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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.