Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice Commentary: What can we learn from narratives of implementing evidence?

Abstract

Objectives To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses. Design Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course. Setting Group general practice in Newcastle upon Tyne. Data sources The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified. Data extraction Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence. Results 114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI − 1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% ( − 3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library. Conclusions Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.

Increased treatment failure after 3‐days’ courses of nitrofurantoin and trimethoprim for urinary tract infections in women: a population‐based retrospective cohort study using the PHARMO database

“…In particular, treatment with nitrofurantoin for 3 days appears to lead to more treatment failure, while the effect for trimethoprim is less evident. In a study from the UK a difference between the number of second consultations within 2 weeks after the first prescription of trimethoprim was shown for 3, 5 and 7 days of treatment [1]. This difference was not significant, probably due to the small number of prescriptions studied ( n = 271).…”

“…For trimethoprim, most evidence is based on extrapolations of randomized controlled trials on cotrimoxazole, which are often of mediocre quality [1,2,21]. For nitrofurantoin, most evidence is based on information from one small clinical trial on 3 days' treatment that demonstrates a very low cure rate of 61% [22], which is significantly lower than the cure rate after treatment with cotrimoxazole.…”

“…Recently, the comparable efficacy of 3, 5 and 7 days' treatment for uncomplicated urinary tract infections was reviewed [1]. One of the conclusions was that the evidence on the efficacy of short 3-day courses was mostly derived from small studies in which different dosages, durations and combinations of antibiotics were compared.…”

“…One of the conclusions was that the evidence on the efficacy of short 3-day courses was mostly derived from small studies in which different dosages, durations and combinations of antibiotics were compared. Moreover, the results of randomized clinical trials on the efficacy of 3-day courses of cotrimoxazole or fluoroquinolones were extrapolated to trimethoprim or nitrofurantoin [1,2].…”

Drug prescribing in out-patient children in Southern Italy

“…The wide utilization of dierent drugs in relation to a limited number of diagnoses, as well as the lack of compliance with therapeutic guidelines, suggest the need for continuous audit and educational programs (also and in particular) in pediatric general practice [34].…”