Antibiotics: Managing common infections Part 1

Doctor checking patient's chest infection

01 November 2019

Professor Michael Moore, Professor of Primary Health Care Research at the University of Southampton 

According to the 2018 English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report, 81% of antibiotics are prescribed in the community, with 70% prescribed in general practice. Most of those prescriptions are for respiratory infections. This article concentrates on management of acute respiratory illness, although opportunities also exist for reducing antibiotic use in the management of skin and urinary tract infections.

Public Health England and the RCGP have produced a TARGET Antibiotics toolkit to support prescribers’ and patients’ responsible antibiotics use.

Most clinical episodes in the UK are coded on practice systems and this routinely available data gives us a fantastic insight into prescribing practices and changes over time. Despite the reductions in prescribing seen over the past five years, rates in the UK remain twice as high as those in Sweden. Between 8 and 23% of antibiotic prescriptions are likely to be inappropriate – the biggest contributors being sore throat (23.0%), cough (22.2%), sinusitis (7.6%) and acute otitis media (5.7%). In addition, one-third of all antibiotic prescriptions lacked an informative diagnostic code so appropriateness could not be determined.1

Symptom Relief

How effective then are antibiotics for the relief of symptoms? In the helpful summary table produced by NICE (Table 1) you can see that the average benefit in terms of symptom reduction is between 12-24 hours in the context of illnesses that last untreated between four days (otitis media) to three weeks (acute bronchitis).

Taking antibiotics is not without risk since a proportion of people will experience side effects with the potential risk of more severe adverse outcomes, for example anaphylaxis. In addition, exposure to antibiotics has been shown to result in the carriage of resistant organisms for up to 12 months.2 The table only shows average benefit and it may be possible to better target antibiotics to those more likely to benefit.

Complications

So with the expectation of modest (at best) relief of symptoms, what drives continued prescribing? Patients and clinicians are concerned about both more severe or prolonged illness and complications.3  Complications and adverse outcomes are rare so the existing randomised trials tend to be underpowered in this respect. Two large cohort studies have shed further light on these risks. Firstly, a large study examined nearly 14,000 sore throat episodes presenting in UK primary care.4

Adverse outcomes like cellulitis and otitis media were rare, occurring following 1.3% of episodes, while quinsy was seen in just 3/1000. While it was possible to identify some clinical factors associated with adverse outcome, the predictive value was too low to have clinical utility. Notably, antibiotics did appear to have some protective effect with a similar study finding a reduction in observed complications in the order of one third following both immediate and delayed prescribing.5 In a large cohort study in acute bronchitis (nearly 29,000 cases in UK primary care) the number of adverse outcomes (pneumonia/admission/death) was similarly low.

While immediate prescribing was not shown to be protective, delayed prescribing was associated with reduced risk of adverse outcome. Observational data must always be interpreted with caution and it is possible that since the sickest patients were those receiving antibiotics that this was not completely controlled for in the analysis. Unlike sore throat it was possible to derive a clinical score which was moderately predictive of adverse outcome.6 The score derived has eight components so may be difficult to use in routine care, and at the moment it is not known if its use would be associated with improved outcomes.

The key message from these two large studies is that most people with simple RTI recover and that adverse outcomes are rare. If there is clinical uncertainty about the need for antibiotics, then using a deferred antibiotic strategy does appear to be associated with a lower risk of adverse events. This assessment of low risk is backed up by population level studies of prescribing and adverse outcomes. While some of the results are conflicting, reduced prescribing at a practice level seems to be associated with only small overall increased risk of complications.7,8,9,10,11

Patient Concerns

The prescribing decision is complex and patient concerns also need to be considered. Different decisions might be appropriate depending on knowledge of the family social support and time and place of consultation. While some patients will have a high expectation for antibiotics many will be seeking advice on how to obtain relief from symptoms (43%) or pain (24%), information regarding the diagnosis (49%), or reassurance no further treatment is needed (13%).12  Exploring expectation and the provision of information, particularly when tailored to the patient, is likely to be helpful.

References:

  1. Smieszek T, Pouwels KB, Dolk FCK, Smith DRM, Hopkins S, Sharland M, Hay AD, Moore MV, Robotham JV: Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother 2018, 73(suppl_2):ii36-ii43.
  2. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD: Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010, 340:c2096.
  3. Cornford CS: Why patients consult when they cough: a comparison of consulting and non-consulting patients. BrJGenPract 1998, 48(436):1751-1754.
  4. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Campbell J, Delaney B, Broomfield S, Barratt P, Hood K et al: Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013, 347:f6867.
  5. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, Campbell J, Broomfield S, Barratt P, Hood K et al: Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis 2014, 14(3):213-219.
  6. Moore M, Stuart B, Lown M, Van den Bruel A, Smith S, Knox K, Thompson MJ, Little P: Predictors of Adverse Outcomes in Uncomplicated Lower Respiratory Tract Infections. Ann Fam Med 2019, 17(3):231-238.
  7. Gulliford MC, Moore MV, Little P, Hay AD, Fox R, Prevost AT, Juszczyk D, Charlton J, Ashworth M: Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016, 354:i3410.
  8. Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC: Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. British Medical Journal 2007:bmj.
  9. Cars T, Eriksson I, Granath A, Wettermark B, Hellman J, Norman C, Ternhag A: Antibiotic use and bacterial complications following upper respiratory tract infections: a population-based study. BMJ Open 2017, 7(11):e016221.
  10. Alves Galvão MG, Rocha Crispino Santos MA, Alves da Cunha AJ: Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age. The Cochrane Library 2014.
  11. Little P, Watson L, Morgan S, Williamson I: Antibiotic prescribing and admissions with major suppurative complications of respiratory tract infections: a data linkage study.[see comment]. British Journal of General Practice, 52(476):187-190.
  12. Linder JA, Singer DE: Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections. J Gen Intern Med 2003, 18(10):795-801.
  13. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J: Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009, 339:b2885.

 

 

 

Find courses & events

The item has been added to your basket.

Continue shopping

Go to basket

This item is out of stock.

Continue shopping

The item is out of stock.

Yes Continue shopping

An error occured adding your item to the basket:

Continue shopping