified and 44 patients were excluded. In total, 73 patients were reviewed across the GP cluster, with 81% (n=59) remaining off prophylactic antibiotics after follow-up. The remaining 14 patients were unable to stop (11 refused, 3 failed a trial). While patient feedback was not formally collected, overall, patients were unaware of the drug-specific side effects and risks, but more informed about antimicrobial resistance. In general, anxiety about stopping prophylaxis was alleviated by provision of stand-by antibiotics.

Conclusions

The GP cluster approach was a key enabler in reducing antimicrobial prescribing. Discussions are now held with the cluster, rather than just at practice level. Workload pressures within general practice are significant, with potential to delay quality work like this. Approaching the task as a cluster project provided focus and motivation, keeping the project on practice agendas despite daily pressures. Lack of patient reported outcomes is a recognised limitation of this project.

Additional authors: Nicola Dunster

This study did not require ethics approval.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.