Green Red Antibiotic Quality Improvement Initiative for Community Prescribers
Key Point 1: A “green/red” list of antibiotics assists community prescribers in choosing an antibiotic that is effective, has fewer side effects and less likely to lead to resistant infections.
Key Point 2: In twelve months a “green/red” prescriber feedback initiative has been associated with a substantial positive change in antibiotic prescribing in the community setting.
The Medicines Management Programme (MMP) together with the Antimicrobial Resistance and Infection Control (AMRIC) team in the HSE developed a preferred antibiotics initiative commonly referred to now to as the Green/Red antibiotic list. The antimicrobial guidelines for community prescribers* on www.antibioticprescribing.ie recommend the preferred use of "green" agents which are effective, have fewer side effects and are less likely to lead to resistant infections than "red" agents.
The green agents are: cefalexin, amoxicillin, doxycycline, trimethoprim, nitrofurantoin, fosfomycin, lymecycline, flucloxacillin and penicillin V
The red agents are: quinolones, most cephalosporins except cefalexin, macrolides , co-amoxiclav and clindamycin.
GPs are provided with this list as a mouse-mat (see Figure 1) to assist in antibiotic decision making at the point of prescribing. The latest version highlights risks associated with the red agents. From October 2020 the mouse-mat will also be made available to Community Pharmacists to increase their awareness of the initiative.
AMRIC are also collaborating with the Primary Care Reimbursement Service (PCRS) to build on this green/red initiative. Each quarter since September 2019 each GP (if list >100 GMS patients) receives an individualised report on antibiotic use for their GMS cohort for an updated rolling 12 month period. The report details the percentage of agent use that are green agents and the percentage that are red agents and places the GP’s own rate within a national quartile of low, midrange or high.
Each report has an educational nudge, examples include:
- Report 1: introduction of green/red concept and report interpretation
- Report 2: tips on safer use of clarithromycin
- Report 3: tips on prescribing for UTIs
- Report 4: tips on telemedicine prescribing, COVID-19 guidelines and azithromycin feedback
- Report 5: moxifloxacin safety reminder, RTI prescribing including COVID-19, web what’s new
See these educational nudges or to note are available on www.antibioticprescribing.ie in the AMRIC key messages section.
Significant improvements in antibiotic use
PCRS data reveals an overall increase of 4.3% in the average 'Green' Percentage from July 2018 to March 2020: from 56.4% to 60.7%. A copy of this report is included as a link at the end of this page.
Moxifloxacin has shown a 50% reduction in one year after the issue of a safety alert to GPs and community pharmacists (see the AMRIC key messages section)
'Even in those particular cases where a fluoroquinolone is necessary, moxifloxacin should only be used where other antibacterial agents, including the other fluoroquinolones, are inappropriate or have failed.'
PCRS data reports only reflect prescribing for patients with medical cards however we have also seen significant improvements in the quality of antibiotic prescribing for non-GMS patients.
Combined GMS and non-GMS community pharmacy dispensing data from Health Market Research data for Jan-Apr 2020 vs. Jan- Apr 2019 shows co-amoxiclav down 28%, clarithromycin down 25%, doxycycline up 19%, cefalexin up 22%. It must be noted this time period comparison may be affected by the change in the nature of clinical consultations as a result of the early phase of the COVID-19 pandemic where there were so many unknowns and care was often delivered via non-traditional means.
Azithromycin is an exception in the positive trends noted, its use is increasing and GP feedback indicates much of its initiation is in the acute setting. AMRIC have initiated engagement with the National Respiratory Programme and it is hoped to commence a quality improvement project for azithromycin in the near future.
Feedback from GPs will assist in the ongoing development of the individualised reports with requests to date to include a rate of prescribing in the individualised reports. AMRIC and PCRS will assess the feasibility of this in 2021.
AMRIC sincerely thanks all community prescribers for engaging so positively in the green/red initiative and we welcome any additional feedback from prescribers or community pharmacists. Thank you to the significant contributions of staff in the MMP and PCRS.
*When we use the term community prescribers, we are acknowledging the majority of antibiotic prescribing in the community is by GPs, however there is a proportion of it initiated by hospital consultants, and medical officers for health who may or may not be a GP.
Figure 1: Preferred antibiotic use in the community “green/red” table
Medicines Management Programme: Prescribing Tips and Tools