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

Abstract

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.

Fusobacterium necrophorum Pharyngitis Complicated by Lemierre’s Syndrome

“…This condition was more frequently encountered in preantibiotic era; it subsequently became a rare disease, but recent reports have documented an increasing number of cases worldwide [7–9]: a possible explanation for this recrudescence is the reduction in the empirical use of antibiotics in patients with sore throat, following the advice of clinical guidelines [10]. However, there is no clear evidence that Lemierre's syndrome is more frequent when antibiotics are prescribed to a lesser extent [11]. In the present case, an empirical course of antibiotics, even active against F. necrophorum (amoxicillin/clavulanic acid), was early prescribed, but the dose and treatment duration were probably insufficient.…”

Controlling antibiotic prescribing for lower respiratory tract infections

“…11 Together, these studies provide good evidence that not prescribing antibiotics at the first visit for these common infections is a safe option and should enable general practitioners to improve communication with concerned patients, perhaps using delayed prescribing among other techniques to help achieve the best possible outcome for everyone.…”

A randomized, double-blind, controlled study to evaluate clinical efficacy and safety of novel filmogen osmotic treatment for pharyngitis

“…It becomes a more worrisome issue when patients experience severe infection and impairing symptoms, as when caused by the influenza virus, with possible serious complications [28][29][30]. Although antibiotics can be necessary in case of secondary bacterial colonization [31], they are still too often systematically resorted to, despite local governmental sensitization campaigns [32,33] to promote more appropriate antibiotic use, which has led to the worldwide bacterial resistance crisis [34][35][36].…”