Abstract
To describe trends and geographical variation in prescribing of trimethoprim and nitrofurantoin to treat urinary tract infections, to describe variation in implementing guideline change and to compare actions taken to reduce trimethoprim use in high- and low-using Clinical Commissioning Groups (CCGs). A retrospective cohort study and interrupted time series analysis of English NHS primary care prescribing data, complemented by information obtained through Freedom of Information Act requests to CCGs. The main outcome measures were variation in practice and CCG prescribing ratios geographically and over time, including an interrupted time series, and responses to Freedom of Information requests. The amount of trimethoprim prescribed, as a proportion of nitrofurantoin and trimethoprim combined, remained stable and high until 2014, then fell gradually to <50% in 2017; this reduction was more rapid following the introduction of the 'Quality Premium'. There was substantial variation in the speed of change between CCGs. As of April 2017, for the 10 CCGs with the lowest trimethoprim ratios, 9 had reported at least one of: formulary change, work plan or incentive scheme to change prescribing behaviour. None of the 10 highest-ratio CCGs did so. Many CCGs failed to implement an important change in antibiotic prescribing guidance, and there is strong evidence suggesting that CCGs with minimal prescribing change did little to implement the new guidance. We recommend: (i) a national programme of training and accreditation for medicines optimization pharmacists; and (ii) remedial action for CCGs that fail to implement guidance-with all materials and data shared publicly for both such activities.
Highlights
Urinary-tract infections (UTIs) are a common presentation in primary care, accounting for between 1-3% of all GP consultations.[1]
Variation between Clinical Commissioning Groups (CCGs) and practices in UTI treatment choices We extracted data on all prescriptions dispensed between January 2011 and December 2017 for prescribing of trimethoprim and nitrofurantoin of any form, using the British National Formulary (BNF) codes for trimethoprim (0501080W0) and nitrofurantoin (0501130R0)
Other treatments such as cephalosporins[2] have been used in the past for UTIs, these were excluded from our analysis as they are not covered by the guideline change nor the incentive scheme; and because they are commonly used for other indications; there is no national prescribing dataset that includes data on indication
Summary
Background Urinary-tract infections (UTIs) are a common presentation in primary care, accounting for between 1-3% of all GP consultations.[1]. Reducing the harm from inappropriate management of UTI is a priority for the NHS.[5]
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