TARGET Workshops Resources Improved Antibiotic Dispensing in Primary Care

Table of Content

Introduction

The ‘Treat Antibiotics Responsibly, Guidance, Education, Tools’ (TARGET) antibiotics toolkit developed by Public Health England (PHE) with the Royal College of General Practitioners (RCGP) and other professional societies aims to influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to responsible antibiotic prescribing.

Aim

To determine the effect of the TARGET 1 h outreach workshop facilitated by existing UK NHS healthcare staff with promotion of TARGET website resources, on general practice (GP) antibiotic dispensing within routine NHS service provision.

Study Participants

  • General practices (n=166)
  • Nurses (n=51)
  • Other staff including receptionists, healthcare assistants and practice managers (n=101)

Methods

  • McNulty–Zelen-design randomized controlled trial
  • The workshop was designed to be delivered to all members of the primary healthcare team
  • Workshops were delivered by trained health professionals already involved locally in antimicrobial stewardship (AMS) (GP, microbiologist or medicines manager).
  • Local facilitators received 1 h of face-to-face or Skype training on the principles of the TARGET toolkit and workshop, and a toolkit pack with a video of the workshop presentation, together with TARGET materials.

Study Design

*clinical commissioning group, antibiotic dispensing rate, and practice patient list size, then randomly allocated to intervention

** incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning

  • ** that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning

Study Outcomes

Primary Outcome

Total oral antibiotics dispensed (per 1000 practice patients, excluding anti -tuberculosis and minocycline) within intervention practices compared with controls in the year following the intervention.

Secondary Outcome

Workshop uptake, dispensing of antibiotics typically prescribed for RTIs UTIs (nitrofurantoin, trimethoprim, and pivmecillinam) and broad-spectrum antibiotics (co-amoxiclav, quinolones, and cephalosporins).

Results 

  • Thirty-six (51%) intervention practices accepted a TARGET workshop invitation
    • 166 GPs, 51 nurses, and 101 other staff
  • In the ITT analysis,
    • Total antibiotic dispensing was 2.7% lower in intervention practices (P=0.06) compared with controls
  • Dispensing in intervention practices was 4.4% lower for amoxicillin/ ampicillin (P=0.02); 5.6% lower for trimethoprim (P=0.03); and a non-significant 7.1% higher for nitrofurantoin (P=0.06)
  • The Complier Average Causal Effect (CACE) analysis,
    • Impact in those that comply with assigned intervention, indicated 6.1% (P=0.04) lower total antibiotic dispensing in intervention practices and 11% (P=0.02) lower trimethoprim dispensing.
Table 1: Estimated DRR comparing intervention practices with controls from ITT and the CACE analyses

 

ITT

 

CACE

 

Oral antibiotics (excluding anti-TB and minocycline)

DRR

P-value

DRR

P-value

Total antibiotics

0.973

0.06

0.939

0.04

Usual respiratory tract infection antibiotics

 

 

 

 

Phenoxymethylpenicillin

0.971

0.39

0.928

0.28

Amoxicillin/ampicillin

0.956

0.02

0.924

0.11

All tetracyclines

0.987

0.71

0.925

0.26

All macrolides

1.007

0.79

1.005

0.93

Usual urinary tract infection antibiotics

 

 

 

 

Trimethoprim

0.944

0.03

0.890

0.02

Nitrofurantoin

1.071

0.06

1.116

0.14

Pivmecillinam

1.611

0.14

a

 

All UTI only: trimethoprim, nitrofurantoin and pivmecillinam

0.988

0.58

0.964

0.35

Broad-spectrum antibiotics

 

 

 

 

All: co-amoxiclav, quinolones and cephalosporins

0.986

0.65

0.967

0.61

Co-amoxiclav only

0.969

0.46

0.945

0.57

Quinolones only

1.037

0.44

1.043

0.69

Cephalosporins only

1.003

0.97

0.976

0.87

a= unable to converge to solution

Conclusion

  • Face-to-face TARGET AMS workshops, including reflection on antibiotic prescribing, guidance, clinical scenarios, strategies to improve prescribing, and demonstration of TARGET patient-facing resources, audits, and educational resources, improved antibiotic dispensing for infections in general practices
  • The authors suggested that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives

J Antimicrob Chemother doi:10.1093/jac/dky004