Antibiotic prescribing and resistance in primary care: implications for intervention

Background
Antibiotic resistance is an important societal health issue. The greatest risk factor for developing a resistant infection is antibiotic use. Almost 75% of all antibiotics in the UK are prescribed in the community, and mostly for acute respiratory tract infections (RTIs). Yet, the majority of RTIs are self-limiting, viral and do not need antibiotic treatment, especially in young children. While the effects of antibiotic-resistant infections have been widely studied in hospitals (e.g. the MRSA ‘superbug’), we know less about how antibiotic-resistant infections affect people in the community, even though this is where most antibiotics are prescribed. There is also widespread public misconception about antibiotic use and resistance despite several high-profile, multimillion antibiotic awareness campaigns. This is important to address because consultation behaviour and expectations for antibiotics are a significant determinant of antibiotic use in the community.
Methods
Three studies were conducted for this thesis. First, a systematic review and meta-analysis to assess the evidence of the impact of antibiotic resistance for patients with common infections in the community; second, a retrospective analysis of routinely collected primary care data to examine the relationship between antibiotic exposure and antibiotic “response failure” in preschool children presenting with acute RTIs; third, a qualitative interview study to explore parents’ perceptions and understanding of antibiotic use and resistance when they consider consulting in the community with their preschool child who has a respiratory tract infection.
Results
Antibiotic resistance significantly impacts on patients’ illness burden for common infections in the community. Patients who presented in community health care settings with antibiotic-resistant E. coli urinary tract infections and S. pneumoniae respiratory tract infections were more likely to experience delays in recovery after antibiotic treatment.
From routinely collected primary data (2009-2016), preschool children receiving two or more antibiotic courses in the previous year for acute RTIs had greater likelihood of antibiotic “response failure” to treatment for subsequent acute RTIs compared to children that had received no previous antibiotics.
When interviewing parents of young children, most parents were quite reticent about antibiotics for their children. However, very few considered antibiotic resistance as a possible harm of antibiotics. Parents thought their families were at low risk of antibiotic resistance because their families were “low users” of antibiotics and did not perceive any association between their individual consumption of antibiotics and the development and spread of antibiotic-resistant bacteria in the community. They wanted future antibiotic awareness campaigns to have a universal message relevant to their families that fit into their daily lives.
Conclusions
The findings challenge the perception that antibiotic prescribing and resistance in the community poses little or no additional risk to patients in the community, or is remote from everyday prescribing decisions. Rapid diagnostic tests and other prognostic tools need to be promoted and evaluated to better identify patients who might need an antibiotic, and reduce the risk antibiotic response failures. Clinicians and parents should exercise caution about whether further antibiotics for acute RTIs are likely to be beneficial in those children who have received two or more antibiotic prescriptions for acute RTIs during the previous 12 months. Incorporating this into clinical practice guidelines and decision-support systems will help clinicians and parents consider a non-antibiotic strategy for acute RTIs. Future guidelines, campaigns and interventions around antibiotic resistance should tailor initiatives to outcomes that patients and clinicians in the community can relate to and slot into their daily lives. More research is needed to evaluate the impact of other common infections in primary care, and determine the relative contribution of antibiotic resistance to patients not responding to antibiotic treatment for common infections.

Keywords: Primary Care
Ambulatory Care
Antibiotic resistance
Infection
Public Health
Advisor: Butler, C
Wang, K
Tonkin-Crine, S