The paper by Tonkin-Crine et al illustrates the views of GPs regarding interventions to promote prudent antibiotic use.1 It was demonstrated that GPs preferred educational meetings where comparison with colleagues reassured them that prudent antibiotic prescribing was possible, and appreciated having evidence-based guidelines to follow.
To follow on from this, if one were to look at the quarter of the population visiting their GP with respiratory tract infections each year, it becomes apparent why a large proportion of antibiotic prescribing is in primary care. Despite guidelines advising against their routine use, in 2000 antibiotics were prescribed to 49% of those with an upper respiratory tract infection (URTI).2
The natural history of an untreated sore throat is resolution by day 3 in 40%, and by day 7 in 85%. Antibiotics reduce the duration of symptoms by just 16 hours, while the number needed to treat to prevent one sore throat at day 3 was fewer than six, at week 1 it was 21.2 There is no benefit of antibiotics for the common cold and although there is a protective effect against serious complications3, over 4000 courses are needed to prevent one complication.4 In addition, antibiotics cause many side effects, and communities build resistance to them.5 Therefore, with insufficient evidence of the benefit to warrant the use of antibiotics, why do GPs continue to prescribe them for the common and uncomplicated URTI?
Possible explanations for varied GP prescribing behaviour is the GPs' own fear of complications developing, along with their lack of certainty in their decision to prescribe.6 As patients expect to receive antibiotics,7 supported by Tonkin-Crine et al, along with 85% of patients believing that antibiotics relieve symptoms,8 a further explanation could be that GPs are unwilling to challenge patient health beliefs. As suggested by the GPs involved in Tonkin-Crine et al's article, the use of educational materials for patients with public campaigns could reduce demand.
Therefore, is it ethical to prescribe antibiotics for URTIs? If a GP is concerned about complications developing, prescribing antibiotics is aimed to manage the fear within the doctor, rather than to treat the patient. This will expose the patient to unwanted side effects where they ultimately feel worse. In addition, by prescribing antibiotics GPs are increasing patient attendance rates and are using up scarce resources in an already financially stricken NHS, on balance doing more harm than good. GPs should consider whether prescribing antibiotics for a URTI is ethically justifiable, in view of guidelines, evidence, and ethics.
- © British Journal of General Practice, January 2011