Editorials

A prescription for improving antibiotic prescribing in primary care

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d7955 (Published 02 February 2012) Cite this as: BMJ 2012;344:d7955
  1. James McCormack, professor1,
  2. G Michael Allan, associate professor2
  1. 1Faculty of Pharmaceutical Sciences, University of British Columbia, BC, Vancouver, Canada V6T1Z3
  2. 2Department of Family Medicine, University of Alberta, AB, Edmonton, Canada
  1. jmccorma{at}interchange.ubc.ca

Comprehensive education programmes can reduce antibiotic prescriptions, but the impact on clinical outcomes is unclear

Over the past 70 years, antibiotics have influenced and improved the treatment of many symptomatic infections. Unfortunately, antibiotics produce side effects and—regardless of whether they are used appropriately or inappropriately—will ultimately lead to a change in the sensitivity of organisms, which can sometimes lead to a reduction in clinical effectiveness.

Many attempts have been made to implement programmes that are designed to improve the use of antibiotics, particularly in primary care. The linked randomised controlled trial by Butler and colleagues (doi:10.1136/bmj.d8173) describes the most recent of these attempts.1 The authors used social learning theories to develop an extensive and comprehensive educational programme (Stemming the Tide of Antibiotic Resistance; STAR) aimed at reducing antibiotic use in primary care clinics in Wales. Their multifaceted intervention incorporated many of the approaches other reviews have identified as helpful, such as education, feedback, and patient involvement.2 Practices randomised to receive the STAR programme dispensed significantly fewer oral antibiotics (26.1 items/1000 registered patients/year)—a total reduction of 4.2% (95% confidence interval 0.6% to 7.7%). The intervention cost about ₤3000 (€3500; $4713) per practice. The results are similar to (although at the lower end of) reductions seen with other such programmes.3

Is a 4% reduction in use of antibiotics clinically important? The authors found no significant differences in hospital admissions or reconsultations for a respiratory tract infection within seven days of an index consultation. Although it was essential to examine these outcomes, the study sample size and the effect on prescribing were too small to ascertain if the decrease in antibiotic use improved or worsened patient outcomes.

The authors did not assess whether resistance patterns changed. In a country-wide programme in Finland, reducing the use of erythromycin by 50% reduced the resistance of group A streptococcal isolates from 17% to 9%.4 Another study found that a decrease of 50 amoxicillin items per 1000 patients per year reduced resistance by 1%.5 Others have found that a 20% reduction in the prescription of ampicillin and amoxicillin resulted in 1% fewer resistant isolates.6 So, although reducing the use of antibiotics can affect resistance, the small reduction seen in the STAR study is unlikely to lead to a clinically important change in resistance patterns.

Most people agree that antibiotic prescribing in primary care needs to be improved. Understanding why antibiotics are prescribed is an essential first step. The ethos of antibiotic prescribing is multifactorial and somewhat unique. Fear on the part of the patient and clinician that the infection may turn into something serious plays a major role in decision making.7

Antibiotic prescribing can also arise from a clinician’s desire to do something that might help or the perception that the patient wants an antibiotic. This is despite research showing that clinicians accurately distinguish only about half of the patients who want or don’t want antibiotics.8 Patients’ satisfaction depends more on improved understanding of their illness, however, than on receiving a prescription.9

Most (80-90%) oral antibiotic prescriptions in primary care are for respiratory tract infections, urinary tract infections, or skin and soft tissue infections. In theory, diagnostic certainty should help improve the use of antibiotics. Reliable diagnostic criteria are available for sore throats but not for sinusitis or other upper respiratory tract infections. Decision support tools may help clinicians reduce antibiotic prescribing for upper and lower respiratory tract infections and urinary tract infections. Some tests may help to distinguish bacterial infections from viral ones. For example, the use of procalcitonin as an indicator of bacterial infection reduced antibiotic use from 97% to 25% in primary care patients with both upper and lower respiratory tract infections.10

When seeing a patient with a possible community acquired infection, clinicians may find it helpful to outline to their patients some of the potential benefits and harms of treatment. The STAR programme, along with many others, provides clinicians with useful bite sized synopses of the evidence. Rational use of antibiotics does not involve quibbling over starting antibiotics in very sick patients, but for non-serious illnesses that may or may not be bacterial a reasonable option to reduce antibiotic prescribing is to use delayed antibiotic prescriptions. This makes clinicians feel they are doing something and gives control to the patient. Delayed prescriptions can reduce the proportion of people who receive antibiotics for upper respiratory tract infections from 93% to 32%,11 a reduction similar to that seen with the use of procalcitonin. Patients who are not given a prescription initially will still ultimately get an antibiotic 14% of the time. However, delaying antibiotics may worsen outcomes—such as fever at day three—and reduce patient satisfaction, but it may also reduce adverse events such as diarrhoea. The 61% (93% minus 32%) absolute difference in antibiotic use from choosing a delayed prescription may be a worthwhile compromise in areas of uncertainty because a strict “no prescription” approach will only “buy” another 18% (32% minus 14%) absolute difference in antibiotic use.

Most community acquired infections still respond to the same antibiotics that have been used for decades and many guidelines still support their use. Amoxicillin for respiratory tract infections and cloxacillin for soft tissue infections (unless community acquired meticillin resistant Staphylococcus aureus is suspected) are still solid treatment choices, with doxycycline (not in children) a reasonable alternative for patients who are allergic to or intolerant of these antibiotics. For uncomplicated urinary tract infections, nitrofurantoin, co-trimoxazole, or trimethoprim alone are still good choices. Clinicians need to question why the above agents are not their first choices, especially for patients who are not seriously ill.

Data on the development of resistance suggest that treatment with high dose shorter duration antibiotics may reduce the emergence of resistance.12 Although several studies show that shorter courses of antibiotics for relatively self limiting infections in primary care are as effective as longer ones, it is never known how an individual patient will respond. Given that, a reasonable approach for most primary care infections would be to tell the patient to continue the antibiotic until they have been asymptomatic or afebrile for 72 hours and then to stop. Patients also need to be advised what to do if no improvement is seen within 24-48 hours. To support this approach, patients need to know that the often used warning to finish the whole antibiotic course is not evidence based. Use of the prescription label “Finish all this medication unless otherwise directed by prescriber” should be discouraged.

Notes

Cite this as: BMJ 2012;344:d7955

Footnotes

  • Research, doi:10.1136/bmj.d8173
  • Competing interests: Both authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • This is an abbreviated reference list and a full list is available from the authors.

References