Antibiotic use in the management of uncomplicated URTIs and bronchitis

Antibiotic use in the management of uncomplicated URTIs and bronchitis Aims of clinical audit To review your prescribing of antibiotics for uncomplicated upper respiratory tract infections (URTIs) and bronchitis. To compare your practice with the recommendations provided in Therapeutic Guidelines: Antibiotic, Version 12, 2003 1 and with the practice of participating doctors. How to participate 1. Select patients Prospectively, as patients present for consultation, identify 20 patients with a principal diagnosis of one of the following: common cold/rhinosinusitis acute or chronic bronchitis pharyngitis/tonsillitis acute otitis media otitis media with effusion (glue ear), or acute sinusitis. Do NOT include patients than those with the diagnoses listed above. Consider patient privacy policy (see attached leaflet and poster). You may use the Patient Record form to record the patients you have included for your future reference. 2. Collect data and review During or soon after the patient s visit, complete sections A, B and C of the clinical audit form for each of the 20 patients you have selected. See notes on pages 2 3 for further information. Please note: Patient information must only be collected and recorded by the participating doctor. Both full-time and part-time GPs are required to submit 20 completed clinical audit forms. 3. Send in the clinical audit forms Return the 20 clinical audit forms and registration form to: NPS Clinical Audit: Antibiotics Locked Bag 4888 STRAWBERRY HILLS NSW 2012 To be received at NPS not later than: Friday 8 August 2003 Please note: Unfortunately, late submissions cannot be accepted. Do NOT send in the Patient Record form. 4. When you receive your results Once results have been analysed, you will receive from the NPS: your original clinical audit forms feedback on your individual results the aggregate results of all participants management practices commentary on the aggregate results review questions which allow you to reflect on your prescribing practice. 5. Completing the clinical audit cycle Review questions will be provided with your results. These must be completed and returned to the NPS for 20 clinical audit points to be allocated* by the RACGP, and for the clinical audit to qualify as an activity for the Quality Prescribing Initiative (QPI) of the Practice Incentives Program. You will then be sent a certificate of completion. * Please note that point allocation is not guaranteed and is subject to review by the RACGP. Further information Contact NPS for: Therapeutic and audit enquiries Kylie Easton-Carter or Clare Bottomley Phone (02) 9699 4499 Guide to clinical audit

Notes for clinical audit form Additional information to assist you to review management Section A: Patient visit details (Q1) Your patient code Choose your own unique identifying code for the patient, e.g. sequential number or the patient s initials (please do not use the patient s name). (Q4) Was symptomatic management prescribed or recommended this visit? Symptomatic management includes rest, fluids and medications such as decongestants or analgesics. Symptomatic management pads are available from the NPS to assist in providing advice to patients. The free pads are available in English, Arabic, Chinese, Greek, Italian and Vietnamese by telephoning NPS on 02 9699 4499. Section B: Management for principal diagnosis (Q9) The light and dark green shading in this section indicate management considered consistent with Therapeutic Guidelines: Antibiotic, Version 12, 2003, and will be used to review your prescribing. Principal diagnosis Mark the main diagnosis this visit in only one of the boxes. Continue working from left to right in only that box. Clinical features Mark if any of the clinical features listed in the dark green shaded area for that diagnosis were seen in this patient; Therapeutic Guidelines: Antibiotic recommends antibiotics be considered for patients with these features. If these clinical features do not apply: Mark the bubble in the light green shaded area, clinical features than those below. For example, if a patient with acute sinusitis has facial pain with discharge of only 2 days duration, mark the bubble in the light green shaded area. If an antibiotic was indicated, was a recommended antibiotic used? The antibiotics recommended by Therapeutic Guidelines: Antibiotic are shaded in dark green. Mark if one of these was prescribed. If the antibiotic prescribed is not listed: Some clinical situations justify prescribing alternative antibiotics to those listed in the dark green shaded area. Mark antibiotic prescribed and record the reason for selecting the antibiotic prescribed (e.g. drug allergy or adverse reaction to first-line drugs, treatment failure in this patient using first-line drugs or pregnancy or lactation). Duration of antibiotic therapy The duration of antibiotic therapy recommended in Therapeutic Guidelines: Antibiotic is shaded in dark green. Section C: Consistency with Therapeutic Guidelines: Antibiotic (Q10) Use the shading in the table to compare your responses to Therapeutic Guidelines: Antibiotic recommendations. To be consistent with the guidelines, responses marked in Q9 must EITHER be wholly within the light green OR the dark green shaded areas. For example: Management considered consistent with Therapeutic Guidelines: Antibiotic clinical features than those below infective exacerbations with both: increased cough and dyspnoea, and increased sputum volume and purulence, or 5 days () 6 days ( ) antibiotic prescribed _ Management NOT considered consistent with Therapeutic Guidelines: Antibiotic Responses marked across the light green and dark green shaded areas or across both shaded and non-shaded areas are NOT considered consistent with the guidelines. For example: clinical features than those below infective exacerbations with both: increased cough and dyspnoea, and increased sputum volume and purulence, or 5 days () 6 days ( ) antibiotic prescribed _ 2

Summary of antibiotic treatment in uncomplicated URTIs and bronchitis 1 Are antibiotics required for this condition? Common cold/rhinosinusitis Acute bronchitis Exacerbations may be due to non-infective causes as well as bacterial infections. Antibiotics have only been shown to be effective when all 3 cardinal symptoms of acute bacterial exacerbations are present: increased dyspnoea, increased sputum volume and purulence. Antibiotics than those listed have not been shown to be superior and are not recommended. Pharyngitis/tonsillitis Antibiotics are not needed for most patients with sore throat in general practice. 2 A Cochrane review concluded that 85% of placebo treated patients were symptom free at one week. 2 Use antibiotics for tonsillitis displaying the four features suggestive of Strep. infection presumptive Strep. in some Aboriginal and communities at risk of rheumatic fever existing rheumatic heart disease scarlet fever quinsy. Acute otitis media (AOM) Antibiotics not routinely needed. A Cochrane review concluded that 66% of children were pain-free 24 hours after the start of treatment whether they received placebo or antibiotic. 3 Children without systemic features (vomiting and fever) In children between 6 months and 2 years, consider delaying antibiotics for 24 hours. If antibiotics are withheld, follow-up by telephone or visit is essential. In children 2 years, consider delaying antibiotics for 48 hours. Reassess if symptoms persist. Children with systemic features (vomiting and fever) If fever and vomiting are marked when the patient first presents antibiotic therapy may be indicated. Otitis media with effusion (OME, glue ear) The aetiology of OME is uncertain and bacterial infection is only one of many factors which contribute to this condition. Those with a more chronic course or with no preceding history of AOM may benefit from antibiotics. Acute sinusitis Antibiotics not routinely needed. Sinusitis improves in approximately 70% of patients not treated with antibiotics. 4 Consider antibiotics for severe sinusitis with at east 3 of the following: mucopurulent discharge > 7 10 days poor response to decongestants facial pain tenderness over the sinuses tenderness on percussion of maxillary molar and premolar teeth. Symptomatic treatment only Symptomatic treatment only Treatment options Antibiotic of first choice (if decision to treat with antibiotics) Patients without penicillin hypersensitivity Patients with penicillin hypersensitivity* Duration adult: 500 mg adult: 200 mg orally, for the first dose, then 100 mg daily for a further five days penicillin V (phenoxymethylpenicillin) adult: 500 mg child: 10 mg/kg (up to 500 mg) 8-hourly adult: 500 mg child: 15 mg/kg (up to 500 mg) or 12-hourly adult: 1000 mg child: 30 mg/kg (up to 1000 mg) If poor response to antibiotic of first choice: +clavulanate for 5 7 days adult: 875+125 mg ** child: 22.5+3.2 mg/kg (up to 875+125 mg) ** 8-hourly adult: 500 mg child: 15 mg/kg (up to 500 mg) or 12-hourly adult: 1000 mg child: 30 mg/kg (up to 1000 mg) adult: 500 mg child: 15 mg/kg (up to 500 mg) If poor response to antibiotic of first choice: +clavulanate for 7 14 days. adult: 875+125 mg ** child: 22.5+3.2 mg/kg (up to 875+125 mg) ** adult: 200 mg orally, for the first dose, then 100 mg daily for a further five days roxithromycin adult: 300 mg orally, daily child: 4 mg/kg (up to 150 mg) cefuroxime adult: 500 mg child: 10 mg/kg (up to 500 mg) (no paediatric preparation available) cefaclor adult: 375 mg child: 10 mg/kg (up to 250 mg) cefaclor adult: 375 mg child: 10 mg/kg (up to 250 mg) cefuroxime adult: 500 mg child: 10 mg/kg (up to 500 mg) (no paediatric preparation available) cefaclor adult: 375 mg child: 10 mg/kg (up to 250 mg) adult: 200 mg orally, initially then 100 mg daily child > 8 years: 4 mg/kg (up to 200 mg) orally, initially, then 2 mg/kg (up to 100 mg) daily : 5 days doxycycline: 6 days 10 days 5 days 10 30 days 5 7 days * Hypersensitivity occurs in up to 10% of people receiving penicillins; anaphylaxis occurs in 0.01%. 1 Intolerance due to common adverse effects such as diarrhoea and nausea may not be due to hypersensitivity. # Not in children 8 years old or in pregnancy/lactation. The four features suggestive of Strep. infection are: fever > 38 o C, tender cervical lymphadenopathy, tonsillar exudate and no cough. ** Note: not included in relevant product information. The usual dosage frequency is 12-hourly. The 8-hourly regimen is used for increased activity. Between 3 and 6% of patients who are hypersensitive to penicillin exhibit cross-reactivity with cephalosporins. Cephalosporins are contraindicated if there is a history of an immediate hypersensitivity reaction to penicillin antibiotics. In these patients specialist advice should be sought. 1 3

Generic and brand names for selected antibiotics Penicillins Macrolides Generic Brand name Alphamox, Amohexal, Amoxil, Amoxil Forte, Bgramin, Cilamox, Maxamox, Moxacin + Augmentin, Augmentin Duo, Augmentin clavulanate Duo Forte, Augmentin Duo 400, Ausclav, Ausclav Duo, Ausclav Duo Forte, Ausclav Duo 400, Clamoxyl, Clamoxyl Duo, Clamoxyl Duo Forte, Clamoxyl Duo 400, Clavulin, Clavulin Duo, Clavulin Duo 400, Clavulin Duo Forte penicillin V Abbocillin-V, Cilicaine V, Cilicaine VK, (phenoxymethyl- Cilopen VK, LPV, Penhexal, Penhexal VK penicillin) procaine penicillin Cilicaine azithromycin Zithromax clarithromycin Klacid erythromycin E.E.S, E-Mycin, Eryc, Erythrocin roxithromycin Biaxsig, Rulide, Rulide D Cephalosporins Tetracyclines Generic Brand name cefaclor Ceclor, Ceclor CD, Cefkor, Cefkor CD, Keflor, Keflor CD cefuroxime Zinnat cephalexin Cilex, Ibilex, Keflex, Sporahexal doxycycline Doryx, Doxsig, Doxy-50, Doxy-100, Doxyhexal, Doxylin, Vibramycin, Vibra-tabs tetracycline Achromycin, Tetrex trimethoprim and Bactrim, Bactrim DS, Cosig Forte, sulfamethoxazole Resprim, Resprim Forte, Septrin, (co-trimoxazole) Septrin Forte, Trimoxazole BC 800/160 Professional development This clinical audit qualifies as an activity for the Quality Prescribing Initiative of the Practice Incentives Program. The NPS has applied for 20 clinical audit points in the 2002 2004 Triennium of the Royal Australian College of General Practitioners (RACGP) Quality Assurance & Continuing Professional Development (QA&CPD) Program, but point allocation is not guaranteed and is subject to review by the RACGP. Confidentiality Patient information must only be collected and recorded by the participating doctor. Individual results of your clinical audit and responses to review questions are kept confidential by NPS. What will happen to: Your patient data: Your de-identified patient data forms are returned to you. Your individual results are provided to you only. Your data are aggregated with that of participants and the de-identified aggregate results: are provided to all participants may be used in NPS evaluation and reports are provided to the RACGP QA&CPD program. The RACGP has advised that program information may be shared with researchers and interested general practitioners for the purpose of continuing education coordination at the discretion of the QA&CPD Program. Your personal details: are provided to the RACGP QA&CPD program for allocation of QA&CPD points (if applicable) are recorded for the purpose of the Practice Incentives Program and NPS evaluation. Individual clinical audit results will not be available after potentially identifying data are removed from NPS records at the close of the clinical audit cycle, i.e. after submission of the review questions in step 4. Please note: You are responsible for advising the NPS of any changes of address during the audit cycle. You can obtain a record of your personal details from the NPS by request in writing. Important: Please sign the confidentiality agreement on the enclosed Registration form References 1. Writing Group for Therapeutic Guidelines: Antibiotic. Therapeutic Guidelines: Antibiotic, Version 12. Melbourne: Therapeutic Guidelines Limited; 2003. 2. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update software. 3. Glasziou PP, Del Mar CB, Sanders SL. Antibiotics for acute otitis media in children (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update software. 4. de Ferranti SD, Ioannidis JPA, Lau J, Anninger WV, Barza M. Are and folate inhibitors as effective as antibiotics for acute sinusitis? A meta-analysis. BMJ 1998;317:632 637. National Prescribing Service Limited ACN 082 034 393 An independent, Australian organisation for Quality Use of Medicines Level 1 / 31 Buckingham Street, Surry Hills NSW 2010 Phone: 02 9699 4499 l Fax: 02 9699 5155 l email: info@nps.org.au l web: http://www.nps.org.au 05/03

Clinical audit: Antibiotic use in the management of uncomplicated URTIs and bronchitis Please see the Guide to clinical audit booklet for additional information to assist you to complete this form. Mark the appropriate response(s) for this patient. Completely fill in bubbles with black biro (as shown here). Do not use pencil. Make no stray marks. If you make a mistake use white correction fluid or cross through the bubble clearly (as shown here), and mark your selected response. Please open for your clinical audit form.

NPS office use only Section A Patient visit details 1. Your patient code: 2. Age: birth < 2 years 2 17 years 18 64 years 65 80 years > 80 years 3. Mark ONE principal diagnosis for this visit: Common cold, rhinosinusitis Acute bronchitis Pharyngitis/tonsillitis Does the patient have co-morbidities relevant to this diagnosis? no yes please specify _ Section B Management for principal diagnosis Acute otitis media Otitis media with effusion (OME, glue ear) Acute sinusitis 4. Was symptomatic management prescribed or recommended this visit? no yes 5. Was an antibiotic(s) prescribed this visit? no Go to Section B yes Go to Q6 6. Record the antibiotic(s) prescribed this visit in BLOCK letters: 9. Mark ONE principal diagnosis for this patient, then work from left to right in that box only and mark appropriate responses. The principal diagnosis marked should be the same as that marked in Q3. Light green shading indicates no antibiotic treatment required, according to Therapeutic Guidelines: Antibiotic, Version 12, 2003. Dark green shading indicates clinical features where antibiotic therapy should be considered, and the antibiotics recommended by Therapeutic Guidelines: Antibiotic. Some clinical situations justify prescribing alternative choices, if antibiotic prescribed is marked, specify the reason for the selected antibiotic. 7. When did you instruct for the prescription to be filled? script to be filled immediately script to be filled later if required 8. Does the patient have a drug allergy/adverse reaction: penicillin allergy/adverse reaction antibiotic allergy/adverse reaction Go to Section B nil history of antibiotic allergy/adverse reaction not known Principal diagnosis (mark one only) Mark whether the patient has clinical features where Therapeutic Guidelines: Antibiotic recommends antibiotic therapy (dark green shaded areas) If an antibiotic was indicated, was a recommended antibiotic used? Was the duration of antibiotic therapy according to guidelines? Common cold, rhinosinusitis Nil (no clinical features specified by Guidelines to require antibiotics) Acute bronchitis Nil (no clinical features specified by Guidelines to require antibiotics) clinical features than those below antibiotic prescribed antibiotic prescribed Pharyngitis/tonsillitis infective exacerbations with both: clinical features than one below increased cough and dyspnoea, and increased sputum volume and purulence tonsillitis with fever >38 o C, tender cervical lymphadenopathy, tonsillar exudate and no cough presumptive Strep. in some Aboriginal and communities at risk existing rheumatic heart disease scarlet fever quinsy, or antibiotic prescribed penicillin V (phenoxymethylpenicillin) roxithromycin antibiotic prescribed 5 days () 6 days ( ) 10 days Acute otitis media (AOM) clinical features than one below Otitis media with effusion (OME, glue ear) Acute sinusitis Children without systemic features (vomiting and fever) between 6 months and 2 years of age persistent pain and fever after 24 hours of symptomatic treatment without antibiotics over 2 years of age persistent pain and fever after 48 hours of symptomatic treatment without antibiotics Children with systemic features (vomiting and fever) vomiting and fever marked on presentation clinical features than one below Chronic OME OME with no preceding history of AOM clinical features than those below severe sinusitis with at least 3 of the following: mucopurulent discharge > 7 10 days tenderness over the sinuses facial pain tenderness on percussion of maxillary molar poor response to decongestants and premolar teeth # not in children 8 years old or in pregnancy/lactation excluding a history of immediate hypersensitivity reaction to penicillin Please complete section C below cefuroxime,or cefaclor antibiotic prescribed cefaclor antibiotic prescribed cefuroxime,or cefaclor,or antibiotic prescribed 5 days 10 30 days 5 7 days Section C Consistency with Therapeutic Guidelines: Antibiotic 10. Use the shading to compare your responses to the Therapeutic Guidelines: Antibiotic recommendations. Are the responses marked in Q9 EITHER wholly within the light green OR the dark green shaded areas? (See example on p.2 of Guide to clinical audit booklet.) no prescribing is not consistent with Therapeutic Guidelines: Antibiotic recommendations yes prescribing is consistent with Therapeutic Guidelines: Antibiotic recommendations