Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP's management of impetigo

Clare Heal; Hilary Gorges; Mieke L van Driel; Amanda Tapley; Josh Davis; Andrew Davey; L Holliday; Jean Ball; Nashwa Najib; Neil Spike; Kristen FitzGerald; Parker Magin

doi:10.1136/bmjopen-2019-031527

Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP's management of impetigo

BMJ Open. 2019 Oct 28;9(10):e031527. doi: 10.1136/bmjopen-2019-031527.

Authors

Clare Heal¹, Hilary Gorges², Mieke L van Driel³, Amanda Tapley^{4

5}, Josh Davis⁶, Andrew Davey⁷, L Holliday⁸, Jean Ball⁹, Nashwa Najib⁷, Neil Spike^{10

11}, Kristen FitzGerald¹², Parker Magin¹³

Affiliations

¹ School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia Clare.Heal@jcu.edu.au.
² Department of General Practice and Rural Medicine, James Cook University, Mackay, Queensland, Australia.
³ Academic Discipline of General Practice, University of Queensland, Brisbane, Queensland, Australia.
⁴ NSW & ACT Research and Evaluation Unit, GP Synergy Ltd - Newcastle, Newcastle, New South Wales, Australia.
⁵ Discipline of General Practice, School of Medicine & Public Health, University of Newcastle, Callaghan, New South Wales, Australia.
⁶ Global and Tropical Health Division, Menzies School of Health Research, Casuarina, New South Wales, Australia.
⁷ GP Synergy Ltd, Liverpool Westfield, New South Wales, Australia.
⁸ The University of Newcastle, Newcastle, New South Wales, Australia.
⁹ Clinical Research Design and Statistics, The University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia.
¹⁰ Eastern Victoria General Practice Training, Melbourne, Victoria, Australia.
¹¹ University of Melbourne, Melbourne, Victoria, Australia.
¹² General Practice Training Tasmania, Hobart, Tasmania, Australia.
¹³ Discipline of General Practice, University of Newcastle, Callaghan, New South Wales, Australia.

Abstract

Objective: To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice).

Design: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study.

Setting: ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states.

Participants: Registrars participating in ReCEnT from 2010 to 2017.

Outcome measures: Management of impetigo with systemic antibiotics.

Results: 1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01).

Conclusions: Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.

Keywords: antibiotic stewardship; general Practice; impetigo.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Anti-Bacterial Agents / therapeutic use*
Antimicrobial Stewardship*
Australia
Child
Child, Preschool
Cohort Studies
Cross-Sectional Studies
Female
General Practice*
Humans
Impetigo / drug therapy*
Infant
Infant, Newborn
Male
Middle Aged
Practice Patterns, Physicians'*
Young Adult

Substances

Anti-Bacterial Agents