Feasibility and efficacy of an antimicrobial stewardship program in general practices in Queensland

Twenty-four urban general practices in Queensland (16 in Brisbane and 8 in the Gold Coast) will be identified and asked to participate: 12 will be intervention practices; their performance in antibiotic prescribing will be compared with 12 control practices. The rate of antimicrobial prescribing will be compared with the preceding year’s rates, in the same time period, as an internal control/comparison. The interventions will be implemented within the first month of the 6 month intervention period by research coordinators and consist of: a delayed prescribing protocol; patient decision aids; communication training; a ‘poster’ on practice prescribing policy for antibiotics, the patient information leaflet and the near patient testing with C-reactive protein. The GP practice staff will be educated about the interventions by the research coordinators at the practice site during the implementation phase and will receive follow up monthly visits plus reminders via emails of the interventions 1. Delayed prescribing Patients who present with Acute Respiratory Infections (ARIs) will be evaluated by the GP. The GP will negotiate with the patient about management decisions for ARIs describing that very few people prescribed antibiotics will receive any benefit, and that benefit is of limited clinical relevance. If antibiotics are not needed immediately the patient will be offered a delayed prescription which is in concordance with the Therapeutic Guidelines: Antibiotics. A sticker will be applied to the prescription labeling it as a delayed prescription. 2. Patient decision aids Patient Decision Aids are brief summaries of evidence for the management of a number of ARI conditions. The decision aids have been developed to assist the patient to make an appropriate decision about their condition in conjunction with the GP. The Patient Decision Aids are laminated cards which are utilised by the GP in the consultation room to aid when discussing the management of ARIs with the patient. The Patient Decision Aids will also be made available on the GPs computers so that a printed copy can be provided to the patient. 3. Communicating training Clinicians will be trained in communication strategies. The interventions will be targeted at GPs rather than patients, and have been developed to be sensitive to cultural and national differences. Training in enhanced communication skills to facilitate the appropriate management of the patient’s illness during consultation will be provided. This will enable the clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient’s values, preferences and circumstances. The communication training package will be offered in combination with background information on the problem of antimicrobial resistance in primary care and the effectiveness of antibiotics for most commonly presenting ARIs as web-based online modules and be provided as a Continuing Professional Development (CPD) activity to GPs. 4. Poster on Practice Antibiotic Prescribing Policy ‘Nudge’ Intervention A ‘nudge’ intervention is one in which the object of the intervention (in this case GPs) is provided with a minimal driver which has a large behavioural effect. Clinicians in the practice would agree on an antibiotic prescribing policy for ARIs which is concordant with Therapeutic Guidelines:Antibiotic. This intervention will consist of displaying a poster-sized commitment letter in the GPs waiting room and/or examination room. Each GPs photograph and signature will be required as endorsement on the letters. The poster(s) will be delivered by the research co-ordinators to the GP practices. All GPs will be asked to sign the poster(s) before displaying them in their waiting room and /or examination rooms. The posted commitment letter, written at the eighth grade reading level and displayed in English emphasises GP commitment to guidelines, i.e. Therapeutic Guidelines: Antibiotic, for appropriate antibiotic prescribing and explains why antibiotics are not appropriate in many cases. 5. Patient information leaflet The leaflet provides information to the patient about inappropriate use of antibiotics for ARIs and the potential harmful effects of antibiotics. It complements the poster in the GPs waiting room and/or examination room. 6. Near patient testing with C-reactive protein. The CRP test is widely used in some European primary care settings and has been shown to significantly reduce antibiotic prescribing for patients with ARIs. The intervention practices will each have access to a CRP testing machine for three months (with 50 CRP tests per practice provided free of charge) to determine the feasibility and uptake of this type of near patient testing. Tests will be performed using the QuikRead CRP kits (Orion Diagnostica). The research co-ordinator, in conjunction with the distribution company (ABACUS ALS), will train the GPs and practice staff in the use and interpretation of the tests. In addition GPs will have access to an online training module on CRP testing (http://gaps.uq.edu.au). The following instructions will be provided regarding CRP testing: a) CRP testing should only be used within ARI consultations for lower respiratory tract infections and acute rhinosinusitis. b) the GP can decide to perform a CRP test as a complement to the routine consultation (including history and physical examination). c) the CRP test is performed on a finger prick blood sample and the result will be available within a few minutes. d) the CRP test result can be used in addition to the clinical assessment to decide whether to prescribe an antibiotic. Two sub-studies are nested in the main study: (1) point prevalence estimation carriage of bacterial upper respiratory pathogens in practice staff and asymptomatic patients; (2) feasibility of direct measures of antibiotic resistance by nose/throat swabbing.