Volume 207 - Issue 2
Can antibiotic prescribing for respiratory infections be reduced?
Authors: Martin Gulliford and Mark Ashworth
Med J Aust 2017; 207 (2): 62-63. || doi: 10.5694/mja17.00382
Published online: 17 July 2017
Published online: 17 July 2017
It must be - as an essential component of the response to the antimicrobial drug resistance problem
It must be — as an essential component of the response to the antimicrobial drug resistance problem
The growing threat of antimicrobial drug resistance (AMR) is attracting the attention of national governments and international organisations. In the words of Margaret Chan, Director-General of the World Health Organization, “We are hearing one alarm bell after another.”1 This is apparent in primary care, where the frequency of antibiotic-resistant infections is increasing. The emergence of AMR is a multifaceted societal problem that requires action from a range of actors, including the pharmaceutical, agricultural and food production industries.2 But it is the health care sector, where antibiotics are prescribed and patients with resistant infections are seen, that the impact of AMR is most acute. This is especially relevant in Australia, where antibiotic consumption is among the highest of the OECD countries.3
Primary care accounts for nearly three-quarters of all antibiotic prescribing in England, and respiratory tract infections (RTIs) comprise the largest single group of indications for antibiotic treatment.4 The article by McCullough and colleagues in this issue of the MJA reports on the use of antibiotics for treating respiratory infections in Australia.5 Their study reveals that acute respiratory infections account for more than half of all antibiotics prescribed in primary care, but fewer than one-quarter of prescriptions for antibiotics — and possibly as few as 11% — could be justified with reference to Australian prescribing guidelines.
The situation is similar in the United Kingdom, where general practitioners prescribe antibiotics at about 52% of consultations for self-limiting RTIs, including common colds, acute cough and bronchitis, sore throat, otitis media, and rhinosinusitis,6 and with little change in practice over the past two decades.7,8 Evidence from randomised controlled trials indicate that antibiotics generally have little if any effect on the severity or duration of symptoms in these conditions, and treatment is frequently associated with unwanted side effects, such as rashes and diarrhoea.9,10 Consequently, UK guidelines recommend that a no-antibiotic prescribing strategy be agreed with most patients who present with self-limiting RTIs.11 The widespread use of antibiotics also has the effect of medicalising conditions that are usually self-limiting and which most patients could manage themselves. Giving a patient even one antibiotic prescription greatly increases the likelihood that they will also visit a GP for future episodes of similar conditions.12
Prescribing an antibiotic may sometimes be motivated by the perceived risk of complications. Antibiotic treatment is associated with reduced risks of peritonsillar abscess after sore throat, and of mastoiditis after otitis media, but these complications are so rare that more than 4000 patients would need to be treated with antibiotics to prevent one case.13 We recently reported a study of 610 UK general practices, with 45.5 million person-years of follow-up between 2005 and 2014.14 We estimated that if a general practice with the UK average list size of 7000 patients reduced the proportion of RTI consultations at which antibiotics were prescribed by 10%, it might see one additional case of pneumonia each year and one of peritonsillar abscess each decade. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess, or Lemierre syndrome were more frequent at low-prescribing practices. Current evidence suggests that antibiotic prescribing is not justified on safety grounds for most patients presenting with RTIs; GPs can use existing guidelines to target patients who are at increased risk of complications because of severity of illness, age or comorbidity.11
Physicians should be able to prescribe antibiotic therapy when it is necessary, and several approaches to promoting more effective antibiotic stewardship in primary care are now being explored. Deferred or delayed prescribing, in which a prescription is given but only filled if needed, is sometimes advocated, but this approach may be less effective in reducing antibiotic use than a no-prescribing strategy, while achieving similar patient satisfaction.15 Point-of-care testing for biomarkers of bacterial infection that enables targeted prescribing of antibiotics is being developed as a strategy, but its effectiveness is not yet fully established, and it may be difficult to integrate into normal clinical practice.16 Behavioural insights are also being harnessed; for example, sending high-prescribing GPs in England a personalised letter signed by the Chief Medical Officer resulted in a 3% reduction in antibiotic dispensing.17 A contractual financial incentive (“quality premium”) for meeting targets for reducing antibiotic prescribing has been introduced by the English National Health Service, with favourable initial results.18
If the alarm bells are to be dampened, reductions in national levels of total antibiotic prescribing will be required. This might be achievable, with the latest figures indicating that antibiotic prescribing in primary care in England was 7.9% lower in 2015 than in the preceding year.19 Sharing national data on successful antibiotic campaigns is one way to contribute to improving global health.
Competing interests
No relevant disclosures.
References
- Chan M. WHO Director-General addresses ministerial conference on antimicrobial resistance. European Union Ministerial Conference on Antimicrobial Resistance, Amsterdam: Netherlands, 10 Feb 2016. http://www.who.int/dg/speeches/2016/antimicrobial-resistance-conference/en/ (accessed Apr 2017).
- O’Neill J (chair). Tackling drug-resistant infections globally: final report and recommendations. May 2016. London: Review on Antimicrobial Resistance, 2016. https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf (accessed Apr 2017).
- Organisation for Economic Co-operation and Development. Health at a glance 2015. How does Australia compare? https://www.oecd.org/australia/Health-at-a-Glance-2015-Key-Findings-AUSTRALIA.pdf (accessed Apr 2017).
- Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). Report 2016. London: PHE: 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/575626/ESPAUR_Report_2016.pdf (accessed Apr 2017).
- McCullough AR, Pollack AJ, Plejdrup Hansen M, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust 2017; 207: 65-69.
- Gulliford MC, Dregan A, Moore MV, et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014; 4: e006245.
- Gulliford M, Latinovic R, Charlton J, et al. Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006. J Public Health 2009; 31: 512-520.
- Ashworth M, Latinovic R, Charlton J, et al. Why has antibiotic prescribing for respiratory illness declined in primary care? A longitudinal study using the General Practice Research Database. J Public Health 2004; 26: 268-274.
- Venekamp RP, Sanders S, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2013; (1): CD000219.
- Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013; (11): CD000023.
- National Institute for Health and Care Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care (Clinical guideline CG69). July 2008. https://www.nice.org.uk/guidance/cg69/chapter/1-Guidance (accessed Apr 2017).
- Little P, Gould C, Williamson I, et al. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997; 315: 350-352.
- Petersen I, Johnson AM, Islam A, et al. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ 2007; 335: 982.
- Gulliford MC, Moore MV, Little P, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016; 354: i3410.
- Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 2013; (4): CD004417.
- Aabenhus R, Jensen JU, Jørgensen KJ, et al. Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database Syst Rev 2014; (11): CD010130.
- Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet 2016; 387: 1743-1752.
- NHS England. Quality premium: guidance for 2016/17. Mar 2016. https://www.england.nhs.uk/wp-content/uploads/2016/03/qualty-prem-guid-2016-17.pdf (accessed Apr 2017).
- NHS England. Success in NHS push to reduce avoidable antibiotic prescribing [media release]. 23 Mar 2016. https://www.england.nhs.uk/2016/03/antibiotic-prescribing/ (accessed Apr 2017).
Provenance: : Commissioned; externally peer reviewed.