Reducing 4C Antimicrobial Overprescribing Through a National Approach in Wales

All Wales Therapeutics and Toxicology Centre (AWTTC), Public Health Wales (PHW) and the Welsh Antimicrobial Pharmacy Group (WAPG)

Project summary

Overprescribing of broad-spectrum “4C” antimicrobials (co-amoxiclav, cephalosporins, fluoroquinolones and clindamycin) increases the risk of healthcare-associated infections, antimicrobial resistance (AMR) and avoidable patient harm. Reducing unnecessary prescribing became an antimicrobial stewardship priority for NHS Wales.

The All-Wales Therapeutics and Toxicology Centre (AWTTC) National Prescribing Indicators (NPI) team worked with Public Health Wales (PHW) and the Welsh Antimicrobial Pharmacy Group (WAPG) to coordinate improvement across Wales. Since 2018/19, broad-spectrum “4C” antimicrobials have been included within the All-Wales Medicines Strategy Group (AWMSG) NPIs, with a target to reduce inappropriate prescribing. The AWTTC NPI team monitors the 4C indicator through analysis of prescribing data and produces quarterly reports using data from the AWTTC NPI dashboard. The reports and dashboard data help identify prescribing trends, variation and areas for targeted improvement supporting an All-Wales approach to antimicrobial stewardship.

A key example of this collaboration was the national response to MHRA safety advice on fluoroquinolones published in January 2024, which highlighted serious, disabling and potentially irreversible adverse effects. PHW and WAPG via the All-Wales Antimicrobial Guideline Group (AWAGG) reviewed and updated AWMSG primary care antimicrobial guidance to reinforce that fluoroquinolones should only be prescribed when no suitable alternatives are available. AWTTC, PHW and WAPG also developed national fluoroquinolone prescribing decision support software messages to provide clinical prompts at the point of prescribing. WAPG members supported local implementation through education sessions, prescribing audits and clinical advice.

This collaborative approach delivered sustained reductions in prescribing. Across Wales, prescribing of 4C antimicrobials reduced year on year and remained consistently lower than in England. Between December 2023 and December 2025, fluoroquinolone prescribing almost halved, with the overall volume prescribed reducing from 21.6 to 11.4 defined daily doses (DDDs) per 1,000 patients - a 47% reduction. Additionally, the overall prescribing volume for co-amoxiclav, cephalosporins and clindamycin decreased by 12.8%, reflecting reduced broad-spectrum prescribing.

These improvements are clinically significant as fluoroquinolones are associated with increased risks of Clostridioides difficile infection, AMR, tendon damage and peripheral neuropathy. Reduced prescribing is expected to deliver wider health economic benefits through avoidance of medicine-related harm, fewer healthcare-associated infections and reduced hospital admissions. This work demonstrates the value of national collaboration in supporting patient safety, antimicrobial stewardship and efficient use of resources.