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An audit to review the podiatry supply of flucloxacillin under Prescription Only Medicines exemption (POM-S) in cases of mild infection within Belfast Health and Social Care Trust

Ashling McElvanna, John McCarry, Suzanne Doyle, Jill Cundell, Anne McDaid
Background: The timely treatment of diabetes foot infections is important to prevent the rapid progression of infection, hospital admissions and amputation (Lipsky et al, 2020). Antibiotic therapy is necessary for all diabetes foot infections (NICE, 2019). Podiatrists with HCPC POM-S annotation can supply flucloxacillin 500 mg (one four times a day for 7 days) for mild foot infections (Health and Care Professions Council, 2021). Aim: The aim of this audit was to review the issue of 500 mg of flucloxacillin and assess patient outcomes within community foot protection teams. Methods: The records of all patients diagnosed with mild infection according to International Working Group on the Diabetic Foot (Lipsky et al, 2020) classification, and issued 500 mg of flucloxacillin (one four times a day for 7 days), between 23/8/19–11/09/20, by a podiatrist working in a Community Wellbeing and Treatment Centre within Belfast Health and Social Care Trust were included. All podiatrists were required to adhere to the Safe Operating Procedure for supply of flucloxacillin to patients. Data analysis was performed using Microsoft Excel 2016®. Results: A total of 35 patients were supplied 500 mg of flucloxacillin (one four times a day for 7 days) by a community podiatrist during 23/8/19–11/09/20. Twenty one cases of infection completely resolved and four cases of infection improved. Four patients changed antibiotic after microbiological/radiological investigations. Two cases of infection deteriorated with the patient requiring hospital admission, two cases of infection did not improve due to deteriorating ischaemia and two cases of infection remained static. Conclusions: This audit has shown the supply of flucloxacillin 500 mg (one four times a day for 7 days) by community podiatrists can improve and resolve mild foot infections. It can also ensure timely access to antibiotics avoiding delays in therapy. Podiatrists with HCPC POM-S annotation should utilise supplying for mild foot infection where appropriate.

Podiatrists diagnose and treat pathologies of the foot and ankle, including foot infections. Infection has been defined as “an invasion and multiplication of microorganisms in host tissues that induces a host inflammatory response, usually followed by tissue destruction” (Lipsky et al, 2020).


Foot infections can be caused by nail pathologies, such as paronychia and onychocryptosis, which sometimes require antibiotic treatment. In patients with diabetes, foot infections are most commonly caused by foot ulcerations (Uçkay et al, 2015). Diabetes foot infections remain the most common diabetes complication requiring hospital admission and lower-extremity amputation (Lipsky et al, 2020).


The National Institute for Health and Care Excellence (NICE) advise diabetes foot infections require antibiotic treatment following clinical rather than microbiological diagnosis of infection, to prevent delay of antibiotic treatment. Timely prescription of antibiotics for diabetes foot infections is key in avoiding the rapid progression of infection, unnecessary hospital admissions and amputation (NICE, 2019). The International Working Group on the Diabetic Foot (IWGDF) clinical classification of infection (Table 1) defines the presence and severity of infection and guides treatment (Lipsky et al, 2020).


The first-choice oral antibiotic recommended by NICE for mild foot infection (Table 1) in non-penicillin allergic adults is flucloxacillin 500 mg — 1g four times daily for 7 days (NICE, 2019). Flucloxacillin is a penicillin, which is bactericidal and acts by interfering with bacterial cell wall synthesis (NICE, 2021).


Health and Care Professions Council (HCPC) Registered podiatrists with the ‘Prescription-Only Medicines, Supply annotation’ (POM-S) are authorised to access and supply flucloxacillin 500 mg, for patients who present with bacterial skin and/or soft tissue infections of the foot (HCPC, 2021). From 2019, podiatrists in Belfast Health and Social Care Trust (BHSCT), with HCPC POM-S annotation, are able to supply flucloxacillin 500 mg (one four times a day for 7 days) for mild foot infections, under POM-S exemption.


The aim of this audit was to review the issuing of flucloxacillin 500 mg (one four times a day for 7 days) to patients with mild foot infection in podiatry community wound clinics, and to assess patient outcomes.


Method
All patients diagnosed with mild infection according to IWGDF classification (Table 1), and issued 500mg of flucloxacillin, one four times a day for 7 days, between 23/8/19–11/09/20, by a podiatrist working in a Community Wellbeing and Treatment Centre within BHSCT were included in this study. There are six community wellbeing and treatment centres and all were included. All podiatrists were required to adhere to the Safe Operating Procedure for supply of flucloxacillin to patients (Table 2).


Each patient supplied 500 mg of flucloxacillin (one four times a day for 7 days) was recorded in the log book at each community wellbeing and treatment centre. The data from the six log books were collated. The electronic records of those patients issued flucloxacillin were then reviewed for the necessary information surrounding each issue of antibiotic including; source of infection, medical history and clinical outcome. Data analysis were performed using Microsoft Excel 2016®. Ethical approval was not required.


Results
A total of 35 patients were supplied 500 mg of flucloxacillin (one four times a day for 7 days) by a community podiatrist during 23/8/19–11/09/20. All podiatrists adhered to Podiatry BHSCT Safe Operating Procedure for supply of antibiotics to patients (Table 2).


An overview of mild infection outcomes following 500mg of flucloxacillin (one four times a day for 7 days) can be seen in Figure 1. Twenty one cases of infection completely resolved and four cases of infection improved. Four patients changed antibiotic after microbiology/radiological investigations. Two cases of infection deteriorated and required hospital admission, and two cases of infection did not improve due to deteriorating ischaemia. Two cases of infection remained static.


Data from electronic records of patients issued flucloxacillin 500mg, one four times a day for 7 days, which can be seen in Table 2.


Discussion
This audit has highlighted the benefits of timely supply of flucloxacillin 500mg, one four times a day for seven days, under POM-S exemption by foot protection team podiatrists, in cases of mild foot infection. The results show 25 cases of mild foot infections completely resolved or improved after the supply of 500 mg of flucloxacillin, one four times a day for 7 days. Two cases of infection deteriorated which required hospital admission and two cases of infection remained static.


Of those patients whose records were audited, 31 had diabetes. NICE guidelines (2019) recommend antibiotics should be started as early as possible to prevent complications in diabetes foot infection. By supplying antibiotics directly to the patient while at clinic, podiatrists can facilitate prompt treatment of diabetes foot infections. Thus, reducing the risk of complications, including hospital admission and lower-extremity amputation.
Thirty-three patients were issued antibiotics for foot ulcerations. Of the total number of foot ulcerations, 13 completely healed, nine were improving and seven remained static or stable. Diabetes wound healing can be delayed by infection, but other factors, such as ischaemia, neuropathy and poor offloading, can also cause delayed healing (Alexiadou and Doupis, 2012). Ten patients had known peripheral arterial disease which may have influenced outcomes. In two cases, the foot condition got worse due to deteriorating ischaemia rather than infection, one of whom underwent a below-knee amputation.


The increase in antibiotic resistance is a major concern across the world and all health and medical professionals have a responsibility to use any antibiotics carefully and appropriately to help preserve their future effectiveness. This is referred to as antibiotic stewardship (NICE 2015). One of the goals of antibiotic stewardship is to prevent misuse and overuse of antibiotics as drivers for the development of antibiotic resistance (WHO, 2021). The data from this audit show all antibiotics were supplied in cases of confirmed infection, which highlights each podiatrist’s consideration of antibiotic stewardship. In four cases, antibiotics were switched from flucloxacillin 500 mg (one four times a day for 7 days), to another antibiotic following review of wound culture sensitivities. Obtaining would culture sensitivities is in adherence to national guidelines (NICE, 2019) and Podiatry BHSCT Safe Operating Procedure for supply of antibiotics to patients (Table 2) and enables antibiotic treatment to be amended as appropriate. This ensures optimal use of antimicrobials to improve patient outcomes.


The results of this audit indicate that POM-S exemptions are a useful tool for the community-based foot protection team podiatrist. Initiation of antibiotic therapy at wound treatment appointments can improve and resolve infection. It can also facilitate timely access to antibiotics in cases of mild infection and avoid delays in therapy. Prior to the utilisation of POM-S exemption by foot protection team, it had been custom and practice for podiatrists to request general practitioners to prescribe antibiotics for patients presenting with a mild infection. This caused delay in therapy and treatment.


Utilisation of non-medical prescribing by other healthcare professionals has been shown to have many benefits, including an increase in the convenience and speed with which patients receive their medication, improvement in continuity of care for patients and improvement in patient safety (Courtenay et al, 2011; Coull et al, 2017). In addition, it enables non-medical prescribers to make more effective use of their knowledge and skills (Coull et al, 2017) and it enables general practitioners and non-medical prescribers to make more efficient use of their time and resources, which has important implications at a time of constraint in the NHS (Courtenay et al, 2011).


Reflecting on the results, podiatrists with HCPC POM-S annotation should utilise supplying for mild infection where appropriate. In addition, podiatrists without HCPC annotation should be encouraged to undertake the required additional training to become POM-S annotated on the HCPC register.


Limitations
The low number of patients involved limited the size of the data available for analysis.
Conclusion
Supply of flucloxacillin 500 mg (one four times a day for 7 days) in cases of mild foot infection can improve and resolve infection. Having the option for supplying 500 mg of flucloxacillin (one four times a day for 7 days) facilitates timely access to antibiotic treatment for mild infections in accordance with national guidelines (NICE, 2019). Timely supply of antibiotics can help reduce the risk of lower-extremity amputation and hospital admission in diabetes foot infections

REFERENCES:

lexiadou K, Doupis J (2012) Management of diabetic foot ulcers. Diabetes Ther 3(1): 1–15

Coull A, Murray I, Turner-Halliday F, Watterson A (2013) The expansion of nurse prescribing in Scotland: an evaluation. Br J Community Nurs 18(5): 234–42

Courtenay M, Carey N, Stenner K et al (2011) Patients’ views of nurse prescribing: effects on care, concordance and medicine taking. Br J Dermatol 164(2): 396–401

Health and Care Professions Council (2021) Medicine and Prescribing Rights. London: Health and Care Professions Council. Available at: https://www.hcpc-uk.org/about-us/what-we-do/medicine-entitlements/ (accessed 03.11.2021)

Lipsky BA, Senneville É, Abbas ZG et al (2020) Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 36(Suppl 1): e3280

National Institute for Health and Care Excellence (2015) Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use (NICE Guideline NG15). London: NICE. Available at: https://bit.ly/3CIZMVh (accessed 03.11.2021)

National Institute for Health and Care Excellence (2019) Diabetic Foot Problems: Prevention and Management. NICE Guideline [NG19]. London: NICE. Available at: https://bit.ly/3q3rZCO (accessed 03.11.2021)

National Institute for Health and Care Excellence (2021) Flucloxacillin. London: NICE. Available at: https://bit.ly/3bA2Ab5 (accessed 03.11.2021)

Uçkay I, Aragón-Sánchez J, Lew D, Lipsky BA (2015) Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis 40: 81–91

World Health Organization (2021) Antimicrobial Resistance. Geneva: WHO. Available at: https://bit.ly/3nQeTpH (accessed 03.11.2021)

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