A new study of general practices in England found that repeat within-episode antibiotic use accounts for a significant proportion of all antibiotics prescribed for respiratory tract infections (RTIs), researchers reported late last week in the Journal of Infection.

Repeat within-episode antibiotic prescribing occurs when a patient who has received an initial prescription receives a repeat prescription because of persisting symptoms. While 54% of RTI consultations in UK primary care result in an antibiotic prescription, and RTI patients frequently reconsult their general practitioner because of ongoing symptoms, data on repeat within-episode antibiotic prescribing for RTIs are lacking. To assess the magnitude of the practice and associated factors, a team of English and Dutch researchers conducted a population-based cohort study among 530 samples from English general practitioners (GPs).

The researchers identified 905,964 RTI episodes with at least one antibiotic prescription from March 2018 through February 2022. Nearly half (48.6%) involved adults consulting their GP for an upper RTI. In children, 89.9% of episodes were related to upper RTI. The overall proportion of within-episode repeat prescriptions was 12.7%. In adults, within-episode repeat prescribing rates were higher for lower RTI (19.9%) than for upper RTI (10.5%). In children, the rates were similar for lower RTI (10.5%) and upper RTI (10.0%). Most episodes occurred more than 7 days after the initial prescription.

Frequent RTI-related GP visits and prior within-RTI-episode repeat antibiotic prescriptions were the main factors associated with repeat prescriptions in both adults and children, irrespective of RTI type. Other factors included age less than 2 years or more than 65 years. Among those aged 2 to 64 years, allergic rhinitis, chronic obstructive pulmonary disease, and oral corticosteroids were associated with repeat prescriptions.

A potential 'quick win' for stewardship

The study authors say clinicians should emphasize to patients that while the natural course of most RTIs is considerably longer than a single course of antibiotics, a single course is likely to be microbiologically adequate. They suggest the practice should be a target for antimicrobial stewardship interventions.

"Reducing within-episode antibiotic prescriptions could represent a 'quick win' for antimicrobial stewardship teams," they wrote.

During the first month of the COVID-19 pandemic in the United States, the Families First Coronavirus Response Act (FFCRA) prevented Medicaid programs from disenrolling people during the public health emergency. For the first time in history, Medicaid-enrolled postpartum mothers were allowed insurance for more than 60 days past birth.

This policy change, and other extensions to Medicaid made in 2021, led to a 40% decline in postpartum lack of insurance, according to a new study in JAMA Health Forum.

The authors suggest that increasing maternal insurance coverage in the postpartum year is a strong first step to fighting increasing US maternal death rates, which are high compared to other Western countries.

"A lot of postpartum maternal deaths are occurring in the late postpartum period, or beyond 43 days postpartum, which is actually around the time Medicaid coverage has historically ended." said senior author Lindsay Admon, MD, in a press release from the University of Michigan.

A lot of postpartum maternal deaths are occurring in the late postpartum period, or beyond 43 days postpartum.

Largest improvement in Black women

The study compared outcomes among 47,716 participants who had a Medicaid-paid birth in 21 states with continuous pre-policy (2017 to 2019) and post-policy (2020 and 2021) participation in the Pregnancy Risk Assessment Monitoring System.

Participants were 18.9% Hispanic, 26.2% Black, 36.3% White, and 18.6% of other race or ethnicity, and 64.4% were under the age of 30. Outcomes assessed included health insurance, contraceptive use, breastfeeding, and postpartum depression.

The authors found that the FFCRA was associated with an 8% increase in postpartum Medicaid coverage and a 40% reduction in being uninsured among those with a Medicaid-paid birth, but was not associated with other outcomes. From baseline, lack of insurance decreased among Black and White people with Medicaid-paid births by 96.9% and 69.3%, respectively.

"These findings suggest that policies extending Medicaid eligibility through the first year postpartum are likely to achieve the first-order goal of improving postpartum coverage," the authors concluded.