30 September 2021

Another nail in the coffin for antibiotics

Clinical Pharmaceuticals Respiratory

Despite being the second-most-prescribed antibiotic in Australia, amoxicillin is “unlikely to be clinically effective” for one of the respiratory conditions it is regularly used to treat, a mounting body of evidence suggests.

“There is now pretty substantial evidence that antibiotics have a limited impact in kids under the age of 12,” says Paul Glasziou, Professor of Evidence-Based Practice at Bond University.

“We already had good evidence in this for adults, but much more limited evidence in children,” said the leading general practice researcher after a recent paper in The Lancet found diminished antibiotic efficacy for lower respiratory tract infections in children, building a strong case for delayed prescribing.

The double-blind randomised placebo-controlled trial of about 430 British children with an uncomplicated chest infection found that amoxicillin was not clinically effective.

Half the cohort received a week-long course of amoxicillin at 50mg/kg, while the other half received a placebo.

The research team found no significant differences in parent-reported symptoms or complications between the placebo and amoxicillin groups.

“Our results suggest that antibiotics do not provide a clinically important benefit on average for symptom reduction nor symptom severity,” they wrote in The Lancet.  

“The question remains whether there are some children who receive a meaningful benefit, but the benefit is diluted by large numbers of children who receive no benefit.”

Importantly, children with suspected pneumonia or symptoms lasting longer than 21 days were excluded from the study.

However, the study did include children with chest signs, fever shortness of breath, who had sputum, and whom the clinician assessed as appearing unwell. And even when the researchers analysed data from these subgroups, they were still unable to find substantial benefits with antibiotic treatment over and above placebo.

According to Professor Glasziou, these results could help empower practitioners to take a “wait and see” approach.

“A delayed prescribing approach might be reasonable if the child is getting worse or there are localising signs,” he said.

He did, however, reiterate that there were several limitations.

“It’s not applicable for every kid with a lower respiratory tract infection, but for those who come in and say ‘I’ve had a cough for three weeks’ but they’re not too sick – don’t give them antibiotics,” Professor Glasziou said.

Usage of the drug has come under considerable scrutiny over the past several years as the threat of antibiotic-resistant pathogens has become clearer.

Data from the last year confirmed that though GPs still account for the bulk of antibiotic prescribing, there have been significant reductions in community dispensing of antibiotics for respiratory tract infections.

However, the reasons behind that decline remain unclear.

Professor Glasziou said bronchitis has been one of the key areas in which antibiotic prescribing has persisted.

“In terms of upper respiratory tract infections, I think there’ve been improvements in that they are no longer being given for simple colds,” he told The Medical Republic.

“The area of greatest problem has been in [attempting to reduce] the prescribing of antibiotics for non-severe acute bronchitis of limited duration.”

The Lancet 2021, online 22 September

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