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Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

BMJ 2019; 364 doi: (Published 27 February 2019) Cite this as: BMJ 2019;364:l440

Linked Editorial

Antibiotic prescribing in primary care

  1. Koen B Pouwels, mathematical modeller123,
  2. Susan Hopkins, consultant in infectious diseases and microbiology456,
  3. Martin J Llewelyn, professor of infectious diseases78,
  4. Ann Sarah Walker, professor of medical statistics and epidemiology69,
  5. Cliodna AM McNulty, consultant microbiologist10,
  6. Julie V Robotham, senior mathematical modeller16
  1. 1Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
  2. 2Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
  3. 3Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  4. 4Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London, UK
  5. 5Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
  6. 6National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
  7. 7Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, Brighton, UK
  8. 8Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  9. 9Nuffield Department of Medicine, University of Oxford, UK
  10. 10Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
  1. Correspondence to: KB Pouwels k.b.pouwels{at} (or @kb_pouwels on Twitter)
  • Accepted 28 January 2019


Objective To evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations.

Design Cross sectional study.

Setting General practices contributing to The Health Improvement Network database, 2013-15.

Participants 931 015 consultations that resulted in an antibiotic prescription for one of several indications: 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.

Main outcome measures The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication.

Results The most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines.

Conclusion For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.


  • Contributors: KBP designed the study, cleaned and analysed the data, and drafted and revised the manuscript. He is the guarantor. SH and MJL contributed to the interpretation of data and revised the draft manuscript. ASW contributed to the statistical analysis plan and revised the draft manuscript. CAMM and JVR contributed to the design of the study and revised the draft manuscript. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: SH, ASW, and JV are supported by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE) (HPRU-2012-10041). ASW is also supported by the NIHR Oxford Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR, Department of Health, or PHE.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at 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.

  • Ethical approval: The Health Improvement Network (THIN) data were used for this work. The data collection scheme for THIN is approved by the UK Multicentre Research Ethics Committee (reference No 07H1102103). In accordance with this approval, the study protocol was reviewed and approved by an independent Scientific Review Committee (reference No 16THIN071, 16THIN071-A1, and 16THIN071-A3).

  • Data sharing: THIN data were analysed under licence and are not available for sharing.

  • Transparency: The guarantor (KBP) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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