Tackling antibiotic overuse

The misuse and overuse of antimicrobials in humans, animals and plants are the main drivers in the development of drug-resistant pathogens.¹ The HSE has launched initiatives to curb the prescribing of “red” antibiotics, while promoting the use of ‘green’ antibiotics. 

“Green” are generally preferred narrow spectrum agents while “red” are broad spectrum agents generally best used very selectively. This initiative ensures safer antibiotic use while safeguarding patient health.² By categorising antibiotics based on risk levels and providing prescribers with structured guidelines, feedback, and educational resources, the HSE aims to reinforce responsible prescribing habits.

Behavioural economics

The use of antibiotics in GP out-of-hours services (OOH) is influenced by many factors including availability, consultation method, diagnostic uncertainty, clinician experience and time pressures.³ The purpose of this audit was to assess if behavioural economics could be applied to doctors’ OOH prescribing patterns. 

A key principle of behavioural economics is ‘choice architecture’. This approach involves designing processes or environments to subtly influence decision-making by changing what options are available – or how they are presented. It uses insights from psychology to design processes that nudge people toward better decisions.

We reviewed our processes where doctors provide emergency supplies of ‘starter antibiotics’ in the out-of-hours setting. The normal procedure is the duty doctor selects the emergency antibiotic required, counts it out, and packs and labels it prior to giving it to the service user. 

A design solution was sought where we applied the principles of ‘choice architecture’. ‘Prepacked’ starter packs of green antibiotics were prepared and labelled, thus reducing the administrative burden of the duty doctor. A 30.7% reduction in the prescribing of red antibiotics resulted following the introduction of prepacked ‘green antibiotic’ starter packs.

Improvement initiative

One of the key strategies introduced by the HSE is the Green/Red Antibiotic Quality Improvement Initiative.¹

This initiative provides community prescribers with a categorised list of antibiotics, distinguishing between ‘green’ antibiotics – preferred for their effectiveness and lower risk of resistance – and ‘red’ antibiotics, which are associated with higher risks.

Green antibiotics include cefalexin, amoxicillin, doxycycline, trimethoprim, nitrofurantoin, fosfomycin, lymecycline, flucloxacillin and penicillin V. 

Red antibiotics include quinolones, most cephalosporins (except cefalexin), macrolides, co-amoxiclav and clindamycin.

Prescriber feedback reports

To encourage adherence to the initiative, the HSE collaborates with the Primary Care Reimbursement Service (PCRS) to provide quarterly feedback reports to GPs. These reports detail the percentage of green and red antibiotics prescribed by each GP and compare their prescribing patterns to national benchmarks, with each report including educational nudges.

Educational campaigns and resources

The HSE has developed various campaign materials to support prescribers in making informed decisions. These materials include:

• Mouse-mats displaying the green/red antibiotic list for easy reference
• Online antimicrobial guidelines for community prescribers
• Training sessions and workshops on antimicrobial stewardship.²

Additionally, the HSE has extended these resources to community pharmacists, ensuring a broader awareness of responsible antibiotic prescribing.

Antimicrobial stewardship (AMS) programmes

The HSE has integrated Antimicrobial Stewardship (AMS) programmes² across healthcare settings to promote the appropriate use of antibiotics. AMS initiatives focus on:

• Delivering the right antibiotic at the right time, dose, and duration
• Protecting patients from harm caused by inappropriate antibiotic use
• Preventing the emergence of antimicrobial resistance.

Antimicrobial stewardship is recognised as a key patient safety priority, and all healthcare professionals are encouraged to participate in stewardship efforts.

Improvements

Since the implementation of these measures, the HSE has observed significant improvements in antibiotic prescribing patterns. PCRS data indicates a 4.3% increase in the use of green antibiotics from July 2018 to March 2020, rising from 56.4% to 60.7%. Additionally, the prescribing of moxifloxacin has decreased by 50% following safety alerts issued to GPs and pharmacists.

The long-term implications of antibiotic resistance include:

• Harder-to-treat infections leading to increased illness and deaths
• Rising healthcare costs due to prolonged treatments and expensive medications
• Greater risks in surgeries, cancer treatments, and organ transplants
• Faster spread of untreatable superbugs across communities and borders
• Impact on food security as resistant bacteria affect livestock and agriculture
• Shortage of new antibiotics, making future treatments more difficult
• Urgent need for global action on responsible antibiotic use and infection prevention.

Impact of pre-packed ‘green antibiotic’ packs on prescribing 

Antimicrobial stewardship is a critical component of healthcare policy, aiming to optimise antibiotic use and reduce antimicrobial resistance.³

This audit examines the prescribing patterns of GP locums in the Laois out-of-hours services before and following the introduction of pre-packed starter packs of green antibiotics. In addition, red antibiotics were removed to secondary, less accessible storage. The review conducted over 12 months, revealed a reduction in red antibiotic prescribing demonstrating the possible influence of choice architecture and behavioural economics on prescribing behaviours in out-of-hours.

Objectives

To assess the impact on prescribing patterns by clinicians in OOH by introducing, for convenience, pre-packed green antibiotic starter packs. By comparison, red antibiotic starter packs were not prepared and red antibiotics were stored in a separate location of the premises.

Methodology

Prescription records were reviewed over a three-month period from June to August 2022. In September 2022, prepacked and labelled starter antibiotics containing 24 hours supply were introduced for emergency dispensing. This replaced the existing process where doctors were required to select, pack and label their preferred antibiotic prior to dispensing. 

Starter packs were only prepacked in the ‘green antibiotic’ category. Red antibiotics were not prepacked and were stored in a separate location in the out-of-hours premises. Prescription records were reviewed from the period June to August 2024. Prescribing rates of red and green antibiotics before and after the intervention were analysed. 

Findings

Reduction in red antibiotic prescriptions

A decrease in the prescribing of red antibiotics followed the intervention of providing pre-packed green antibiotics. Prescribers anecdotally reported that the lack of immediate availability of red antibiotic starter packs helped reinforce adherence to prescribing guidelines, particularly during busy periods.

Increased use of green antibiotics

Green antibiotic prescriptions increased proportionally, aligning with antimicrobial stewardship goals.

Prescriber behaviour and decision-making

Clinical guidelines reinforced the preference for green antibiotics, supporting the observed shift. 

Following our audit, it was recommended:

• To maintain the restriction on pre-packed red antibiotics to support responsible prescribing
• To provide ongoing education for prescribers on antimicrobial stewardship principles
• To conduct further audits to assess long-term trends. 
• To continue monitoring and reinforcement of prescribing guidelines which are essential to sustain improvements.

Conclusion

The introduction of convenient pre-packed green antibiotics in out-of-hours was followed by an overall reduction in the prescribing of red antibiotics by 30.7%. This shift aligns with antimicrobial stewardship objectives and highlights the potential role of behavioural economics in shaping prescribing behaviours.

References

1. World Health Organization, Fact sheet on antimicrobial resistance.
2. www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
3. www.hse.ie, search under ‘preferred antibiotic prescribing’
4. www.hse.ie search under ‘antimicrobial stewardship’
5. Shah M, Barbosa TM, Stack G, Fleming A. Trends in antibiotic prescribing in primary care out-of-hours doctors’ services in Ireland. JAC Antimicrob Resist, 2024 Feb 9;6(1):dlae009. doi: 10.1093/jacamr/dlae009. eCollection 2024