UTI Friday: The Review of Antibiotic Prophylaxis for Recurrent Urinary Tract Infection (rUTI) in Primary Care

Abstract

Abstract Introduction There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines [NG15, NG112] state that patients on antibiotic prophylaxis for rUTI should be reviewed within 6 months and consideration given to discontinue the antibiotic. Self-care measures should be promoted instead. Aim This project aims to assess current practice in relation to rUTI management in Primary Care and identify opportunities for improved antimicrobial stewardship. Methods An audit was developed to review rUTI management and it was used in three GP practices (patient population 35,134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. A search for all repeat prescriptions issued between 1st July 2017 and 30th June 2018, for any strength of antibiotic, was run and 179 patients were identified as being on antibiotic prophylaxis for rUTI. The results of the audit were fed back to the practice and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract, remaining until 2022 due to the COVID pandemic. Ethical approval not required. Results Primary care initiated prophylaxis accounted for 69% of the total number of patients identified (n=123). Of those taking prophylaxis for >6 months (n=160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for >3 years accounted for 39% of the total (n=70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend Locality (patient population 152,041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed and of those reviewed 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2,223 fewer antibiotic prescriptions per year. Discussion/Conclusion Initial results suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. The impact of this in terms of antimicrobial resistance is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019-2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.