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| Trends in the Prescribing of Antibacterial Drugs in General Practice in England (Chart 1) |
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The widespread use of antibiotics and the increasing prevalence of antimicrobial resistant micro-organisms have given rise to considerable international concern. In June 2000 the Government published the 'UK Antimicrobial Resistance Strategy and Action Plan'1 in response to the House of Lords Select Committee on Science and Technology's report 'Resistance to antibiotics and other antimicrobial agents'2. The UK Action Plan expands the action set out for the NHS in HSC 1999/049. This strategy includes measures ranging from developing, implementing and reviewing policies and guidelines on the management of infections and the appropriate use of antimicrobial drugs, through supporting continued professional development, to monitoring antimicrobial prescribing at health authority level and taking appropriate action to reduce inappropriate prescribing and variation.
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The aims of the Government's strategy are: in the face of the ability of micro-organisms resistant to antimicrobial agents to emerge and spread, the increasing prevalence of resistant strains and the dearth of new agents likely to be available for therapeutic use in the near future,
i. to minimise the morbidity and mortality due to antimicrobial resistant infection;
ii. to maintain the effectiveness of antimicrobial agents in the treatment and prevention of microbial infections in man and animals. |
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| Trends in Spending on Antibacterial Drugs in General Practice in England (Chart 2) |
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The strategy has 3 key elements to control antimicrobial resistance:
- Surveillance - monitoring and providing data
- Prudent antimicrobial use - reducing unnecessary and inappropriate exposure of micro-organisms to antimicrobial agents
- Infection control - reducing the spread of infection in general and antimicrobial resistant microorganisms in particular.
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| The extent of the problem of antimicrobial resistance was reviewed in a Drug and Therapeutics Bulletin in February 19994. Although the dynamics of the emergence, spread and maintenance of antibiotic resistance in populations are still unclear, the development of resistance has been linked to high consumption of antibiotics. A retrospective survey of Welsh GP practices showed that there was a correlation between antibiotic resistance in coliform organisms in urine samples and the use of antibiotics by a GP practice5. |
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The Department of Health co-ordinates the national professional education Campaign on Antibiotic Treatment (CAT) along the lines recommended by SMAC, 'Four things you can do to make a difference':
- No prescribing of antibiotics for simple coughs and colds
- No prescribing of antibiotics for viral sore throats
- Limit prescribing for uncomplicated cystitis to 3 days in otherwise fit women
- Limit prescribing of antibiotics over the telephone to exceptional cases.
To encourage realistic public expectations for antimicrobial prescribing the Department of Health will run a further publicity campaign - National Advice to the Public (NAP). They will also encourage the inclusion of antimicrobial resistance in the national curriculum.
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| Another initiative, which will help with this strategy, is that the Public Health Laboratory Service, in conjunction with PRODIGY have produced a draft antibiotic guidance document, which has been placed on their website (www.phls.co.uk/advice/Antibiotic%20guidance.htm). The template is designed so that the antibiotics and advice given may be changed to suit local circumstances, for example to reflect laboratory resistance data and cost. |
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| At the peak of prescribing in 1995, antibacterial usage was 5.7 DDD/inhabitant/year, that is equivalent to the treatment of every person in England with a 5.7-day course of an antibacterial drug. By 1999 this had fallen to the equivalent of a 4.7-day course. Charts 1 and 2 show National trends in the prescribing of antibacterial drugs over the last 7 financial years. The number of prescriptions for antibacterial drugs has fallen each year from a peak of 44.5 million items in 1995/6 to 34.2 million items in 1999/2000. The proportion of prescribing for each of the different groups of antibacterials in chart 1 has not changed during this time. Spending on antibacterial drugs for the last financial year was £170.5 million. |
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| The publication of the House of Lords report and the SMAC guidelines occurred during the financial year 1998/9. Prescribing of antibacterial drugs had already started to fall sharply and has continued to do so. By keeping antibacterial prescribing and antimicrobial resistance as a high priority with the publication of the UK Action Plan, this positive trend should continue. |
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| Penicillins remain the most commonly prescribed group of antibiotics with nearly 19 million prescriptions in 1999/2000 at a cost of £67 million. Since 1996/7 the prescribing of amoxycillin has fallen, but it still accounts for 60% of all penicillin prescriptions (11.3 million items) and 36% of costs (£24 million). Prescribing of flucloxacillin continues to increase and is now 14% of items (2.7 million) and 22% of costs (£14.6 million). Penicillin V prescribing has been falling since 1994/5 and is now 13% of items (2.4 million) and 10% of costs (£6.8 million). Co-amoxiclav although only 10% of prescribing (1.9 million items) is the second highest penicillin for cost (28%, £18.4 million). |
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| Macrolides are the second most commonly prescribed group of antibiotics at 4.6 million items and a cost of £29.5 million last year. Although prescribing of erythromycin has been falling since 1994/5, it is currently 81% of macrolide prescribing (3.7 million items) but just 58% of costs (£17 million). On the other hand clarithromycin at just 17% of prescribing (768,000 items) has costs of 38% (£11.2 million). The prescribing of clarithromycin started to decrease in 1997/8. |
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| Cephalosporins cost £16.9 million last year (3.2 million prescriptions). The most frequently prescribed cephalosporin is cephalexin at 40% of items (1.3 million) and 35% of costs (£6 million). Cefaclor is next at 25% of items (790,000) and 34% of costs (£5.8 million). The third most commonly prescribed is cephradine at 13% of items (419,000) and 15% of costs (£2.6 million). |
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| Tetracyclines prescribing has fallen over the last 7 years to 2.6 million items with costs of £24.4 million. The most commonly prescribed tetracycline is oxytetracycline with 46% of items (1.2 million) and just 16% of costs (£4 million). Minocycline is only 19% of tetracyclines prescribing (494,000 items) but 63% of the costs (£15.3 million). Doxycycline is 27% of the prescribing (717,000) with 17% of the costs (£4.1 million). |
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| Quinolone prescribing began to decline 2 years ago. Nationally 80% of quinolone prescriptions are for ciprofloxacin (905,000 items and £15.3 million i.e. 84% of costs). Chart 3 shows the health authority variation in quinolone spending. Overall there is a 3.5 fold variation between the health authorities with no particular geographical pattern. There is a large difference between the 99 English health authorities in the percentage spent per 1,000 antibacterial STAR(97)-PUs on ciprofloxacin, ranging from 52% to 97% of all quinolone spending. |
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Variation Between Health Authorities in Quinolone Spending
(April 1999 - March 2000, Chart 3) |
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| All other antibacterial groups i.e. those not mentioned above accounted for 4 million items (£14.5 million) in 1999/2000. The prescribing of co-trimoxazole has fallen dramatically over the last 7 years from 1.6 million items to 52,000 items with a cost of £364,000 for the year 1999/2000. Trimethoprim prescribing has remained fairly constant over the last 5 years and is currently 2.7 million items (£2.6 million). The prescribing of trimethoprim 200mg tablets has been analysed, using National paper PACT, to determine the percentage of prescriptions that have been written for 6 x 200mg tablets i.e. a 3 day course. There has been a definite move towards 3 day courses as recommended in the SMAC guidelines; 5% in 1997/8, 11% in 1998/9 and 16% in 1999/2000. |
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References
1. UK Antimicrobial Resistance Strategy and Action Plan. www.publications.doh.gov.uk/arbstrat.htm
2. House of Lords Select Committee on Science and Technology. Resistance to antibiotics and other antimicrobial agents. HMSO, 1998.
3. Standing Medical Advisory Committee on Antimicrobial Resistance. The Path of Least Resistance. Department of Health, 1998.
4. Anonymous. Drug & Therapeutics Bulletin 1999; 37:9-16.
5. Magee JT et al. Antibiotic prescribing and antibiotic resistance in community practice: retrospective study, 1996-98. BMJ 1999; 319:1239-40.
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Summary
- Maintaining the effectiveness of antimicrobial agents in the treatment and prevention of microbial infections is vital
- Unnecessary use of antibiotics is likely to lead to increased antibiotic resistance
- Do not prescribe antibiotics for simple coughs and colds
- Do not prescribe antibiotics for viral sore throats
- Limit prescribing for uncomplicated cystitis to 3 days in otherwise fit women
- Limit prescribing of antibiotics over the phone to exceptional cases
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