Antibiotic overuse: a key driver of antimicrobial resistance

Laura J Shallcross; Dame Sally C Davies

doi:10.3399/bjgp14X682561

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RE: Antibiotic overuse: a key driver of antimicrobial resistance.
Laura J. Shallcross and Sally C. Davies

Published on: 29 December 2014
RE: GP antibiotic overuse and microbial resistance: as bad as we think or much worse?
Richard Weiler

Published on: 09 December 2014

Published on: (29 December 2014)

RE: Antibiotic overuse: a key driver of antimicrobial resistance.
Laura J. Shallcross, Clinical Lecturer in Public Health, University College London
Other Contributors:
Sally C. Davies, Chief Medical Officer for England
Dr. Weiler correctly highlights some of the limitations of primary care prescribing data: Research databases such as the Clinical Practice Research Datalink (CPRD, formerly the GPRD) record information on issued prescriptions, prescribing analyses and cost (PACT) data records prescriptions that are dispensed. Neither of these methods will record the proportion of prescriptions that are actually taken by the patient and we are unaware of any research studies that have specifically addressed this important question. GPs can record delayed prescriptions using the Vision software system, but it is unclear how frequently this Read code is used.

However, estimates suggest 80-90% of antimicrobials are prescribed in the community so even if we are overestimating antibiotic use, it is clear that the majority of antimicrobials are prescribed and dispensed in primary care. Research studies based on both issued and dispensed prescriptions using different populations all deliver the same message: there is major heterogeneity in prescribing, and this offers scope to reduce antibiotic use.^1-3

There is a clear need for better surveillance data on antimicrobial prescribing and resistance in hospitals and in primary care and this is the rationale behind the English Surveillance Program on Antimicrobial Resistance (ESPAUR).⁴ Optimising antibiotic use is a fundamental part of the response to antimicro...
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Dr. Weiler correctly highlights some of the limitations of primary care prescribing data: Research databases such as the Clinical Practice Research Datalink (CPRD, formerly the GPRD) record information on issued prescriptions, prescribing analyses and cost (PACT) data records prescriptions that are dispensed. Neither of these methods will record the proportion of prescriptions that are actually taken by the patient and we are unaware of any research studies that have specifically addressed this important question. GPs can record delayed prescriptions using the Vision software system, but it is unclear how frequently this Read code is used.

However, estimates suggest 80-90% of antimicrobials are prescribed in the community so even if we are overestimating antibiotic use, it is clear that the majority of antimicrobials are prescribed and dispensed in primary care. Research studies based on both issued and dispensed prescriptions using different populations all deliver the same message: there is major heterogeneity in prescribing, and this offers scope to reduce antibiotic use.^1-3

There is a clear need for better surveillance data on antimicrobial prescribing and resistance in hospitals and in primary care and this is the rationale behind the English Surveillance Program on Antimicrobial Resistance (ESPAUR).⁴ Optimising antibiotic use is a fundamental part of the response to antimicrobial resistance. This will only be achieved by changing patient and clinician behaviour in the community and in hospitals.

References

1. Hawker JI, Smith S, Smith GE, et al. Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011: analysis of a large database of primary care consultations. J Antimicrob Chemother 2014; 69(12): 3423-3430

2. Majeed A, Moser K. Age- and sex-specific antibiotic prescribing patterns in general practice in England and Wales in 1996. Br J Gen Pract 1999; 49(446): 735-6.

3. Shallcross LJ, Davies DS. Antibiotic overuse: a key driver of antimicrobial resistance. Br J Gen Pract 2014; 64(629): 604-5.

4. Ashiru-Oredope D, Hopkins S. Antimicrobial stewardship: English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR). J Antimicrob Chemother 2013; 68(11): 2421-3.

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Competing Interests: None declared.
Published on: (9 December 2014)

RE: GP antibiotic overuse and microbial resistance: as bad as we think or much worse?
Richard Weiler, Locum General Practitioner and Consultant in Sport and Exercise Medicine, The Red House Surgery
I read the article on antibiotic overuse and resistance by Shallcross & Davies in last month’s BJGP¹ with interest and doubt many would debate the conclusions, but have been left wondering the degree to which the robustness of the data supports the overuse of antibiotics in primary care.

Many doctors may treat patients using delayed prescriptions,² which can be a reasonable part of presumed viral illness management safety netting, yet are not reflected in the data because many will not be taken to a pharmacy and no read code for such a prescription exists in computerised note keeping systems. Furthermore, adherence to medication is very low³ and patient behaviours with green script in hand as they leave their surgeries suggest that many will not even take their prescription to a pharmacy and a huge chunk more will not take the medication at prescribed therapeutic doses. If the data from pharmacies does not reflect the indication for the prescription and cannot be linked to GP records, then is it possible to make public health inferences about the causes of antibiotic resistance being GP overprescribing of antibiotics for sore throats and viruses?

If patient behaviours determine that the observational prescribing data should be considerably discounted, then either microbiological resistance pathways are much worse than we think, or we cannot conclude much at all,...
Show More

I read the article on antibiotic overuse and resistance by Shallcross & Davies in last month’s BJGP¹ with interest and doubt many would debate the conclusions, but have been left wondering the degree to which the robustness of the data supports the overuse of antibiotics in primary care.

Many doctors may treat patients using delayed prescriptions,² which can be a reasonable part of presumed viral illness management safety netting, yet are not reflected in the data because many will not be taken to a pharmacy and no read code for such a prescription exists in computerised note keeping systems. Furthermore, adherence to medication is very low³ and patient behaviours with green script in hand as they leave their surgeries suggest that many will not even take their prescription to a pharmacy and a huge chunk more will not take the medication at prescribed therapeutic doses. If the data from pharmacies does not reflect the indication for the prescription and cannot be linked to GP records, then is it possible to make public health inferences about the causes of antibiotic resistance being GP overprescribing of antibiotics for sore throats and viruses?

If patient behaviours determine that the observational prescribing data should be considerably discounted, then either microbiological resistance pathways are much worse than we think, or we cannot conclude much at all, as we do not understand patient medication use behaviours, which is more relevant. It is very important that those reading such articles and related headlines understand there are considerable limitations and problems with the data upon which GPs could be held accountable for causing major medical problems, such as antibiotic resistance.

References

1.   Shallcross LJ & Davies SC. Antibiotic overuse: a key driver of antimicrobial resistance. Br J Gen Pract 2014; 64(629): 604-605.
2.   Arroll, B., Kenealy, T., Goodyear-Smith, F., Kerse, N. Delayed prescriptions. BMJ 2003, 327(7428), 1361-1362.
3.   Oxford Handbook of General Practice. Compliance. Oxford: Oxford Handbooks, 94–95.

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Competing Interests: None declared.

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