PACT Centre Pages - ANTIBACTERIAL DRUGS


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Several policy documents about healthcare-associated infection and antimicrobial resistance have now been produced to support efforts to reduce unnecessary prescribing of antibiotics and to slow the advance of antimicrobial resistant microorganisms, for example:

• The Standing Medical Advisory Committee’s report - UK Antimicrobial Resistance Strategy and Action Plan. June 2000.


• The Chief Medical Officer’s strategy for combating infectious diseases - Getting Ahead of the Curve. January 2002.


• The Chief Medical Officer’s report - Winning Ways. December 2003.

Antibiotic resistance is still making many infections difficult to treat. Winning Ways identifies the prudent use of antibiotics as a key area and includes the following action points:

• Antibiotics will normally be used only after a treatable infection has been recognised or there is a high degree of suspicion of infection.


• Antibiotics will only be taken by patients over the prescribed period at the correct dose.


• Prescription of antibiotics for children will be carefully considered; they are often unnecessarily prescribed for common viral infections and the child is subsequently more likely to develop a resistant infection.


• Antibiotics will be used for prevention of infection only where benefit has been proven.⁴

Handwashing by healthcare staff is vitally important in the control of infection.⁴ NICE guidelines address prevention of healthcare-associated infection in primary and community care settings. Hand hygiene is an important principle, hands must be decontaminated immediately before every episode of direct patient contact and after activity that could potentially result in hands becoming contaminated. If hands are visibly soiled, or potentially contaminated with dirt or organic material, they must be washed with liquid soap and water.⁵

The Health Protection Agency (HPA) infection guidance for primary care can be used for consultation and local adaptation to take account of bacterial sensitivities. Principles of the guidance include not prescribing antibiotics for viral sore throats, simple coughs and colds; avoiding the use of new and more expensive antibiotics (e.g. quinolones) when standard and less expensive antibiotics remain effective; and avoiding widespread use of topical antibiotics.⁶

Watchful waiting is advocated in acute otitis media. In three meta-analyses with various sample sizes, spontaneous resolution occurred in 2-14 days in 80% of children.⁷ A poor outcome is unlikely if there is no vomiting or temperature is below 37.5°C.⁸ Simple painkillers reduce associated earache.

New evidence confirms that most patients do not benefit from antibiotics for sore throat. 156 children aged between 4-15 years with a sore throat for less than seven days and two of the four Centor criteria (history of fever, absence of cough, swollen tender anterior cervical lymph nodes and tonsillar exudate) received phenoxymethylpenicillin for three or seven days or placebo.⁹ Phenoxymethylpenicillin treatment had no beneficial effect on reducing symptom duration or the consumption of analgesics. The number of school days missed and recurrence of sore throat were similar in both treatment and control groups.

A recent trial investigated the effectiveness of interventions to reduce antibiotic prescribing for respiratory tract symptoms in primary care. The interventions employed were: group education meetings for GPs’ and pharmacists’ “assistants”; a consensus procedure on indication for and type of antibiotics for acute otitis media, sinusitis, tonsillitis and acute cough, with training in communication skills; monitoring and feedback on prescribing behaviour; and education material for patients. The control group did not receive these measures. After nine months the prescription rates in the intervention group fell to 23% (baseline 27%) whereas the control group rose to 37% (baseline 29%).¹⁰

New diagnoses of sexually transmitted infections (STIs) in genitourinary medicine (GUM) clinics increased by 4% to 708,083 in 2003. HPA figures show chlamydia is the most commonly diagnosed STI, new cases rose by 9% between 2002 and 2003 (82,558 to 89,818) for England, Wales and Northern Ireland. Untreated chlamydial infection can lead to pelvic inflammatory disease and subsequent infertility. Patients with symptoms which could be attributable to chlamydial infection should be tested. Patients who attend a GUM clinic, those with another STI and women undergoing termination of pregnancy should also be tested. Ten opportunistic screening programmes for chlamydia were implemented in 2002, with a further 16 programmes announced in January 2004. Screening now covers over 25% of PCTs in England. Treatment for chlamydia includes doxycycline, azithromycin, erythromycin or oxytetracycline.⁶ There is no strong evidence available to suggest that one of these drugs is anymore effective than the others. A systematic review found no significant difference between doxycycline and azithromycin in curing chlamydial infection.¹¹

Since 2001/02 the Healthcare Commission performance ratings for Primary Care Trusts have included an indicator for prescribing of antibacterial drugs measuring the number of antibacterial drug items/antibacterial STAR-PU. The number of items is expected to decrease as strategies to slow the advance of resistant antimicrobial agents are implemented. However, in over half of strategic health authorities prescriptions for antibacterial drugs increased between 2002/03 and 2003/04 (Chart 3).

Macrolides are the second most commonly prescribed group of antibiotics in the year to June 2004 (4.1 million items, £31.0 million). Erythromycin accounts for 78% of all macrolides (3.2 million items, £16.0 million) but its prescribing has decreased by 20% over the past 5 years. During the same period prescribing of clarithromycin decreased by 12%. Azithromycin accounts for only 2% and 7% of total macrolide prescribing and spending.

REFERENCES

1. Health Protection Agency website. www.hpa.org.uk
2. Fleming D. M, Ross A. M, Cross K. W, Kendall H. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. British Journal of General Practice 2003; 53: 778-783
3. Kendall H, Holdsworth S, Sharland M. GP antibiotic prescribing for children in England has halved in last decade. Arch Dis Child 2004; 89 (Suppl 1): A1
4. Department of Health. Winning Ways: Working together to reduce Healthcare Associated Infection in England. December 2003
5. National Institute for Clinical Excellence. Infection control, prevention of healthcare-associated infection in primary and community care. Clinical Guideline 2, June 2003
6. Health Protection Agency. Management of infection guidance for primary care. November 2003 www.hpa.org.uk/infections/topics_az/
   antibiotic_guidance/antibiotic_guidance_290404.pdf
7. Rovers M. M, Schilder A. G. M, Zielhuis G.A, Rosenfeld R.M. Otitis media. Lancet 2004; 363: 465-473
8. Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002; 325: 22-26
9. Zwart S, Rovers M.M, De Melker R.A, Hoes A.W. Penicillin for acute sore throat in children: randomized, double blind trial. BMJ 2003; 327:1324-1328
10. Welshcen I, Kuyvenhoven M, Hoes A, Verheij T. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ 2004; 329: 431-435
11. Clinical Evidence freelance writers. Chlamydia (uncomplicated, genital). Clinical Evidence 2004; 11: 2064-2072

• Antimicrobial resistance continues to be a problem which can be addressed by reducing unnecessary antibiotic prescribing, particularly for children.⁴
• Watchful waiting is advised for otitis media in children, little benefit is gained from initial antibiotic treatment.⁷
• Suitable treatments for chlamydial infection include azithromycin, doxycycline, erythromycin or oxytetracycline.⁶
• The use of new and more expensive antibiotics should be avoided where less expensive, standard antibiotics are effective. ⁶