Improving outpatient antibiotic prescribing

The United Kingdom has a culture of high antibiotic prescribing. While the National Institute for Health and Care Excellence recommends that most self-limiting respiratory tract infections (RTI) can be managed without antibiotics, some 50% of RTI consultations in primary care are associated with an antibiotic prescription.[1] For some international comparators, including Sweden and the Netherlands, antibiotic prescribing is at half these levels.[2] Antibiotic prescribing has also varied over time, being lower now than five years ago but still higher than 10 or 15 years ago.

Hicks et al.[3] give examples of social norm feedback employed to increase the effectiveness of interventions to reduce antibiotic prescribing in other studies, but this approach also has difficulties. In qualitative interviews to support intervention development for the REDUCE trial,[4] general practitioners expressed scepticism that external norms could be applied easily to their patient populations. Antibiotic prescribing is driven by consultation rates, which are typically higher in deprived areas. Antibiotic prescribing is also highly dependent on the age distribution of patient populations and the prevalence of comorbidities, which vary between practices.[5] Estimates for individual general practices are often based on small numbers. Comparative metrics require rigorous development in order to avoid some of the negative connotations associated with targets and league tables.[6]

High antibiotic prescribing appears to be acceptable in the UK at present, with a 'norm' of prescribing rather than withholding antibiotics. In order to reduce antibiotic prescribing across UK primary care, future interventions need to address this 'norm' rather than simply using it as a reference point.[7]

Martin Gulliford, Professor of Public Health, King’s College London

Dorota Juszczyk, Research Associate, King’s College London

Lucy Yardley, Professor of Health Psychology, University of Bristol

REFERENCES

1. Gulliford MC, Dregan A, Moore MV, et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ open 2014;4:e006245. doi: 10.1136/bmjopen-2014-006245

2. House of Commons. Health and Social Care Committee. Antimicrobial resistance. Eleventh report of session 2017-2019. London: House of Commons., 2018. Source: https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/962/962... accessed 21st February 2019.

3. Hicks LA, King LM, Fleming-Dutra KE. Improving outpatient antibiotic prescribing. BMJ 2019;364:l289. doi: 10.1136/bmj.l289

4. Gulliford MC, Prevost AT, Charlton J, et al. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ 2019;364:l236. doi: 10.1136/bmj.l236

5. Hope EC, Crump RE, Hollingsworth TD, et al. Identifying English Practices that Are High Antibiotic Prescribers Accounting for Comorbidities and Other Legitimate Medical Reasons for Variation. EClinicalMedicine 2018;6:36-41. doi: 10.1016/j.eclinm.2018.12.003

6. Goldstein H, Speigelhalter DJ. League Tables and Their Limitations: Statistical Issues in Comparisons of Institutional Performance. J Royal Statist Soc, A 1996;159:385-443.

7. Little P, Stuart B, Francis N, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 2013;382:1175-82. doi: 10.1016/S0140-6736(13)60994-0