How to reduce antibiotic use in primary care

“It will take the combined efforts of diverse UK public and private sector bodies as well as all members of the public to fulfil our high-level ambitions and help contain and control antimicrobial resistance. Each one of us needs to be ready, willing and engaged to play our part."
Contained and controlled: The UK’s 20-year vision for antimicrobial resistance, 2019

Antimicrobial resistance arises when the organisms that cause infection evolve ways to survive treatment. Once standard treatments, such as antibiotics, are ineffective, it is easier for infections to persist and spread. Around 70% of antibiotics are prescribed in general practice; research shows at least 20% of these antibiotic prescriptions are inappropriate. Antibiotic prescribing in primary care will need to be reduced to slow the spread of antimicrobial resistance. But healthcare professionals and patients may be concerned about possible risks arising from withholding antibiotic prescriptions.

The NIHR held a webinar in January 2024 to share evidence from NIHR-funded research that provides reassurance. The webinar covered:

the safety of reducing antibiotic use in primary care
antibiotic use for children with chest infections
a digital intervention that can help reduce antibiotic prescribing in primary care.

This Collection summarises the three studies presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for prescribers in primary care.

Background

Antibiotic resistance occurs naturally, but overuse or misuse of antibiotics accelerates the process. One study showed that rates of antibiotic resistance were higher in the European countries that prescribe the most antibiotics in primary care, compared with countries that prescribe fewer.

‘Individuals who are exposed to antibiotics are much more likely to harbour a resistant organism for the next infection they get.’
Paul Little, Professor of Primary Care Research, University of Southampton, and former GP

In 2019, the World Health Organisation listed antimicrobial resistance among the top 10 threats for global health. In 2019, 1.27 million deaths worldwide were caused by drug-resistant infections, and a further 4.95 million were associated with drug-resistant infections. The number of antibiotic-resistant infections and deaths in the UK is rising. According to the UK Health Security Agency, more than 58,000 people in England had an antibiotic-resistant infection in 2022. This is 4% more than in 2021.

National Institute for Health and Care Excellence (NICE) guidelines recommend education and feedback for prescribers to support antimicrobial stewardship and change their attitude towards antibiotic prescribing. Antibiotic use declined by almost a quarter from 2014 to 2020, but the latest data show that antibiotic use in all settings (except dental) increased again in 2022.

1. Is it safe to reduce antibiotic prescribing in primary care?

This is a summary of an original study published in the NIHR Journals Library, May 2021.

‘You’re much more likely to be brought up on missing something and not prescribing antibiotics than giving antibiotics when it wasn’t necessary.’
GP interviewed in the study

Do fewer antibiotic prescriptions result in more serious bacterial infections?

The researchers used electronic health records from 706 general practices, including data from more than 11 million people, to examine whether practices that prescribe fewer antibiotic prescriptions report more serious bacterial infections. Prescribing rates varied widely between general practices, but the team found no evidence that practices with lower rates of antibiotic prescribing saw more infection complications than those with higher prescribing rates.

What concerns clinicians and patients about reducing antibiotic prescribing?

Martin Gulliford and his team explored the concerns of healthcare professionals and patients about reducing antibiotic use. The researchers interviewed 30 GPs, nurses and pharmacists, and 31 patients. GPs and nurses said they were concerned about the risks of both prescribing and not prescribing antibiotics. They were particularly concerned about sepsis, a severe form of infection. Patients said they were concerned about antibiotic resistance and the side effects of antibiotics.

Who is most likely to develop sepsis?

Using the electronic health records, the researchers examined data from all infection consultations to see which groups might be most likely to develop sepsis. Those most at risk:

were older
presented with urinary tract infection (including cystitis)
had greater frailty.

The number of antibiotics needed to prevent a single episode of sepsis (the number needed to treat) decreased with age. For girls aged 0 – 4 years, more than 27,000 antibiotic prescriptions would be needed to prevent a single episode of sepsis. For women aged 85 and older, one sepsis event might be prevented with every 385 antibiotic prescriptions.

The findings provide evidence that the risk of sepsis and localised serious bacterial infections associated with reduced antibiotic prescribing is generally low. The results from this research provide data that clinicians might use to identify groups of patients in whom antibiotic prescribing could be safely avoided.

2. Are antibiotics needed for most children with chest infections?

This is a summary of an original study published in the NIHR Journals Library, June 2023.

‘This study should help GPs and other prescribing clinicians, and patients, feel much more comfortable about not using an initial antibiotic [in children with chest infections].’
Paul Little, Professor of Primary Care Research, University of Southampton

Children with chest infections are often prescribed antibiotics. Until recently, few studies have explored whether children taking antibiotics for chest infections get better faster than those who do not. At the webinar, Paul Little presented findings from the ARTIC-PC trial, which assessed how effective a common antibiotic (amoxicillin) is for chest infection in children.

Who took part?

This randomised controlled trial included 432 children (6 months – 12 years) at 56 GP practices in the UK. They all had a chest infection; they were excluded if pneumonia was suspected. Half (221) received antibiotics and the others (211) received placebo for 7 days.

Families kept a diary for at least a week and recorded the number of days their child had symptoms (on a scale from ‘no problem’ to ‘as bad as it can be’).

Did antibiotics make a difference?

Children taking antibiotics had around 1 day less with symptoms (5 days) than those who took placebo (6 days) - the difference was not significant. Costs (NHS and societal, such as parents’ time off work) were similar, regardless of whether the child had taken antibiotics or placebo.

The researchers considered separately those children with symptoms that commonly trigger antibiotic use (fever, a rattly chest, or shortness of breath, for example). The findings were similar even among children with these additional symptoms.

What did parents and clinicians say?

The researchers interviewed 16 parents and 14 clinicians about their experience of managing chest infections. Parents found it difficult to gauge their child’s symptoms, but accepted that antibiotics should only be used when necessary. Clinicians noted a shift in parents’ views; they are more accepting of not being prescribed antibiotics than in the past.

Paul Little highlighted that prescribing fewer antibiotics will make GPs less busy in the long-term.

‘Patients prescribed antibiotics are more likely to believe that this is an effective treatment and are more likely to consult in future. We have shown that for one individual, you have a 40% increase in re-consultation rates over the next year for one antibiotic prescription. It’s a very big effect.’ Paul Little

Sensible, accurate information helps people to self-manage and know how long they can expect symptoms to last.

Who was likely to need antibiotics?

The researchers developed a model to help clinicians predict a child’s risk of worsening illness. The model suggests which children are most likely to benefit from antibiotics (those with a breathing rate different to their peers; oxygen saturation of less than 95%; and rattly chest, for instance). This could help clinicians limit antibiotics to only those children likely to benefit most. But robust evidence is needed before widespread use. At the webinar, Paul Little said his team had developed an app which is currently being trialled with pharmacists.

Can a digital intervention reduce antibiotic prescribing for respiratory infections?

This is a summary of an original study published in the NIHR Journals Library, March 2019.

‘We delivered these interventions electronically and yes, they did have an effect on antibiotic prescribing in these trial practices… There was no evidence of adverse impact on safety outcomes.’
Martin Gulliford, Professor of Public Health, King's College London

Most people with colds, sore throats, cough, infections of the middle ear (otitis media) and sinusitis get better without specific treatment. Antibiotics generally offer little if any benefit for respiratory infections, yet many are prescribed. Martin Gulliford and his team explored whether a digital intervention could help primary care clinicians reduce antibiotic prescribing for these self-limiting respiratory infections. Their randomised controlled trial, REDUCE, involved 79 general practices. Half (41) used the intervention and half (38) did not.

What was the digital intervention?

The intervention included:

a short webinar (6 minutes) to provide brief training
monthly antibiotic prescribing feedback reports delivered over a 12 month period
decision-support tools (which provide advice to clinicians on when to issue a prescription, and information leaflets for patients on self-care, and whether to see the GP again).

What impact did the intervention have?

Over 1 year, compared with practices not using the intervention, practices using the intervention:

prescribed 12% fewer antibiotics overall
prescribed 16% fewer antibiotics to people aged 15 – 84
had a similar prescribing rate for children under 15 years, and adults aged 85 and older.

Analysis of the data found no indication that the intervention increased the risk of 12 bacterial infections, including pneumonia and peritonsillar abscess.

The digital intervention reduced antibiotic prescribing for self-limiting respiratory infections in primary care overall, but not in children or the elderly. At the webinar, Martin Gulliford said that the team had hoped to see a larger reduction in antibiotic prescribing, and they would like to explore how to further increase the reduction. The intervention provided helpful guidance for clinicians to use in consultations, plus information they could give patients to inform their expectations.

Conclusion

Antibiotic prescribing in primary care needs to be reduced to slow the development and spread of antibiotic-resistant bacteria. It has other benefits: it could save clinicians’ time in the long-run, and prevent unnecessary side-effects for patients, such as diarrhoea and feeling sick.

Prescribers and patients still have concerns about not prescribing. Some people expect to receive antibiotics, which means clinicians have to spend time explaining the decision not to prescribe. Some people do need antibiotics. As Paul Little said: “for some groups of people, for instance those with chronic obstructive pulmonary disease and recurrent infections, it might not be safe to reduce antibiotic prescribing. The focus for reducing prescribing is on uncomplicated conditions.”

The research presented at the NIHR Evidence webinar provides evidence that antibiotic prescribing may be reduced safely. It also highlights groups of people who are at greater risk and for whom antibiotics may still be preferred. Clinicians need clear information to support clinical decision-making during consultations, and tools to assess the risk and benefits of prescribing antibiotics to individual patients. Follow-on research from some of that presented at this webinar is ongoing, and, once validated, the tools could help clinicians prescribe fewer antibiotics.

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