Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trialBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l236 (Published 13 February 2019) Cite this as: BMJ 2019;364:l236
All rapid responses
Re: Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial
Rapid response to Video Martin Gulliford Currently displayed on BMJ Website regarding his paper Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial Martin C Gulliford, A Toby Prevost, Judith Charlton, Dorota Juszczyk, Jamie Soames, Lisa McDermott, Kirin Sultana, Mark Wright, Robin Fox, Alastair D Hay, Paul Little, Michael V Moore, Lucy Yardley, Mark Ashworth BMJ 2019; 364: l236 (Published 13 Feb 2019)
At the beginning of his video presentation, Dr Gulliford states that (Quote) antibiotic use in the UK is twice as high as that in Sweden and the Netherlands. I should like to ask him to evidence this statement as the reality appears much more nuanced than he implies. Of course, we should not be complacent but British GPs most certainly are not as he implies “the bad boys of Europe”.
Looking at ECDC/EFSA/EMA second joint report on the integrated analysis of the consumption of antimicrobial agents and occurrence of antimicrobial resistance in bacteria from humans and food-producing animals June 2017, it would appear that the facts may be significantly different from the opinions stated by Prof Gulliford. https://efsa.onlinelibrary.wiley.com/doi/epdf/10.2903/j.efsa.2017.4872
According to this paper, some Countries of the EU were able to produce less than 95% data coverage and consumption will be greater than stated. These Countries included Germany (85%) and (surprise) the Netherlands (92%). It is stated that consumption for these Countries will be an underestimate. Spain, Germany, The Czech Republic, Iceland and Austria were only able to provide community consumption figures, so hospital usage is not included. There are also difficulties in data collection, some Countries reporting “sales” and some “reimbursement data” which will miss antibiotics prescribed through the private sector and OTC sales.
Overall human antibiotic consumption (Figure 6, Page 32) does show the UK is slightly above average but only slightly above Sweden and, yes, twice as high as The Netherlands.
However: Looking at use of 3rd and 4th generation Cephalosporins (page 32), the UK is less than a quarter of average, Sweden is more than double and The Netherlands slightly higher, Italy uses twelve times as much and France about seven times as much as the UK (the second lowest user in the EU)
Looking at the use of Quinolones (Page 46), both Sweden and The Netherlands were higher than the UK (the lowest user in the EU)
In its use of Macrolides (page 70) the UK was certainly significantly higher than The Netherlands and Sweden. My own immediate thought on this is that it might reflect a difference in the treatment of acne from Country to Country.
In Tetracyclines (page 80) the UK uses about half EU average but significantly more than both Sweden and The Netherlands. This might again reflect use in acne.
Use in food producing animals is massive and varies widely from Country to Country
Looking at another information source (admittedly a little dated now) the UK is well below many other developed and comparable Countries in the World. This is a US source so the US bar is highlighted. https://cddep.org/tool/antibiotic_prescribing_rates_country/
Yet another source shows the UK not to appear in the top ten countries by highest usage of antibiotic. https://www.weforum.org/agenda/2015/11/which-countries-use-the-most-anti...
My last point is that “Antibiotic purchased” does not necessarily equate in any way to “Antibiotic consumed”. For instance, Practices are required to keep Cefotaxime injection on the premises contingent on a possible rare case of meningitis in a penicillin sensitive individual. This is not available to purchase in single ampoules and so each of 7500 practices will purchase a pack of ten vials each of 1G and has a shelf life of two years and the vast majority is therefore thrown away and never gets near to a patient.
I do not for a moment suggest that we should prescribe antibiotic for common colds. It should however be noticed that there has been an increase in cases of sepsis at the time when British GPs have been heavily pressured to reduce antibiotic prescribing. Unless I am very much mistaken, all “serious infections” start as “mild infections”. May I suggest to Dr Gulliford that a fruitful area of research for his team might be to examine cases of sepsis to see if there had been a “missed opportunity” to treat the infection at an early stage before it turned into septicaemia, and if such an opportunity had been missed, whether the pressure not to prescribe had influenced the decision?
Competing interests: No competing interests