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Gold, incentives and meh

Reduced GP antibiotic prescriptions linked with ‘small’ increase in complications

GP practices that prescribe relatively fewer antibiotics for respiratory infections have a slightly increased complication rate compared to other practices, a study has found.

However, investigators said they found the increase was only seen for pneumonia and quinsy, both of which can be treated easily, whereas there was no increase in other serious infections.

They concluded that GPs can cut back substantially on the amount of antibiotics they prescribe for coughs and sore throats without fear of missing serious complications like meningitis.

GP experts said that while the findings should offer some reassurance to GPs, who have already reduced antibiotics prescribing considerably in recent years, it remains unclear how much further GPs can safely cut back on prescriptions. GPs were recently hailed for reducing antibiotic prescribing by 7% over the past year alone.

The study included data from more than 600 UK GP practices, and found that with each 10% lowering of antibiotic prescribing rates, there was a 13% relative increase in the rate of pneumonia and a 10% higher rate of peritonsillar abscess (quinsy).

The researchers estimated that an average practice of 7,000 patients could expect to see one extra case of pneumonia a year, and an extra case of quinsy every ten years, if they reduced the rate at which they prescribed antibiotics for respiratory complaints by 10%.

By contrast, there was no sign that incidences of more serious complications, namely mastoiditis, empyema, meningitis, intracranial abscess or Lemierre’s syndrome, differed with antibiotic prescribing rates.

The team argued that the small increase in these cases would be offset by the advantages of reduced prescriptions, since both pneumonia and peritonsillar abscess are readily treatable conditions, and the reduction in prescriptions would cut resistance, side effects and unnecessary medicalisation.

They concluded that 'even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall’ although they noted that ‘caution might be required in subgroups at higher risk of pneumonia'.

Lead author Professor Martin Gulliford said: ‘Our results suggest that, if antibiotics are not taken, this should carry no increased risk of more serious complications.

‘General practices prescribing fewer antibiotics may have slightly higher rates of pneumonia and peritonsillar abscess but even a substantial reduction in antibiotic prescribing may be associated with only a small increase in the numbers of cases observed. Both these complications can be readily treated once identified.’

Co-author Dr Mark Ashworth, a GP and researcher at King’s College London, said: ‘Our paper should reassure GPs and patients that rare bacterial complications of respiratory infections are indeed rare.

‘Fortunately, if there are any signs of a complication, the GP can quickly step in and offer an appropriate antibiotic.’

Dr Bill Beeby, deputy chair of the GPC’s clinical and prescribing subcommittee, said it was ‘reassuring that somebody has produced a study that is supportive of what we are doing’.

But he added that 'extrapolating to further reductions could be dangerous'.

Dr Beeby said: ‘There will be a level at which you probably can’t reduce your prescribing much without taking bigger risks. Given we have already reduced prescriptions, public health people are going to have to watch the rates of these conditions as the decline in prescribing continues.’


BMJ 2016; available online 4 July

How GPs are cutting back on antibiotics prescribing

GPs were recently praised for 'dramatically' reducing antibiotic prescriptions - after it was revealed they had cut overall antibiotics prescribing 7% over the past year alone. NHS chiefs have attributed the fall at least partly to financial rewards given out to CCGs for hitting targets on antibiotics prescriptions, athough GP leaders have pointed out that GPs are already the most judicious prescribers of antibiotics in the NHS and have been reducing antibiotics use steadily over recent years.

Official Public Health England surveillance data confirmed GP prescribing is the one area where antibiotic use is now falling year on year, with another drop observed between 2013 and 2014 such that levels are below those for 2011.

Despite this, GPs are set to face increasing scrutiny of their antibiotic use, with the Department of Health and CQC working on bringing new antimicrobial stewardship measures into the practice inspection regime and Government calls for GPs to halve 'inappropriate' prescribing of antibiotics by 2020.

Professor Mark Baker, director of the centre for clinical practice at NICE, even said ‘soft-touch’ GPs should face a GMC referral for ‘persistently’ prescribing the antibiotics inappropriately.

Readers' comments (19)

  • Our consumerist society wont forgive individual GPs the increase in infections such as pneumonia, quinsy or other more serious infections without the usual front page headline of newspapers. Especially when they feel they "need" antibiotics and are denied them. Another issue here is the increase in GP consultation rates as a result of reduced antiobiotic prescribing. Why cant we be happy with the reductions we have made so far. Studies can only assess so much but not the collateral effects eg pushing GPs to greater risks,number of increased A+E visits, number of increase in GP appointments etc etc etc

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  • GPs aren't the problem, patients demanding antibiotics are the problem.

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  • Once again focus on GPs without addressing the issues on patient demand/education and complaints. It is a bit rich to ask GPs to reduce prescribing mainly for cost reasons. We need to be professional and resist these pressures distorting clinical decisions. Our 1st rule of medicine is do no harm.....a slight increase in complications says it has bottomed out. The last time I know, pneumonia is still serious and a cause of death.

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  • Question;

    Has this lead to increase in complaints or litigation?

    If the answer is yes, then I suggest
    1. legislate to make individual clinicians immune to litigation
    2. Increase GP income to reflect the increase amount of risk we are having to take.

    After all, this is what happens in any private industry

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  • Being devil's advocate here. There was a Panorama programme recently highlighting the huge use of antibiotics in the agricultural industry. As we prescribe less than in Europe, does the rate reduction really make any difference?
    Just wondwring

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  • since when was quinsy and pneumonia mild!

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  • been through a recent legal case in which was accused of failing to prescribes antibiotics for what evolved into pneumonia several weeks after seeing patient. Patient consulted lawyer who found a GP who said that we should have prescribed even though NICE advises not to prescribe. This dragged on for years until eventually the case was thrown out. We need some form of protection from this as I am sick of being fall guy for everything.

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  • Russell Thorpe

    And you have a 1 yr old dying for the sake of a bottle of amoxil. The research team won't be by your side during a complaint or God forbid an inquest.

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  • David Banner

    "So, Dr X, you refused antibiotics for Little Timmy on Monday, and by Thursday he was dead from pneumonia. Anything to say in your defence?"
    "M'Lud, I was only following guidelines"
    "Precisely, they are only guidelines, you should have used your 30 years clinical experience. Now where did I put my black cap?"

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  • and if they don't get their amoxil from the GP they go to the Walk in centre, 111, Out of hours, A&E, or anywhere else they can get them .

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