Long-term Effects of Reduced Antibiotic Use for RTIs Far Outweigh Potential Short-term Consequences

The belief that patients may face increased risks of complications following reduced antibiotic use after experiencing self-limiting respiratory tract infections (RTIs) may not be well-founded, according to the results of a study published recently in the British Journal of Medicine.¹

The overuse or misuse of antibiotics has become a topic of significant interest to the medical community and the general public, as it is widely believed that such prescribing patterns have contributed to the recent and alarming rise in antibiotic resistant strains that have the potential to be lethal.² Because primary care settings in the United Kingdom are often the point of first contact for patients in general, it is important to note that over 60% of all antibiotics prescribed by primary care providers in the United Kingdom are for the treatment of largely self- limiting RTIs, such as common colds, sore throat, cough, acute bronchitis, otitis media, and sinusitis.^3,4 However, there is no good evidence that such treatment is efficacious,⁵ and therefore the high prescription rate in primary care settings heavily implies unnecessary antibiotic prescription and use.

Attempts have been made to reduce primary care antibiotic prescription rates in appropriate cases in the United Kingdom; however, physician prescribing patterns continue to remain high post RTI and show wide variation.^3,6,7 Despite the fervor for lowering antibiotic prescription rates post RTI in the primary care setting, it is unclear if such a strategy would actually have any impact on patient safety with regard to subsequent risk for complications including pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome.

In response to this ongoing medical challenge, Martin Gulliford, FFPH, MA, a professor of public health in the Division of Health and Social Care Research at King’s College London, and his colleagues posed three important questions that they intended to address in a study including, "Is there a safe level of antibiotic prescribing for RTIs? What target can general practices safely adopt in reducing the proportion of consultations for RTIs with antibiotics prescribed? Is there a threshold for antibiotic prescribing below which complications may increase?". In order to find answers for these clinical questions, Dr. Gulliford and his colleagues conducted a retrospective cohort study using electronic medical records collected from 2005 to 2014 on approximately 4.5 million registered patients and stored in the UK Clinical Practice Research Datalink.⁷

The study results indicated that when general practices were divided into fourths according to the proportion of RTI consultations with antibiotics prescribed, mastoiditis, empyema, bacterial meningitis, intracranial abscess, and Lemierre’s syndrome were not associated with any antibiotic prescribing category. Only the incidences of pneumonia and peritonsillar abscess showed differences between the highest and lowest antibiotic prescribing groups. For pneumonia, the incidence in the highest prescribing group (119 per 100,000) was slightly lower than for the lowest prescribing group (157 per 100,000). Similarly, 15.6 per 100,000 and 12.9 per 100,000 were the incidences for peritonsillar abscess in the lowest and highest prescribing groups, respectively. According to the authors, "These results show that general practices prescribing fewer antibiotics for RTIs may expect to have a slightly higher incidence of pneumonia and peritonsillar abscess than higher prescribing general practices."

Additional results showed that for every 10% decrease in antibiotic prescribing proportion, there was a corresponding relative increase of 12.8% and a 9.9% for pneumonia and peritonsillar abscess, respectively. This means that an average sized UK general practice (7000 registered patients) that decreased antibiotic prescribing by 10% could expect to see an additional 1.1 and 0.9 cases of pneumonia and peritonsillar abscess, respectively each year.

In a press release regarding the broader implications of his team's study results, Dr. Gulliford said, "Overuse of antibiotics now may result in increasing infections by resistant bacteria in the future. Current treatment recommendations are to avoid antibiotics for self-limiting respiratory infections. Our results suggest that, if antibiotics are not taken, this should carry no increased risk of more serious complications. General practices prescribing less 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."

William Perlman, PhD, CMPP is a former research scientist currently working as a medical/scientific content development specialist. He earned his BA in Psychology from Johns Hopkins University, his PhD in Neuroscience at UCLA, and completed three years of postdoctoral fellowship in the Neuropathology Section of the Clinical Brain Disorders Branch of the National Institute of Mental Health.

References

1. Gulliford MC, Moore MV, Little P, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016;354:i3410.
2. Chief Medical Officer. 2011. Infections and the rise of antimicrobial resistance. Vol 2. Department of Health, 2013. (Annual Report of the Chief Medical Officer.).
3. National Institute for Health and Care Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. National Institute for Health and Clinical Excellence, 2008.
4. Little P, Stuart B, Hobbs FD, et al. DESCARTE investigators. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis 2014;14:213—219.
5. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013;11:CD000023.
6. Gulliford M, Latinovic R, Charlton J, Little P, van Staa T, Ashworth M. Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006. J Public Health (Oxf) 2009;31:512-520.
7. Gulliford MC, Dregan A, Moore MV, et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014;4:e006245.