Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database

Petersen, Irene; Johnson, Anne M; Islam, Amir; Duckworth, G.; Livermore, David M.; Hayward, Andrew

doi:10.1136/bmj.39345.405243.be

Cited by 268 publications

(235 citation statements)

References 21 publications

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“…A cute sore throat is one of the most common symptoms among patients presenting to primary care. 1,2 Sore throats resulted in 92 million estimated visits by adults to primary care practices and emergency departments in the United States between 1997 and 2010, averaging 6.6 million annually; with unnecessary antibiotic prescribing costs of at least $500 million. 3 Antibiotics are prescribed at 60% of UK primary care sore throat consultations, 4 and the trend is not decreasing 3,5 despite the low risks of suppurative complications, limited symptomatic benefit, 6 and national guidelines advising against prescriptions.…”

Section: Resultsmentioning

confidence: 99%

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults

Hayward

Moore

Jawad

et al. 2017

JAMA

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IMPORTANCE Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment.OBJECTIVE To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics. Double-blind, placebo-controlled randomized trial (April 2013-February 2015 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy. DESIGN, SETTING, AND PARTICIPANTSINTERVENTIONS Singleoraldoseof10mgofdexamethasone(n = 293)oridenticalplacebo(n = 283). MAIN OUTCOMES AND MEASURESPrimary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events. RESULTSOf 565 eligible randomized participants (median age, 34 years [interquartile range, 26.0-45.5 years]; 75.2% women; 100% completed the intervention), 288 received dexamethasone and 277, placebo. At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. Results were similar among those who were not offered an antibiotic prescription and those who were offered a delayed antibiotic prescription. At 48 hours, more participants receiving dexamethasone than placebo had complete symptom resolution. This difference also was observed in patients not offered delayed antibiotics. There were no significant differences in any other secondary outcomes. Resolution of Symptoms at 24 h (Primary Outcome)

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Section: Resultsmentioning

confidence: 99%

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults

Hayward

Moore

Jawad

et al. 2017

JAMA

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“…Evidence from clinical trials suggests that antibiotics may reduce the risk of suppurative complications of RTIs,5 but the more serious complications are generally too rare to evaluate precisely in randomised studies. A cohort study in 162 general practices in the General Practice Research Database from 1991 to 2001 evaluated the effect of antibiotic treatment on the incidence of pneumonia after upper RTI, peritonsillar abscess after sore throat, and mastoiditis after otitis media 14. The results suggested that antibiotic treatment was associated with lower odds of each of these complications, but the overall risk of complications was generally small and the number of patients who would have to be treated to avoid one complication was estimated to be in excess of 4000.…”

Section: Introductionmentioning

confidence: 99%

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Gulliford

Moore

Little

et al. 2016

BMJ

123

114

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Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs).Design Cohort study.Setting 610 UK general practices from the UK Clinical Practice Research Datalink.Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014.Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients.Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice.Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome were similar in frequency at low prescribing and high prescribing practices.Conclusions General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

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“…Selection bias is a potentially important issue among low recruiting doctors, but the study found no evidence of clinical differences comparing higher and lower recruiting doctors. Overall fewer children than expected from historical data sets 27 were recruited which probably reflects reluctance of parents and/or GPs to expose children to a throat swab, but since the study elected not to include age per se in the model, the impact of this should be slight.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

Little¹,

Hobbs²,

Mant³

et al. 2012

Br J Gen Pract

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Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database

Cited by 268 publications

References 21 publications

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

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