Antibiotics for ARI vastly exceed guidelines

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Clinical General Practice

By

Ruby Prosser Scully

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

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Glenn Rosendahl
Glenn Rosendahl
7 years ago

The article presents the naivety of the authors. ‘Academic general practice’ has very little knowledge of the practical ‘day to day’ (I will even say ‘run of the mill’) problems of treating acute respiratory infections, particularly in the wintertime epidemic. A first problem – never mentioned – is the real risk that if the doctor spends any length of time with the patient – particularly if one examines the patient’s throat – one will one’s-self contract several of the infections in the course of the season. To seriously obviate that risk one needs effective eye protection, as well as nose/mouth protection – a face mask. A short consultation is protective, as is a minimal clinical assessment. A second problem is the diagnosis. The Guidelines present 10 different diagnoses. Most of my patient have at least two of them, by the time they attend. A third problem is my observation of commonly inadequate and incomplete recorded clinical notes – if one judges them by the quality needed for valid inclusion in a study such as this. I would suggest to Dr Seidel that his acknowledgement of this problem – although welcome – is still grossly inadequate. The $38 bulk-billed fee, which is what the patient wishes to pay for a one-time visit for this condition, must cover the running cost of the clinic, and the total cost of the doctor, which must include the equivalent of all professional costs, superannuation and sick leave – as well as the doctor’s equivalent before tax private income. A fourth factor is the adult patient is looking both for a sick leave certificate, and rapid relief, and commonly believes that – after more than 4 days of symptoms – an antibiotic is the treatment of choice. The patient information leaflets provided by the AUSTRALIAN COMMISSION in SAFETY and QUALITY in HEALTH CARE are – in my view – utterly useless. Dense, confusing, and in one argument, manifestly untrue. “What is antibiotic resistance? …This means that antibiotics may not work if you or your child needs them in the future to treat a bacterial infection. A person who has recently used antibiotics is more likely to have resistant bacteria in their body.” The statement is absolute. But the vast majority of cultures – at worst – still demonstrate an incomplete panel of resistance. There will be some antibiotics to which the bacteria are sensitive. That is why we take a throat swab. Particularly if I do not prescribe an antibiotic. How are the information leaflets supposed to be used? Obviously not to be handed over partway through a consultation.
I have an argument I very commonly use with otherwise healthy adult patients who had caught what I consider is an uncomplicated intercurrent viral respiratory infection. It has not yet been mentioned in these discussions. I tell them the likely clinical – symptomatic -response to an antibiotic, if the infection is bacterial, will be up to 4 days. A prescription for a codeine-paracetamol analgesic will provide a major reduction in general misery and in relevant forms of pain: throat, sinus, general somatic, substantially reduce respiratory secretion and cough. This symptomatic relief begins almost immediately and will continue for the 3 days of the script. Lesser concentrations of codeine are available – if subsequently needed – over the counter. ‘That is probably all you need’.
The patient has come for help. The patient thinks that means an antibiotic. What they most commonly need is prompt symptomatic relief. It is convincing them you can provide that – is what is critical.

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