Antibiotic prescribing in primary care
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l780 (Published 27 February 2019) Cite this as: BMJ 2019;364:l780Linked Research
Duration of antibiotic treatment for common infections in English primary care
Linked Research
Antibiotic management of UTIs in elderly patients and its association with bloodstream infections and all cause mortality
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The danger here is that antibiotics will be over prescribed. I have found in practice ABXs are prescribed routinely in the age group over 65 presenting with confusion and a positive urine dip. A urine dip is not recommended in this age group as they are more unreliable in the over 65s. Up to half of older adults, and most with a urinary catheter, have asymptomatic bacteria present in the bladder/urine without an infection. The symptoms are important and two or more symptoms should be present before a UTI is diagnosed. There are many more reasons for confusion in this age group and should be investigated (PHE, 2018).
Diagnosis of urinary tract infections: quick reference tool for primary care. 2018. Flowchart for men and women over 65 years with suspected UTI. [ONLINE] Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploa... [Accessed 3 March 2019].
Competing interests: No competing interests
After the UK Chief Medical Officer Sally Davies put antibiotic drug resistance on the national threat list in 2013, the WHO developed the global action plan to combat antimicrobial resistance (AMR) on a global scale. This strategy was approved by the World Health Assembly in 2015 (1). Simultaneously the Obama administration ordered the development of the US CARB-X initiative and currently, almost 100 countries have done similar (2, 3). AMR is recognized as a crisis that must be resolved by international collaboration and through local actions. One common action in most national action plans is the establishment of antibiotic stewardship programs in order to ensure evidence-based prescription practices and reduce the unnecessary prescription of these drugs.
UTI infections account for 25% of antibiotic prescriptions in Norway (4). They are often prescribed due to the chief complaint being pain. In a recent study, ibuprofen was found inferior to antibiotics for treating uncomplicated UTIs. More than half of the patients that did not receive antibiotics did recover spontaneously, but 7 out of 181 developed pyelonephritis. We cannot recommend NSAIDs alone as initial treatment to women with uncomplicated UTIs, especially for those above 65, as now published in the BMJ (5). Prescribers however need individual feedback on their prescription practice/prevalence compared to colleagues, as part of establishing primary care antibiotic stewardship programs.
The concepts of an efficient intervention in UTI cases are perceived by the health care provider. Perceived susceptibility, severity, benefits and barriers include all of the possible short term and long term adverse effects of initiated or prolonged antibiotic exposures varies for different patients (6, 7) . This varies for different patients. For babies future adverse effects will be weighed different than for those above 65 years. Clinical urgency, uncertainties and responsibilities varies for individual patients and the responsibility often lie on the individual clinician. It is therefore imperative that policy makers encourage primary health care stewardship programs and that guidelines follow evidence-based prescription practices (6). Stewardship programs should always include reserving broad-spectrum antibiotics for special risk cases and revising treatment once culture results become available in all patients as recommended for neonatals (8).
References
1. World Health Organization (2015). Global action plan on Antimicrobial resistance. Retrieved from: https://www.who.int/antimicrobial-resistance/global-action-plan/en/
2. The White House (2014). Executive Order -- Combating Antibiotic-Resistant Bacteria. Retrieved from: https://obamawhitehouse.archives.gov/the-press-office/2014/09/18/executi...
3. World Health Organization (2018). Antimicrobial resistance. Library on national action plans Retrieved from: http://www.who.int/antimicrobial-resistance/national-action-plans/librar...
4. Straand J, Rokstad KS, Sandvik H. Prescribing systemic antibiotics in general practice. A report from the Møre & Romsdal Prescription Study. Scand J Prim Health Care 1998; 16: 121 – 7.
5. Hay A, Antibiotic prescribing in primary care. BMJ 2019;364:l780
6. Lawrence KL, Kollef MH (2009). Antimicrobial Stewardship in the Intensive Care Unit Advances and Obstacles. Am J Respir Crit Care Med. 179:434-8
7. Paul SP, Caplan EM, Morgan HA, Turner PC (2018). Barriers to implementing the NICE guidelines for early-onset neonatal infection: cross-sectional survey of neonatal blood culture reporting by laboratories in the UK. J Hosp Infect. 98(4):425-428
8. Shipp KD, Chiang T, Karasick S, Quick K, Nguyen ST, Cantey JB (2016). Antibiotic Stewardship Challenges in a Referral Neonatal Intensive Care Unit. Am J Perinatol 33(5):518-24
Competing interests: No competing interests
Infections and antibiotic prescribing might be reduced if vitamin D food fortification is introduced
Antibiotic prescribing would be reduced if susceptibility to infections could be reduced.
Providing a vitamin D deficient population with sufficient vitamin D might help reduce such susceptibility as shown by Martineau for respiratory tract infections (1). A link to increased infections in vitamin D deficient individuals has often been pointed out (2-4).
Recently, two consensus statements of a large group of researchers suggested food fortification if vitamin D deficiency exceeds 20% in a population (5,6). This might be an appropriate action for the UK, because both, the Scientific Advisory Committee on Nutrition (7) and the Scottish Food Standard Agency (8), report high prevalences of vitamin D deficiency in England and Scotland (approximately 25-40%). Finland, US, Canada are amongst other countries whose populations benefit from vitamin D food fortification.
In his editorial Alistair Hay mentioned the risk of bloodstream infections being especially high in areas of deprivation. Sepsis is reduced if better vitamin D supply is provided (10). Areas of deprivation also show the highest rate of vitamin D deficiency (7) and they would therefore benefit most from food fortification, especially as the rate of health improvements is exponentially linked to vitamin D intake (5). This might even be a (maybe not so) small step towards a reduction of health inequalities, in addition to the reduction of infections in all.
1. Martineau AR, et al. Vitamin D supplementation to prevent acute respiratory infections: individual participant data meta-analysis. Health Technol Assess 2019;23(2)
2.Prietl B, et al. Vitamin D and immune function. Nutrients. 2013 Jul 5;5(7):2502-21
3. Zhou J, et al. Preventive Effects of Vitamin D on Seasonal Influenza A in Infants: A Multicenter, Randomized, Open, Controlled Clinical Trial. Pediatr Infect Dis J. 2018 Aug;37(8):749-754
4. Jorde R, et al. Prevention of urinary tract infections with vitamin D supplementation 20,000 IU per week for five years. Results from an RCT including 511 subjects. Infect Dis (Lond). 2016 Nov-Dec;48(11-12):823-8
5. Pilz S, et al. Rationale and Plan for Vitamin D Food Fortification: A Review and Guidance Paper.
Front. Endocrinol., 17 July 2018
6. Roth DE, et al. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann. N.Y. Acad. Sci. 2018 Oct;1430(1):44-79
7. SACN 2016 Vitamin D and health. https://www.gov.uk/government/groups/scientific-advisory-committee-on-nu...
8. Food Standards Agency in Scotland. Vitamin D status of Scottish adults: Results from the 2010 & 2011 Scottish Health Surveys . Purdon G, et al. September 2013
9. BMJ 2019;364:l780
10. Shojaei M, et al. The Correlation between Serum Level of Vitamin D and Outcome of Sepsis Patients; a Cross-Sectional Study. Arch Acad Emerg Med. 2019; 7(1): e1.
Competing interests: No competing interests