An audit of acute respiratory antibiotic prescribing in COPD patients during the COVID-19 pandemic

Introduction

Coronavirus-2 is the virus responsible for the COVID-19 pandemic. People with certain risk factors, such as having chronic obstructive pulmonary disease (COPD) may be more likely to develop complications. Research has identified that ~7% of patients with COVID-19 have a bacterial infection, however antibiotic prescribing rates have been found to vary from 38% to 72% (1,2). Primary care is estimated to make up 75% of antibiotic prescribing and was therefore a key target to evaluate whether antimicrobial stewardship principles were being followed during the COVID-19 pandemic.

Aim

To audit the adherence of antibiotic prescribing in people with COPD during the COVID-19 pandemic across a primary care network (PCN) in England against national and local guidelines.

Methods

The management of patients with COPD should follow NICE Guideline (NG) 114, NG168 and the local formulary. Three audit standards were created: 1) 100% of COPD patients should not be started on prophylactic antibiotics to reduce risk from COVID-19; 2) 100% of COPD patients should not be prescribed antibiotics for COVID-19 symptoms; 3) 90% of antibiotic prescription regimens should adhere to local and national guidelines. Prescribing data was collected from 12 practices linked to the PCN. Data of patients who had COPD, were prescribed an antibiotic, and had an indication for the antibiotic between 01/03/20 and the 30/06/20 were extracted and transferred into an anonymised spreadsheet. A total of 1088 data points were extracted. Random stratified sampling provided 300 data points for analysis, ensuring each GP surgery was represented proportionally; the required sample size to determine significance was 291. For each practice, the total number of antibiotics prescribed to COPD patients between March-June 2019 and March-June 2020 was extracted. Descriptive statistics were used to determine antibiotic prescribing adherence and overall rates of prescribing. Inferential statistics were used to compare rates of prescribing pre-vs-during the pandemic.

Results

Antibiotics were not prescribed for any patient for prophylaxis against COVID-19 (100% adherence to criteria 1). Two patients were prescribed antibiotics for ‘suspected disease caused by COVID-19’ (99.4% adherence to criteria 2). In only 28.7% of cases, the antibiotic was prescribed in line with the national and local guidelines (criteria 3). In most cases, treatment duration was the main reason for poor adherence, with longer courses of antibiotics being prescribed (7 rather than 5 days). Prescribing rates did not change significantly in 2020 compared to 2019 (1134 antibiotic prescriptions vs 1029 antibiotic prescriptions; p>0.05).

Conclusion

The audit was successful in determining that the COVID-19 pandemic did not significantly affect antibiotic prescribing rates across the PCN for people with COPD. Adherence to NICE and local guidelines was low, specifically concerning the duration of antibiotic treatment. This highlights an area for improvement; to ensure healthcare professionals across the PCN prescribe in-line with antimicrobial stewardship principles. Extracted data was limited to antibiotic prescribing and could have been expanded to include steroids to provide a fuller audit of prescribing in COPD exacerbations. A re-audit may be beneficial since the publication of NG191.

References

(1) Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect. 2020 Aug;81(2):266-275.

(2) Seaton RA, Gibbons CL, Cooper L, Malcolm W, McKinney R, Dundas S, Griffith D, Jeffreys D, Hamilton K, Choo-Kang B, Brittain S, Guthrie D, Sneddon J. Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals. J Infect. 2020 Dec;81(6):952-960.