Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

Objectives To describe a group general practice's implementation of a decis ion to prescribe 3 day courses of 200 mg trimethoprim twice daily for urina ry 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 i nfections, and critical appraisal of evidence originally presented in suppo rt 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 du ring a 12 month period were reviewed. 271 valid records were identified. Data extraction Prescribing rates for different courses of trimethoprim, ra tes 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 treat ment 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 d ifference 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 wh ich the practice based its recommendations showed that it was flawed. Addit ional evidence was found in the Cochrane Library. Conclusions Our original decision, made by consensus at a meeting of the pr actice's partners, had not led to a consistent change in practice. We did n ot find a significant increase in treatment failures among patients treated with the 3 day regimen.