Prescribers are being urged to adhere more closely to guidelines for antibiotics
The rate of antibiotic prescribing for acute respiratory infections in Australia is up to nine times higher than recommended guidelines, a study has found.
An analysis of BEACH data found that just over half of all new problems managed with antibiotics in general practice were acute respiratory infections. But when the authors compared the rates of prescribing with what would be expected under guidelines, they found that only 11% to 23% of cases were justified.
“GPs are doing what they think is best for patients and erring on the side of caution, and that is very laudable,” lead author Professor Chris Del Mar, academic GP and professor of public health at Bond University, told The Medical Republic.
“But GPs and their patients overestimate the benefits of antibiotics, and that is probably the fundamental reason why there is such a difference between what should be prescribed, under the guidelines, and what really is prescribed.”
While there were earlier reports local GPs were overprescribing the drugs, this study was the first to quantify the level, the authors said.
On average, almost six million cases of acute respiratory infection were managed with antibiotics in general practice annually, equivalent to 230 cases per full-time GP, the study found.
Antibiotics are not recommended for acute bronchitis or bronchiolitis, and yet the study found 85% of patients presenting to their GP were given such drugs. Similarly, one in 10 patients with influenza were given antibiotics, despite that being contrary to the Therapeutic Guidelines recommendations.
Antibiotics are also considered appropriate for up to 8% of cases of acute rhinosinusitis, compared with the current prescription rate of 41%; up to 31% of cases of acute otitis media should be treated with antibiotics, which is substantially fewer than the 89% currently being treated; and a maximum of 40% of cases of acute pharyngitis or tonsillitis, despite almost all cases in Australia being treated with antibiotics.
On the other hand, community-acquired pneumonia should always be treated with antibiotics under the guidelines, whereas only 72% of cases currently are.
Professor Del Mar said work in the infectious diseases field was now showing that antibiotic resistance in hospitals was coming in from the community, rather than the reverse.
“I think it’s important that we put things straight in our own backyard as GPs, and actually it’s a task that’s not impossible.”
This study identified a clear avenue of reducing antibiotic harms, specifically resistance, Professor Del Mar said, adding he hoped this research would help to set clear targets for reducing prescribing levels.
The study used acute respiratory infection management data from the BEACH survey to generate its findings. GPs were asked to record patient problems as specifically as possible, based on the data they had.
Professor Del Mar said the researchers had taken great care to ensure they did not overestimate the difference between usage and guideline recommendations and that it erred on the most conservative reading of the guidelines.
“The guidelines are pretty conservative and they err on the side of safety, and all of our adjustments take that into account,” he said.
“Had GPs adhered to the guidelines, they would have prescribed antibiotics for 0.65–1.36 million ARIs per year nationally, or at 11 to 23% of the current prescribing rate,” the study found.
“Diagnostic uncertainty — concern by the treating doctor that a serious infection or complications might be missed — is one potential explanation for this finding,” the authors found.
While clinicians often point to the agricultural industry as a major user of antibiotics, Professor Del Mar said that fact did not let doctors off the hook for growing rates of antibiotic resistance.
“Sure, animal production is another area that needs a focus on it, and people are working on that,” he said.
“[But] there are a whole lot of unknowns about that. The first is that we don’t know the extent to which prescribing antibiotics in prawn farms, for example, affects antibiotic resistance in the community.” It might be the case that antibiotic resistance from farms was a pathway for causing antibiotic resistance in people in the community, but it was not certain yet, he said.
Meanwhile, the Australian Commission on Safety and Quality in Health Care has released new data showing the use of antibiotics in hospitals has dropped 7.6% since 2011 – a positive reflection on strategies to curb resistance.
MJA 2017; online 10 July
