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| Trends in the Prescribing of Antibacterial Drugs in General Practice in England (Chart 1) |
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Combating the increasing prevalence of antimicrobial resistant micro-organisms continues to be a priority for the NHS. Following the work of the House of Lords Select Committee and the Standing Medical Advisory Committee (SMAC) in 1998, the Department of Health published the UK Antimicrobial Resistance Strategy and Action Plan in June 2000.1 It identifies 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 micro-organisms in particular.
In January 2002 the Chief Medical Officer produced his strategy for combating infectious diseases: Getting Ahead of the Curve.2 Actions proposed in the strategy include: a new National Infection Control and Health Protection Agency; a strengthened and expanded system of infectious disease surveillance; rationalisation of microbiology laboratories; a programme of new vaccine development; better public information and stronger professional education and training.
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Antibacterial drugs is one of the few areas where prescribing, and therefore cost, is decreasing (charts 1 and 2). Prescribing began to fall in 1996/97, which was before the publication of the reports and strategy documents. In the last 3 years although the number of items has continued to fall, the rate of decrease has slowed. On current evidence, efforts to reduce unnecessary prescribing could continue in the UK without greatly increasing the risk of complications from bacterial infections that have not been treated early with empirical antibiotics. Obviously measures to prevent the spread of antimicrobial resistance must not lead to patients being denied antibiotics when they are indicated. The NHS Performance Indicators for Primary Care Organisations 2001/02 include an indicator for prescribing of antibacterial drugs that measures the number of antibacterial drug items/antibacterial STAR-PU. This is included as an indicator of good practice. Spending on antibacterial drugs has been falling except in 1999/00 when the prices of many generic products rose. Following the introduction of the maximum price scheme for generic drugs in August 2000, the trend to lower cost has been restored.
Although GPs can readily identify situations when an antibiotic is not needed, it can still sometimes be difficult to avoid prescribing. Patients are usually aware that colds and most coughs do not require antibiotic treatment. However GPs are still faced with requests for antibiotics which may be inappropriate for example for acute otitis media or sinusitis. More evidence is now available as to when to use antibiotics in these conditions and when "watchful waiting" would be appropriate. In acute otitis media, children who do not experience fever and vomiting gain little benefit from antibiotic treatment and a poor outcome is unlikely if antibiotics are witheld.3 PRODIGY guidance recommends that in adults with acute sinusitis antimicrobials are reserved for those with severe symptoms or persistent symptoms of at least 7 days' duration.4 Patients who experience an exacerbation of chronic obstructive pulmonary disease are only likely to benefit from antibiotics if they have increased purulent sputum and dyspnoea.5 The UK antimicrobial resistance strategy includes a public information campaign as one of its key actions.1 Studies from the US have shown that targeted educational interventions aimed at physicians and families simultaneously can reduce antibiotic use among children.
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| Trends in Spending on Antibacterial Drugs in General Practice in England (Chart 2) |
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Improving patient care will also sometimes require increased prescribing of antibiotics, for example treating chlamydia trachomatis infection. This is now the most commonly diagnosed sexually transmitted infection. Chlamydial infection is frequently asymptomatic but can have severe consequences such as pelvic inflammatory disease and tubal damage, which may lead to infertility and increases the risk of ectopic pregnancy. Diagnostic testing should be offered to all men and women who present with symptoms suggestive of chlamydial infection. It is also recommended for all attendees at genitourinary medicine clinics and for women seeking termination of pregnancy. If the chlamydia test result is positive, partner notification is an essential part of follow-up management.8 A pilot of opportunistic screening in women under 25 years is being extended to a further 10 sites.9 The strongest evidence supports prescribing doxycycline or azithromycin for eradication of chlamydia. Alternatives include oxytetracycline and erythromycin. Azithromycin is given as a single dose of 1g whereas doxycycline 100mg should be taken twice a day for 7 days.10, 11 For these dose regimens azithromycin costs £7.33 compared to £2.92 for doxycycline.
Guidance on appropriate antibiotics (with information on dose and duration of treatment) for the infections commonly seen in primary care can be found on the Public Health Laboratory Service (PHLS) website.11 The guidance is evidence-based and can be adapted to take into account local information on bacterial sensitivity. Newer more expensive antibiotics are not usually recommended since there are few infections where they would be more cost-effective than older antibiotics. Co-amoxiclav, for example, is only recommended for second line use in acute exacerbations of COPD and the guidance does not recommend it for other lower respiratory tract infections.11 Spending on co-amoxiclav varies considerably (6.7-fold) across the former health authorities whereas spending on amoxycillin shows less variation (2.4 fold) (chart 3). Most health authorities in the former Regions of Northern and Yorkshire, Trent and London have below average spending on co-amoxiclav. These areas would not be expected to have lower rates of infection and the most likely explanation is that effective action has been taken to reduce co-amoxiclav prescribing.
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| Penicillins are the most commonly prescribed antibiotics (18.2 million items in 2001/02, £53.7 million). Use of penicillins has decreased from the peak of prescribing in 1995/96 except for flucloxacillin prescribing which has increased. 60% of all penicillin items are for amoxycillin, 17% for flucloxacillin, 13% for penicillin V and only 9% for co-amoxiclav. Last year more was spent on co-amoxiclav (£16.6 million) than on amoxycillin (£15.8 million). Flucloxacillin accounts for 24% of penicillin cost and penicillin V for 11%. |
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| Macrolides are the second most commonly prescribed group of antibiotics (4.2 million items in 2001/02, £28.9 million). Erythromycin prescribing has decreased to 3.4 million items (80% of all macrolides) and its cost has also fallen to £15.8 million. Although prescribing of clarithromycin is decreasing (0.7 million items), its cost has risen over the last 2 years to £11.8 million in 2001/02. Only 2% of macrolide items are for azithromycin and this is 4% of cost. |
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| Cephalosporin prescribing has changed very little in the last 2 years (3.1 million items in 2001/02) however cost has decreased to £14.6 million. Cephalexin is the most often prescribed (59% of all cephalosporin items, 36% of cost) followed by cefaclor (22% of items, 34% of cost). |
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| Tetracycline prescribing has also shown little overall change (2.5 million items in 2001/02, £22.4 million). There were 1.1 million items for oxytetracycline, 0.7 million for doxycycline and 0.46 million for minocycline. The latter is considerably more expensive than oxytetracycline or doxycycline. Spending on these 3 antibiotics was £3.1 million, £3.8 million and £14.2 million respectively in 2001/02. |
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| Quinolones are prescribed less often than the other major groups of antibacterial drugs (1.1 million items, £18.8 million in 2001/02). The PHLS guidance only recommends quinolones for first line use in infections where they are more effective than other agents such as in acute prostatis or acute pyelonephritis.11 This is to reduce the risk of resistance and other drugs are usually more cost-effective. Ciprofloxacin accounts for 83% of prescribing and 86% of cost. |
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Trimethoprim prescribing has remained steady over the last few years (2.7 million items, £2.3 million in 2001/02). There has however been an increase in the number of prescriptions written for 6 x 200mg tablets i.e. a 3-day course. 18% of all prescriptions for 200mg tablets were for a 3-day course in the quarter to March 2002. This suggests that GPs are following the SMAC recommendation to limit prescribing for uncomplicated cystitis to 3 days in otherwise fit women.
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Variation Between Health Authorities in Spending
(April 2001 - March 2002, Chart 3) |
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References
- Department of Health. UK Antimicrobial resistance strategy and action plan. June 2000; For more information click here
- Department of Health. Getting ahead of the curve. January 2002; www.publications.doh.gov.uk/cmo/idstrategy/index.htm
- Little P et al. Predictors of poor outcome and benefits from antibiotics in children with otitis media: pragmatic randomised trial. BMJ 2002; 325: 22-26
- PRODIGY guidance - sinusitis. July 2002
- Scottish Intercollegiate Guidelines Network. Community management of lower respiratory tract infection in adults. June 2002; SIGN Publication No. 59.
- Finkelstein JA et al. Reducing antibiotic use in children: a randomized trial in 12 practices. Paediatrics 2001; 108: 1-7
- Perz JF et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA 2002; 287: 3103-3109
- Department of Health. Summary and conclusions of CMO's Expert Advisory Group on Chlamydia Trachomatis. November 2001; Click here for more information.
- Department of Health. The national strategy for sexual health and HIV. Implementation and action plan. June 2002; www.dh.gov.uk/assetRoot/04/06/55/43/04065543.pdf
- Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Clinical effectiveness guideline for the management of Chlamydia trachomatis genital tract infection. July 2002; www.agum.org.uk/ceg2002/c4a0901c.htm
- Public Health Laboratory Service. Management of infection guidance for primary care. March 2002; For more information click here.
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Summary
- Reducing unnecessary antibiotic prescribing is a key element in combating the spread of antimicrobial resistance.
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In acute otitis media, children who do not experience fever and vomiting gain little benefit from antibiotic treatment.
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In adults with acute sinusitis, antibiotics should be reserved for those with severe symptoms or persistent symptoms of at least 7 days' duration.
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Chlamydia trachomatis infection is the most commonly diagnosed sexually transmitted infection. Prescribe doxycycline or azithromycin first line for eradication of chlamydia.
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It is not cost-effective to prescribe co-amoxiclav first line for lower respiratory tract infections.
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| Prescribing and Spending on Antibacteria; Drugs in England for Quater to September 2002 |
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Quarter to September 2002
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National
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Items/1000 PUs
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Cost/1000 PUs |
Amoxycillin
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28.55
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42.72 |
Co-amoxiclav
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5.44
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57.8 |
Clarithromycin
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2.27
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39.55 |
Erythromycin
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10.39
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53.42 |
Doxycycline
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2.30
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12.77 |
Minocycline
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1.65
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55.96 |
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