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Steep rise in antibiotic use for coughs and colds

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GPs are still giving out antibiotics to treat coughs and colds, the Mail Online, The Daily Telegraph and BBC News report, as a study reveals efforts to curb antibiotic use has had “mixed success”.

The study found the proportion of people with coughs and colds given antibiotics rose from 36% in 1999 to 51% in 2011: an increase of around 40%.

The rise comes amid warnings that the over-prescription of antibiotics could lead to the emergence of drug-resistant bacteria. 

Antibiotics are medications used to treat, and in some cases prevent, bacterial infections. They are ineffective at treating coughs and colds, which are usually viral infections.

Researchers from Public Health England (PHE) and University College London (UCL) looked at trends in the prescription of antibiotics in more than 500 UK GP surgeries between 1995 and 2011.

They focused on coughs and colds, sore throats, urinary tract infections (UTIs) and middle ear infections (otitis media), which are all subject to specific government recommendations to help curb antibiotic use.

Antibiotic use for sore throats fell between 1995 and 2011, although it was still high considering that approximately 90% of sore throats resolve without antibiotics. The recommended antibiotic for acute sore throat was given in the majority of cases.

The proportion of women prescribed antibiotics for UTIs who were prescribed the recommended short course increased, although there was variation between GP practices.

For middle ear infections, the proportion of cases that were prescribed an antibiotic was broadly unchanged over the study period, but the proportion of people who were prescribed the recommended antibiotic increased.

“The implementation of national guidelines in UK primary care has had mixed success,” conclude the study’s authors.

Prescriptions of antibiotics for coughs and colds are now “greater than before recommendations were made to reduce it”.

The study also found significant variation in antibiotic use for these conditions between GP practices, suggesting that further improvements in antibiotic prescriptions could be made.

Where did the study come from?

The study was carried out by researchers from PHE, the Royal College of General Practitioners Research and Surveillance Centre, and UCL.

It was funded by the Health Protection Agency (HPA) and published in the peer-reviewed Journal of Antimicrobial Chemotherapy.

Generally, the media reporting of this story was accurate.

What kind of research was this?

This was a cross-sectional study that analysed trends in antibiotic prescription at 537 GP practices in the UK between 1995 and 2011.

The aim of this study was to examine and compare antibiotic use over time and see whether it was in line with recommendations.

Antibiotic prescription in line with recommendations is one of the strategies being implemented to try to limit resistance to antibiotics.

What did the research involve?

Researchers analysed antibiotic use in 537 UK GP practices over a 16-year period.

They looked at antibiotic use, the type of antibiotic used, and the length of treatment for:

  • coughs and colds
  • sore throats
  • UTIs
  • middle ear infection (otitis media)

These conditions are subject to recommendations made in 1998 by the UK Department of Health’s Standing Medical Advisory Committee (SMAC) that clinicians should:

  • not prescribe antibiotics for simple coughs and colds
  • not prescribe antibiotics for viral sore throats
  • limit prescribing for uncomplicated UTIs to three days in otherwise healthy women

This advice has been supplemented with further professional guidance on antibiotic use from the UK Public Health Laboratory Service in 2000, which recommends that:

  • antibiotics should be avoided for acute sore throat unless specific clinical criteria are met, in which phenoxymethylpenicillin may be prescribed (or clarithromycin if the patient is allergic to penicillin)
  • amoxicillin may be prescribed (or erythromycin if the patient is allergic to penicillin) for acute otitis media if specific clinical criteria are met
  • short-course trimethoprim or nitrofurantoin should be prescribed for UTIs in women if specific clinical criteria are met

The researchers looked at changes over time, as well as variation in antibiotic prescription between practices.

What were the basic results?

Coughs and colds
The proportion of cases of coughs and colds where antibiotics were used decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011.

There was marked variation by primary care practice in 2011, with 10% of practices prescribing antibiotics for less than 32% of cases and 10% of practices prescribing antibiotics for more than 65% of cases.

Sore throats
Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999, and then stayed broadly stable.

Again, there was variation by primary care practice seen in 2011, with 10% of practices prescribing antibiotics for less than 45% of cases, and 10% of practices prescribing antibiotics for more than 78% of cases.

Where antibiotics were prescribed for a sore throat, the appropriate type of antibiotic was used in 69% of cases in 2011, representing a slight increase from 64% in 1995.

Urinary tract infections in women
Trimethoprim or nitrofurantoin are the recommended antibiotics for UTIs, which includes conditions such as cystitis.

The proportion of women aged 16-74 years with a UTI who were prescribed trimethoprim fell from 62% in 1995 to 54% in 2011, and the proportion who were prescribed nitrofurantoin rose from 5% in 1995 to 24% in 2011.

The researchers calculated the length of antibiotic dose from the amount of antibiotic prescribed. When trimethoprim was prescribed, the use of a recommended short course rose from 8% in 1995 to 50% in 2011. When nitrofurantoin was prescribed, the use of a recommended short course rose from 6% in 1995 to 20% in 2011.

Again, there was variation between practices, with a quarter of practices prescribing short courses in fewer than 16% of episodes that were prescribed trimethoprim in 2011.

Otitis media
The proportion of otitis media cases that were prescribed an antibiotic was broadly unchanged over the study period.

Again, there was variation between practices, with 10% of practices prescribing antibiotics for less than 63% of cases and 10% of practices prescribing antibiotics for more than 97% of cases.

Where antibiotics were prescribed, prescriptions for recommended antibiotics rose from 77% in 1995 to 85% in 2011.

How did the researchers interpret the results?

The researchers conclude that, “The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.”

Conclusion

This cross-sectional study has found the proportion of people with coughs and colds that are prescribed antibiotics rose from 36% in 1999 to 51% in 2011 – an increase of approximately 40%. This is despite the publication of guidance recommending that GPs do not prescribe antibiotics for coughs and colds.

It also found substantial variation between different GP practices, with 10% of practices prescribing antibiotics for less than 32% of cases and 10% of practices prescribing antibiotics for more than 65% of cases, suggesting that substantially lower rates of prescribing could be achieved.

The study also looked at antibiotic prescription for sore throats, UTIs and otitis media. Antibiotic prescription for sore throats fell, and prescription of recommended antibiotics increased.

Over the study period, more women with UTIs were prescribed the recommended short course of antibiotics. For otitis media, the proportion of cases that were prescribed an antibiotic was broadly unchanged, and prescriptions for recommended antibiotics rose.

There was variation between GP practices in antibiotic prescription for these conditions, suggesting that further improvements in antibiotic prescription could be made.

In conclusion, this study suggests there is a need to improve the way antibiotics are prescribed.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

 

  • 1 Comment

Readers' comments (1)

  • It doesn't matter how much I try to tell patients that they dont need AB's, the story is the same, ie - "my doctor always gives me AB's because it wont clear up without it", "I have to work otherwise I wont get paid, I need the AB's," "the last time I had to come into hospital" etc etc.

    I am in a more privileged position in that I can take a bit more time than the average GP, 15mins (in urgent care) instead of the usual 10mins (in surgeries), but it is still hard. People are still extremely demanding and adamant that only AB's will work, and suggest it will be my fault if they get worse or are unable to earn a living.

    I am amazed that there are still clinicians who want to work in these fields due to the agression of patients who DEMAND anti-biotics.

    To sit and explain why they do not need anti-biotics is time consuming, something that most clinicians do not have with our time and motion culture with private providers in the health service.

    I am under constant pressure and threats by our cheap as chips provider to "see, treat and get them out as quickly as possible" so that they can perform to their targets with not enough clinicians and too many patients, especially those spurious patients sent by a useless 111 who just overload the service even more.

    I am leaving within the month and now there are only 2 nurses and an ambulance paramedic left, all of them inappropriately qualified, but they will be under pressure to "get them in and out" quickly. Mistakes will be made. It is easy to get anti-biotics out of the cupboard under PGD's.

    Until this new business ethos in the NHS changes, and until GP's are under less strain by constant underfunding, AB use will continue to rise. Forced austerity measures in the NHS = increased cheap anti-biotic use.

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