a Public Health Laboratory, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN; b S&W Devon Health Authority, The Prescribing Team, Lascaze Office, Shinners Bridge, Dartington TQ9 6JE; c City University, Northampton Square, London EC1V 0HB, UK
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Abstract |
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Introduction |
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The guidance was developed by the project team, in collaboration with GPs, and aimed to complement, rather than replace, other much more extensive management advice available on the internet. The antibiotic guidance provided a short, simple quick reference guide to the empirical treatment of common infections seen in primary care. The conditions covered were those infections most commonly managed in primary care and GPs would not usually need to refer to it during consultation with every patient, therefore it was not designed to be interactive with the patient record. The guidance encouraged the rational and cost-effective use of antibiotics to minimize the emergence of bacterial resistance in the community. The guidance was set out in A4 format over four pages with clear aims and objectives, recommendations for the treatment of common infections in primary care with antibiotic dose, duration, contraindications to use and advice on when to avoid antibiotics.
The draft guidance was circulated widely for consultation to those with expertise in each subject area, GPs and microbiologists. We ensured that there was a consistent approach between Prodigy and the PHLS guidance. Prodigy (http://www.prodigy.nhs.uk) is the computerized clinical support system on the management of all common conditions presenting to primary care and is used by 30% of GPs.6 It is funded by the Department of Health (DH). The Prodigy system was designed so that GPs could use it on their own practice computer system during consultations.
The PHLS antibiotic guidance was posted on the PHLS website, in the Advice and Guidelines section, in January 2000 with an accompanying note explaining the site development. In order to draw the guidance to the attention of all those involved with the development of primary care antibiotic guidance, the website (http://www.phls.co.uk/advice/antibiotic/antibiotic%20guidance.htm) was advertised in the Communicable Disease Report Weekly, which is circulated to 4000 individuals with an interest in infectious disease,7 and an explanatory letter containing the website address was sent to regional prescribing leads, regional directors of public health in England and Wales, and relevant British professional societies.
The CDR information, letter and notes on the website explained that the guidance template was in draft format and that we welcomed and actively encouraged opinions on the range of topics covered and advice given. We recommended that suggestions or comments should be accompanied by supporting evidence or references. We asked addressees to draw the guidance to the attention of all relevant personnel involved in antibiotic guidance development. We indicated that the website antibiotic guidance template was designed to be downloaded, and that the antibiotics and advice given could be changed to suit local circumstances.
In the four months after posting the guidance on the website numerous e-mailed and written comments were received from around the UK from microbiologists, pharmacy advisors and GPs involved in the production of guidance. Some typographical errors were identified but most of the comments were about the antibiotic choice, dose and duration of course. As a result of the comments received, 59 substantial changes were made to the comments column in the guidance; 14 changes were made to the antibiotics listed and the dose or duration of treatment. Several requests were made for the guidance to be graded to the strength of each recommendation and fully referenced so that writers of local guidance could read the relevant papers. Grading of evidence used was added to 47 statements on advice in line with a previous review of this subject.4,8 All the major papers and systematic reviews used in the development of the guidance were quoted. The guidance was updated again in January 2001 (24 alterations) and July 2001 (23 alterations) taking account of further comments from users of the guidance and any new evidence and systematic reviews on the management of infectious disease.9 Changes were referenced where appropriate.
The electronic production and posting of this antibiotic guidance greatly facilitated the open review process and consequent modifications. Electronic review is non-confrontational, does not require travel to meetings and allows much wider review, including by the end-users. Typographical errors that often occur in printed copies can be corrected very easily and other changes can be made quickly if important new evidence comes to light. The website can be accessed rapidly if the address is stored or the guidance can be printed if the clinician prefers that format.
Printed guidance can become outdated easily; this does not occur with regularly reviewed electronic guidance. We plan to review the guidance at six monthly intervals with any comments received, recent systematic reviews and any other evidence.9 Recently, draft guidelines for the prevention of catheter-associated UTIs were posted on the internet for consultation before submission to the DH for approval and subsequent publication.10 We would encourage the electronic production of all guidance that is targeted at a large population of end-users.
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Notes |
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References |
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2 . British National Formulary (No. 40). (September 2000). British Medical Association/Royal Pharmaceutical Society of Great Britain. BMJ Books, London, UK.
3 . McNulty, C. A. N. & Smith, G. on behalf of the PHLS Primary Care Co-ordinators. (2001). PHLS works towards effective interaction with primary care. Review. Communicable Disease and Public Health 3, 2349.
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Shekelle, P. G., Woolf, S. H., Eccles, M. & Grimshaw, J. (1999). Developing guidelines. British Medical Journal 318, 5936.
5 . Fox, N. J., Dolman, E. A., Lane, P., O'Rourke, A. J. & Roberts, C. (1999). The WISDOM Project: training primary care professionals in informatics in a collaborative virtual classroom'. Medical Education 33, 36570.[ISI][Medline]
6 . Purves, I. N. (1998). Prodigy: implementing clinical guidance using computers. British Journal of General Practice 48, 15523.[ISI][Medline]
7 . CDSC. (2000). Antibiotic guidance for primary care. Communicable Disease Report CDR Weekly 10, 12.
8 . Cluzeua, F., Littlejohns, P., Grimshaw, J. & Feder, G. (1997). Appraisal Instrument for Clinical Guidelines. St George's Hospital Medical School, London, UK.
9 . Clinical Evidence. (2001). Issue 5. BMJ Publishing Group, London, UK.
10 . Guidelines for preventing catheter associated urinary tract infectionson internet for consultation. (2000). Communicable Disease Report CDR Weekly 10, 14952.
Received 12 April 2001; returned 30 October 2001; accepted 25 November 2001