Personal View
The role of evidence in the decline of antibiotic use for common respiratory infections in primary care

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Summary

Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a “one size fits all” mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.

Introduction

In the UK, 80% of all antibiotic prescriptions are from primary health-care.1 Most patients consulting in primary care present with respiratory tract infections,2 and these conditions are commonly treated with antibiotics.3 In this Personal View, we examine the changing trends in infectious disease, primary-care consulting behaviour, and antibiotic prescribing. We then explore the influence that primary-care research has had on these trends, and how this research has led not only to fundamental changes in the way infectious diseases are managed, but also to changes in the very structure of primary care in more developed countries. Finally, we consider the consequences of overprescribing or underprescribing antibiotics and how future research can best address the complex challenges that lie ahead.

Section snippets

Overestimating the role of antibiotics in the management of common infections

The 20th century witnessed a pronounced decline in infectious disease mortality. Although not unrelated to Sir Alexander Fleming's discovery of penicillin, this decline was mainly the result of improvements in a number of social determinants of health—for example, diet, housing, and sanitary water.4, 5, 6, 7, 8, 9, 10, 11 Penicillin did, however, revolutionise the management of many serious infectious diseases.12 Nevertheless, the striking results seen in the treatment of these serious

Research evidence from primary care and declining trends in antibiotic prescribing

By 1976, primary-care researchers began challenging the consensus that outcomes in common infections were generally improved by antibiotic treatment. Stott and West18 published a landmark randomised controlled trial showing that otherwise healthy adults with acute cough and productive or discoloured sputum did not benefit from treatment with tetracycline. Table 1 summarises the meta-analyses of trials of antibiotics from the Cochrane Library for a range of common infections, and shows the

Emerging evidence and the changing organisation of primary care

Acute upper respiratory tract infections were the most common diagnoses in emergency department visits in the USA between 1992 and 2002,40 with 38–50%38, 41 of patients prescribed an antibiotic; however, these prescriptions were often inappropriate. For example, a retrospective study of 22 million influenza visits to ambulatory clinics and emergency departments in the USA found that 26% of antibiotic prescriptions were inappropriate.42 Similarly, the most common reason for consulting a GP in

Explanations for the decline in use of antibiotics

Three main hypotheses have been offered to explain the decline in antibiotic dispensing in the community, each of which underscores the crucial importance of the role of research evidence from primary care. We suggest that a combination of all three of the following factors is at play.

First, researchers suggest reduction in incidence and severity of common infections. Fleming and colleagues55 argue that a reduction in the incidence (or severity) of common infections from 1995 to 2000 resulted

Has the use of antibiotics reduced too far?

Some physicians fear that reducing consultations and antibiotic treatment for common infections has begun to harm patients by allowing complications caused by these illnesses to increase. For example, a UK-based GP recently wrote that based on his 30 years of experience, he believes that requests by academics and the government to use fewer antibiotics has led to increases in respiratory tract infections and death.61 To summarise his challenge to researchers: why do patients who get very ill

Challenges on the front line

Decisions about antibiotic use are not easy for physicians, patients, or policymakers. Many competing factors need to be balanced (panel 1), and physicians are often challenged with pitting the interests of individual patients against larger societal concerns—for example, antibiotic resistance. Furthermore, physicians must do this without an adequate evidence base to support accurate diagnosis and prognosis. Several studies have shown that in the minds of physicians, the needs of individual

Choosing targets for reductions in antibiotic use

There is considerable variation in prescribing rates between countries and between individual practices within countries. For example, in 2002, substantially more patients in the UK were prescribed antibiotics compared with the Netherlands (unpublished data, Welsh Common Infections Study Group, Cardiff University, Cardiff, UK). However, should all practices strive to prescribe at the levels achieved in the Netherlands, currently enjoying the lowest rates of antibiotic prescribing and resistant

Changing prescribing behaviour

There is no universal intervention that will work in changing prescriber behaviour.97 Some infections require interventions to reduce antibiotic prescribing more than others,98, 99 and high prescribers may require different types of interventions to low prescribers.100 Standardised messages provide a disservice to physicians who have already reduced use as much as they feel is safe. The barriers to change are variable and often context dependent, and interventions need to take this into account.

Conclusions

Antibiotics can be life-saving drugs, but their overuse may lead us back to a time when many serious infections could not be treated.107, 108 Primary-care research has identified the limited benefits that antibiotics have for otherwise healthy people with common respiratory tract infections. This research has led to fundamental changes in the clinical management of these conditions and has influenced the organisation of primary health-care delivery, resulting in reduced antibiotic prescribing.

Search strategy and selection criteria

Data for this Personal View were identified by searches of Medline, PsycINFO, Google Scholar, the Cochrane library, and references from relevant books, articles, and reports, including the files collected by the authors. Literature search terms included “determinants of health”, “common infections”, “antibiotics”, “upper respiratory tract infections”, “cough”, “sore throat”, “trends”, “primary care”, “resistant”, “prescribing”, and “developed countries”. Only English language articles

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