Most antibiotic prescriptions for several common infections treated in primary care in England are longer than they need to be, according to a study yesterday in the British Medical Journal (BMJ).
Delving into a nationwide database of electronic medical records from primary care offices, a team led by researchers from Public Health England (PHE) found that more than 80% of antibiotic courses for upper respiratory tract infections and acute cough and bronchitis exceeded national guideline recommendations, resulting in 1.1 million days of treatment beyond the recommended durations for those conditions.
The authors of the study say the findings highlight poor adherence to guidelines on treatment duration, an important aspect of antibiotic stewardship in primary care that may get overlooked in the focus on whether the initial prescribing decision is appropriate. To date, limited research has been conducted on antibiotic durations for common infections in English primary care.
"Although previous work has shown that antibiotic use can potentially be substantially reduced by not prescribing antibiotics when they are unnecessary, this study shows that unnecessary exposure to antibiotics may also be substantially reduced by aligning the course length more with guidelines and best available evidence," the authors write.
Exceeding recommendations
For the study, the researchers obtained data from The Health Improvement Network (THIN) on oral antibiotic prescriptions written from 2013 through 2015 for 13 common conditions: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis.
They then compared the actual durations of the prescriptions with durations recommended for each condition by PHE guidelines from the study period. Chronic and recurrent conditions were excluded. The main outcomes of the study were the percentage of antibiotic prescriptions that lasted beyond the guideline recommendation and the total number of days beyond the recommended duration for each condition.
Overall, 931,015 consultations led to antibiotic prescriptions for the 13 conditions, and antibiotics were prescribed most commonly for acute cough and bronchitis (41.6%), acute sore throat (25.7%), acute otitis media (8.9%), and acute sinusitis (8.2%). More than 80% of the antibiotic courses for acute cough and bronchitis and acute respiratory indications (including otitis media) exceeded guideline recommendations. Notable exceptions among acute respiratory conditions were acute sinusitis, in which only 9.6% of prescriptions exceeded the recommended 7 days, and acute sore throat, where only 2.1% of prescriptions exceeded 10 days.
For acute cough and bronchitis, for which 2013 PHE guidelines recommended 5 days of treatment, the median number of excess treatment days was 2. For acute otitis media (recommended treatment duration of 5 days), treatment also lasted 2 days beyond recommendations.
For all 13 conditions grouped together, which accounted for roughly 20% of total antibiotics prescriptions from the included practices during the study period, the authors identified an estimated 1.3 million excess days of antibiotic treatment.
While fewer antibiotic prescriptions exceeded recommended durations for non-respiratory tract infections, 54.6% of the prescriptions for acute cystitis in women went beyond the recommended 3 days. For acute pyelonephritis, acute cystitis among men, impetigo, and cellulitis, only 4% to 18% of prescriptiona exceeded guidelines, but this still translated to more than 155,000 excess antibiotic days.
For conditions with longer recommended treatment, the percentage of prescriptions exceeding guideline recommendations was significantly lower than it was for conditions with shorter recommended treatment. In addition, a significant percentage of shorter-than-recommended courses was noted for certain indications, including acute prostatitis and acute cystitis in men.
To determine whether comorbidities or past use of immunosuppressive drugs or inhaled or systemic corticosteroids might affect the duration of antibiotic prescriptions, the researchers conducted an analysis that excluded those patients. That analysis provided similar results. In addition, the researchers found no clear indication of longer antibiotic prescriptions for children compared with adults.
"This provides further support for the argument that treatment durations are not increased because individual patient factors indicated a clinical need for prolonged treatment," the authors write.
Increasing awareness, adherence
While the authors say the study highlights the magnitude of the problem, it doesn't answer the question of why UK general practitioners prescribe longer antibiotic courses than necessary, especially given the growing body of evidence that shorter courses of antibiotics are just as effective as longer courses for treating many conditions.
Among the possibilities they suggest are lack of awareness of guideline recommendations or skepticism of those recommendations. This could be compounded by the fear that undertreatment could lead to treatment failure, and the idea that shorter courses may increase the risk of antibiotic resistance.
"Understanding the reasons would enable the development of interventions and support tools that could increase adherence to the guidelines and reduce unnecessary exposure to antibiotics," they write.
In an accompanying editorial, Alistair Hay, MD, a general practitioner and professor at the University of Bristol Medical School, says the findings indicate that prescribers need to familiarize themselves with national guidelines for managing common infections, many of which have been updated in recent years and in some cases recommend shorter treatments than earlier guidelines.
He also suggests public health campaigns can play an important role in promoting shorter antibiotic courses.
"Both clinicians and patients may need convincing to abandon longer courses of antibiotics, and future campaigns by Public Health England to 'Keep Antibiotics Working' could usefully emphasise that when antibiotics are needed, shorter courses are sufficient to kill bacteria and less harmful than longer courses," he concludes.
See also:
Feb 27 BMJ study
Feb 27 BMJ editorial
