Background Work on antimicrobial resistance in England has led to the creation of guidelines to minimise inappropriate prescription of antibiotics. Unaware of previous work on the performance of telephone advice services in this regard, we examined antibiotic usage in an NHS 111 service for patients over the age of 65 with lower urinary tract infection (UTI).

Methods We conducted a retrospective audit of telephone assessments during the period 1^st June to 31^st August 2022. Antibiotic prescriptions for the indication of lower UTI were identified, and notes for a random sample of 25 cases were retrieved from the computer-aided dispatch system. Cases relating to catheter-associated infection and cases where a decision was made jointly with a paramedic on scene were excluded. Resources from the TARGET antibiotics toolkit and NICE guideline NG109 were used to prioritise outcome measures relevant to remote assessment in the NHS 111 setting, and records were coded against these measures by a trainee Advanced Clinical Practitioner with experience in telephone assessment.

Results 327 prescriptions for the cohort were identified, representing 11% of all service prescriptions for the period. The prescribing decision was inconsistent with guidelines in 3/25 audited cases (12%), and suboptimal antibiotic choice, dose, frequency, or duration was noted in 8/25 cases (32%). Dipstick urinalysis was recorded in 5/9 care home cases (56%), documentation of advice given was incomplete in 18/25 cases (72%), and non-UTI differential diagnoses were unmentioned in 20/25 cases (80%).

Conclusion The audit revealed disparities between guidelines and practice in this service, with particular work remaining around appropriate use of urinalysis, advice given to patients, and consideration of non-UTI pathologies. The audit was limited to a documentation review; call recordings may have revealed undocumented rationales or advice. We recommend replication of this audit in similar services to enable understanding of wider patterns in this area of practice.