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One in seven GP-prescribed antibiotic courses fails, study finds  

Around 15% of antibiotic courses prescribed by GPs for common infections fail, a rate that has risen markedly in recent years alongside a rise in prescriptions, a study in the BMJ has reported.

The authors called for closer monitoring of antibiotic failure in primary care and for GPs to take more care to prescribe recommended first-line antibiotics.

The study – backed by Abbott Healthcare – considered nearly 11 million prescriptions of first-line antibiotics for four common infections over the period 1991 to 2012, using data from the UK Clinical Practice Research Datalink.

The researchers found antibiotics failed in 13.9% of episodes in 1991, rising to 15.4% in 2012. The vast majority of these were identified by evidence of a switch to an alternative antibiotic, while just under 5% were flagged because the patient was referred to an infection-related specialist clinic.

The failure rate was higher for lower respiratory tract infections, rising from 16.9% to 21.0% over the study period, with a big increase in cephalosporin failure seen in particular.

Trimethoprim failure when used for upper respiratory tract infections was also high, rising from 24.7% to 55.9% in 2008-12, whereas failure rates for flucloxacillin in skin and soft tissue and macrolides in general remained largely stable.

The researchers said the increase in treatment failure coincided with a rise in the proportion of consultations in which an antibiotic was prescribed, which went up from 64% to 66% between 1991 and 2012, with a temporary fall to 61% in 2000.

The authors concluded: ‘Our data suggests that primary care physicians could play a central role in helping to contain rises in antibiotic treatment failure by managing patients’ expectations and carefully considering whether each prescription is justified; once the decision is made to prescribe an antibiotic, the choice should follow current guidelines regarding first-line drugs.’

Lead author Professor Craig Currie, from the Cochrane Institute of Primary Care and Public Health at Cardiff University, said: ‘Antibiotic resistance in primary care needs to be more closely monitored, which is actually quite difficult given that primary care clinicians seldom report treatment failures.

‘The association between antibiotic resistance and antibiotic treatment failure also needs to be further explored. From the general level of feverish debate, it’s not quite the “cliff” we would have imagined, but clearly this is worrying.’

BMJ 2014; available online 23 September

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Readers' comments (6)

  • The litigation driven society makes not prescribing simply lead to complaints, and eventually in the rare occasion the URTI does end up in a bacterial secondary infection, the patient then feels justified in expecting compensation for a missed diagnosis, when just a complication of their original infection.

    You then fail the friends and family test of the uncaring GP who never does anything except tell you to use Calpol, while your colleagues who give them out like Smarties glow in the bask of being excellent GPs while undermining any educational attempts.

    Until antibiotics again become the exception rather than the norm, with a large national DOH based advertising campaign it is doomed to fail.

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  • Vinci Ho

    CRP near patient testing may have a role. But it is about time and funding. Has been used a lot in Scandinavian countries. One recent Irish study identified (2011):
    A pilot study of the use of near-patient C-
    Reactive Protein testing in the treatment of adult respiratory tract infections in one Irish general practice


    Kim E Kavanagh, Eamonn O’Shea ,Rita Halloran ,Peter Cantillon and Andrew W Murphy


    Abstract
    Background: New approaches are being sought to safely reduce community antibiotic prescribing. A recent study demonstrated that CRP testing resulted in decreased antibiotic prescribing for lower respiratory tract infection in primary care. There is little other published primary care data available evaluating CRP in the treatment of lower respiratory tract infections in routine clinical practice. This pilot study aims to describe the performance of near- patient CRP testing, in a mixed payments health system. Specific areas to be reviewed included the integrity of the study protocol, testing of data collection forma and acceptability of the intervention.
    Patients: Patients over the age of 18 years, with acute cough and/or sore throat with a duration of one month or less, in routine clinical practice.
    Method: Design: A pilot with a cross-sectional design. The first 60 recruited patients were treated with routine clinical management, and GP’s had no access to a CRP test. For the subsequent 60 patients, access to CRP testing was available.
    Participants: 3 GP’s in one Irish primary care practice recruited 120 patients, fulfilling the above criteria over five months, from January 1 to May 31, 2010.
    Main outcome measures: The primary outcome was antibiotic prescription at the index consultation. Secondary outcomes were the numbers of delayed prescriptions issued, patient satisfaction immediately after consultation and re-consultations and antibiotic prescriptions during 28 days follow-up.
    Results: The protocol and data collection forms worked well and the intervention of CRP testing appeared acceptable. Thirty-five (58%) patients in the no-test group received antibiotic prescriptions compared to 27 (45%) in the test group. Both groups demonstrated similarly high level of patient satisfaction (85%). Fourteen (23%) patients in the CRP test group re-attended within 28 days compared to 9 (15%) in the no-CRP test group.
    Conclusion: This pilot study confirms the potential feasibility of a full trial in Irish general practice. Further consideration of possible increased re-attendance rates in a mixed payments health system is appropriate. We intend to pursue a larger trial in a newly established regional primary care network

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  • I am surprised it is only 1 in 7 courses. When seeing patients with ? infection ? other course for symptoms I often take a CRP/FBC/LFT- sometimes ESR - marked as urgent I will have the result back by 2 pm or 5 pm this is also great for the " I still have cellulitis /my cough /diverticulitis " scenarios but is obviously tricky for patients on Prednisolone as their readings can be way out ...

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  • So, 6 in 7 "succeeds. Surely reassuring, that!!

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  • 3 main contributing factors:

    1.Clinical uncertainty.
    2.Demanding patients
    3:Litiginous society

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  • worth reading the study & looking at antibiotics without increased "failure" rates.
    Soft tissue infection includes acne

    Decrease in consultation rate might mean more self-care for minor infection
    Rates of consultations per 1000 patients per year decreased from 152 to 86 (P<0.01) for upper respiratory tract infection, from 40 to 13 (P<0.01) for acute otitis media, and from 80 to 45 (P<0.01) for lower respiratory tract infection. The consultation rate for skin and soft tissue infections increased in a non-linear way from 51 to 63 consultations per 1000 patients per year (P<0.01).

    In 'what this paper adds'
    The most commonly prescribed antibiotics were associated with relatively stable failure rates

    Treatment failure rates increased in some notable cases, especially when the antibiotic selected was not considered first choice for the indications studied

    As I say, read the paper ..

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