Tuesday, July 05, 2016

BMJ: Safety Of Reducing Antibiotic Prescriptions For Respiratory Infections


Over the past decade we've looked at rising concerns over increased antibiotic resistance, and repeated calls for curbing the excessive (and often `defensive') prescribing of antibiotics for outpatients with  respiratory infections.

As the chart above illustrates, the rate of antibiotic prescribing varies widely by region. The CDC reports:

Key U.S. Statistics

Below are a number of statistics that help describe how antibiotics are currently being prescribed in outpatient settings in the United States and how these practices are contributing to the larger issue of antibiotic resistance.

Click to view antibiotic prescribing rates for U.S. health provider offices (2013/2014)

  • Approximately 50% of antibiotic prescriptions written in the outpatient setting may be inappropriate.1,2,3
  • In one year, 262.5 million courses of antibiotics are written in the outpatient setting. This equates to more than 5 prescriptions written each year for every 6 people in the United States.4
  • Antibiotic prescribing in the outpatient setting varies by state.4
  • Local outpatient prescribing practices contribute to local resistance patterns.5
  • Outpatient antibiotic prescribing is greatest in the winter months.6
  • The majority of antibiotic expenditures are associated with the outpatient setting.7
  • Azithromycin and amoxicillin are among the most commonly prescribed antibiotics.4

To be fair, your average GP is put in a very tough position when faced with a patient with an unknown respiratory infection.

Most will be viral, and antibiotics will be ineffective (or worse), but even among those, a small percentage will progress into a bacterial infection.

Rather than having a patient return in a few days (or end up in the hospital) if they get `worse’ – they will go ahead and prescribe an antibiotic . . . just in case.  

It’s not an unreasonable concern, considering how difficult it can be for a patient to get in to see a busy doctor on short notice, and the potential downside for both the patient and the doctor if things go unexpectedly south. 

The question becomes, just how much risk is there to patients when doctors curb their prescribing of antibiotics?

Two years ago, in BMJ: Delayed Antibiotic Prescriptions For Respiratory Tract Infections, we looked at varying strategies to reduce or delay the dispensing of antibiotics for acute respiratory infections, and their relative outcomes.

The authors wrote:

Delayed prescription is recommended in international guidance, and the National Institute for Health and Care Excellence currently recommends using a strategy of either no antibiotic prescriptions or a delayed antibiotic prescription for dealing with uncomplicated acute sore throats and other respiratory infections.

Assessing nearly 900 patients (aged 3 years and older) presenting with respiratory tract infections, clinicians across 25 practices in the UK deemed 37% were ill enough to require immediate antibiotics, while 63% were assigned to different delayed Rx strategy cohorts.

The primary finding — patient-reported symptom severity on days 2 to 4 — did not differ significantly between the five groups, including those who were prescribed antibiotics initially.

Today the BMJ has another research article that looks at the outcomes of much larger cohort - more than 4 million patients over a 10 year span - who presented at one of 610 UK GPs with respiratory infections or sore throats.

The reassuring findings, summarized in a press release from King's College London, reads:

General practices with lower rates of antibiotic prescribing for respiratory tract infections did not have higher rates of serious bacterial complications, including: meningitis, mastoiditis (infection of the mastoid bone behind the ear), empyema (infection of the lining of the lungs), brain abscess or Lemierre's syndrome (an infection of the jugular vein in the neck).

The research found that practices that prescribed fewer antibiotics had slightly higher rates of pneumonia and peritonsillar abscess (also known as quinsy) - a rare complication of sore throats. Both of these conditions are treatable with antibiotics once identified. 

The researchers estimated that if an average-sized GP practice with 7,000 patients reduced its antibiotic prescribing to people with respiratory tract infections by 10 per cent, there could be one extra case of pneumonia each year. They also estimated that this reduced prescribing could be linked to one extra case of peritonsillar abscess every 10 years.
The authors caution that the results represent averages across general practice populations; this study did not evaluate the outcome of prescribing decisions for individual patients.  
(Continue . .  )

We're talking targeted reduction of antibiotic prescribing for respiratory infections, not an outright ban.  Clinical judgment, based on the patient's risk factors and office presentation, always come into play.

The full study may be read on the BMJ. You'll find the link and excerpts from the abstract below.

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i3410 (Published 04 July 2016) Cite this as: BMJ 2016;354:i3410

Martin C Gulliford, professor of public health1, Michael V Moore, professor of primary healthcare research2, Paul Little, professor of primary care research2, Alastair D Hay, professor of primary care3, Robin Fox, general practitioner4, A Toby Prevost, professor of medical statistics1, Dorota Juszczyk, research associate1, Judith Charlton, research associate1, Mark Ashworth, reader in general practice1

General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome.
Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

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