The worldwide increase in resistance to antimicrobial drugs has made reducing the unnecessary use of antibiotics a public health priority. There have been campaigns in many countries to educate the public about appropriate use of antibiotics in outpatients. By use of a comprehensive search strategy and structured interviews, we were able to identify and review the characteristics and outcomes of 22 campaigns done at a national or regional level in high-income countries between 1990 and 2007. The intensity of the campaigns varied widely, from simple internet to expensive mass-media campaigns. All but one campaign targeted the public and physicians simultaneously. Most campaigns that were formally evaluated seemed to reduce antibiotic use. The effect on resistance to antimicrobial drugs cannot be assessed accurately at present. Although the most effective interventions and potential adverse outcomes remain unclear, public campaigns can probably contribute to more careful use of antibiotics in outpatients, at least in high-prescribing countries.

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(09)70305-6.pdf

Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries.

Pneumonia is an important cause of illness and death in England. To describe trends in pneumonia hospitalizations, we extracted information on all episodes of pneumonia that occurred from April 1997 through March 2005 recorded in the Hospital Episode Statistics (HES) database by searching for International Classification of Diseases 10th revision codes J12-J18 in any diagnostic field. The age-standardized incidence of hospitalization with a primary diagnosis of pneumonia increased by 34% from 1.48 to 1.98 per 1,000 population between 1997-98 and 2004-05. The increase was more marked in older adults, in whom the mortality rate was also highest. The proportion of patients with recorded coexisting conditions (defined by using the Charlson Comorbidity Index score) increased over the study period. The rise in pneumonia hospital admissions was not fully explained by demographic change or increasing coexisting conditions. It may be attributable to other population factors, changes in HES coding, changes to health service organization, other biologic phenomenon, or a combination of these effects.

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Increasing hospital admissions for pneumonia, England.

Objective: To determine the extent to which antibiotics reduce the risk of serious complications after common respiratory tract infections. 
Design: Retrospective cohort study. 
Setting: UK primary care practices contributing to the general practice research database. 
Data source: 3.36 million episodes of respiratory tract infection. 
Main outcome measures: Risk of serious complications in treated and untreated patients in the month after diagnosis: mastoiditis after otitis media, quinsy after sore throat, and pneumonia after upper respiratory tract infection and chest infection. Number of patients needed to treat to prevent one complication. 
Results: Serious complications were rare after upper respiratory tract infections, sore throat, and otitis media, and the number needed to treat was over 4000. The risk of pneumonia after chest infection was high, particularly in elderly people, and was substantially reduced by antibiotic use, with a number needed to treat of 39 for those aged 65 and 96-119 in younger age groups. 
Conclusion: Antibiotics are not justified to reduce the risk of serious complications for upper respiratory tract infection, sore throat, or otitis media. Antibiotics substantially reduce the risk of pneumonia after chest infection, particularly in elderly people in whom the risk is highest.

https://www.bmj.com/content/bmj/335/7627/982.full.pdf

Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15.7 to 12.6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5-14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

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Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme.

Objective To establish whether an interactive booklet on respiratory tract infections in children reduces reconsultation for the same illness episode, reduces antibiotic use, and affects future consulting intentions, while maintaining parental satisfaction with care.

Design Pragmatic cluster randomised controlled trial.

Setting 61 general practices in Wales and England.

Participants 558 children (6 months to 14 years) presenting to primary care with an acute respiratory tract infection (7 days or less). Children with suspected pneumonia, asthma or a serious concomitant illness, or needing immediate hospital admission were excluded. Three withdrew and 27 were lost to follow-up, leaving 528 (94.6%) with main outcome data.

Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients (and provide it as a take home resource). Clinicians in the control group conducted their consultations as usual.

Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period. Secondary outcomes included antibiotic prescribing, antibiotic consumption, future consulting intentions, and parental satisfaction, reassurance, and enablement.

Results Reconsultation occurred in 12.9% of children in the intervention group and 16.2% in the control group (absolute risk reduction 3.3%, 95% confidence interval −2.7% to 9.3%, P=0.29). Using multilevel modelling (at the practice and individual level) to account for clustering, no significant difference in reconsulting was noted (odds ratio 0.75; 0.41 to 1.38). Antibiotics were prescribed at the index consultation to 19.5% of children in the intervention group and 40.8% of children in the control group (absolute risk reduction 21.3%, 95% confidence interval 13.7 to 28.9), P<0.001). A significant difference was still present after adjusting for clustering (odds ratio 0.29; 0.14 to 0.60). There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness (odds ratio 0.34; 0.20 to 0.57). Satisfaction, reassurance, and parental enablement scores were not significantly different between the two groups.

Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care.

Trial registration Current Controlled Trials ISRCTN46104365

https://www.bmj.com/content/bmj/339/bmj.b2885.full.pdf

Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial

Background Antibiotic prescribing by general practitioners (GPs) increased in the 1980s and peaked in 1995. Prescribing volumes subsequently fell by over a quarter between 1995 and 2000, mostly accounted for by reduced antibiotic prescribing for acute respiratory illnesses. We aimed to investigate changes in consultation rates and the proportion of consultations with antibiotics prescribed for different types of respiratory tract infections. Methods Data were derived from108 UK general practices, covering a mean of 642 685 patients, reporting data to the General Practice Research Database (GPRD) continuously between 1994 and 2000. Outcome measures: annual ageand sex-standardized consultation rates for 11 different acute respiratory infections per 1000 registered patients and proportions of these consultations resulting in an antibiotic prescription. Results The standardized consultation rate for ‘any respiratory infection’ declined by 35 per cent from 422 to 273 per 1000 registered patients, per year. The largest relative reductions in consultation rates were observed for ‘common cold’ (50 per cent), ‘laryngitis’ (43 per cent) and ‘sore throat’ (43 per cent). The standardized proportion of consultations that resulted in an antibiotic prescription for ‘any respiratory infection’ declined from 79 per cent in 1994 to 67 per cent in 2000. The largest relative reductions in antibiotic prescribing rates occurred in patients recorded as suffering from ‘influenza’ (52 per cent), ‘upper respiratory tract infections’ (33 per cent) and ‘laryngitis’ (30 per cent). Overall, antibiotic prescriptions for all acute respiratory infections declined by 45 per cent. Conclusion The reduction in antibiotic prescribing in common respiratory infections between 1994 and 2000 has occurred partly because GPs are prescribing antibiotics less frequently when patients consult but mainly because there are fewer consultations with these conditions. Further work should aim to understand the reasons for the decline in consultations for respiratory infections and whether further reductions in antibiotic prescribing are feasible.

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Kate Cox

Papers

Why has antibiotic prescribing for respiratory illness declined in primary care? A longitudinal study using the General Practice Research Database