Pharmacist antibiotic prescribing rose when testing rules were dropped

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Pharmacist antibiotic prescribing rose when testing rules were dropped

Removing the need to test sore throat patients for streptococcal bacteria before supplying an antibiotic made pharmacists more than twice as likely to prescribe the drugs, a study of a Welsh community pharmacy service has found.

Researchers from Cardiff University compared pre-2020 data from Wales’ sore throat test and treat service (STTT) with data gathered during the pandemic, when the requirement to carry out point of care testing (POCT) was temporarily relaxed.

They looked at 4,468 STTT consultations carried out in 56 pharmacies across two health boards between November 2018 and September 2019.

Of these, 3,369 patients were eligible for POCT based on their self-reported clinical scores using the FeverPAIN or Centor metrics.

Nine hundred and twenty two (27 per cent) of these eligible patients ended up receiving an antibiotic after a POCT returned a positive result for group A. Streptococcus (GAS).

The use of testing to rule out GAS meant that around a third of patients who, in accordance with NICE guidance, would have been offered an antibiotic prescription based on their clinical score alone, were not offered antibiotics after a negative POCT result.

The service was paused during the early months of the coronavirus pandemic to allow pharmacy teams to focus on essential work, and then reintroduced in November 2020 with modifications to comply with social distancing guidance.

The new version of the service relied more on remote consultations and removed the POCT requirement, allowing pharmacists to supply antibiotics to patients with sufficiently high clinical scores who wished to take antibiotics following a discussion with the pharmacist.

Looking at 199 consultations carried out in 25 pharmacies between November 2020 and May 2021 using the new service structure, the Cardiff researchers identified an overall supply rate of 48 per cent.

Among patients who were eligible for POCT, the supply rate was even higher at 63 per cent.

Only around 10 per cent of those who would have been eligible for antibiotic according to NICE guidance ended up without antibiotics.

The authors write: “Significant differences in the supply of antibiotics were found between the two periods, with an overall increase of 36 percentage points from the pre-pandemic period to the Covid period, and 47 per centage points specifically in those with severe symptoms.

“Changes to the delivery model necessitated by the Covid-19 pandemic reduced the number of steps prior to community pharmacists offering antibiotics, and consequently the number of opportunities to rule out GAS infection and target antibiotics more appropriately.”

They say that pharmacists were “significantly more likely to offer antibiotics when they relied on clinical scoring” and that supply rates in these cases “were higher and similar to those reported for GPs”.

“We recommend that policymakers ensure pharmacists providing STTT should do so only when diagnosis is confirmed by the use of a validated POCT.”

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