Antibiotic prescribing in England has fallen for the first time. Dr Bianca Potterton considers why
Antibiotic prescribing has fallen for the first time ever in England. Between April 2014 and December 2015, the number of antibiotics prescribed fell from 40.7 to 38.5 million – a reduction of 4.3%. The reversal reflects how policy has positively affected prescribing trends.
The reversal of trend sits against the policy background of the Antimicrobial Resistance Strategy 2013-2018, which was published in 2013, and the commissioning of the 2014 Review of Antimicrobial Resistance (the subsequent report by economist Jim O’Neil). It also follows the introduction of financial incentives to help curb antimicrobial prescribing introduced by NHS England/Public Health England and implemented by Clinical Commissioning Groups (CCGs): these financial incentives are set to continue as CCGs aim to reduce the number of antibiotics prescribed in primary care by 4%, or to the average performance levels of 2013/14.
This is fantastic news and reflective of a lot of hard work by clinicians on the frontline who have begun to change their prescribing habits. I personally have seen the difference in prescribing trends during the past eight years in which I have practised medicine. In my various hospital jobs prior to GP training, which included a year of acute medicine and four months of A&E, co-amoxiclav used to be handed out like smarties. Now, following the drive from the local CCG to reduce prescriptions for coamoxiclav, cephalosporins, and quinolones to 10% of the total number of antibiotics prescribed, there has to be an extremely good reason for prescribing it.
Following on from the recent guidance on antimicrobial stewardship, NICE is currently consulting on guidelines on prescribing for common infections. The guidelines intend to cover a list of common infections broken down into area of infection (bone and joint, CNS, eye, genital, intra-abdominal, upper and lower respiratory tract, sepsis, skin and soft tissue, urinary tract). The guidance may be used in addition to local CCG guidelines. It will be interesting to see what effect this guidance may have on prescribing habits.
I personally find guidelines helpful when justifying a decision not to prescribe to a patient or relative and already use local guidance in this respect.
In primary care, there are certainly areas where we can improve. Along with the frequent expectation of antibiotics for the viral URTI, I have noticed the widespread expectation from parents of small children for antibiotics for simple cases of otitis media and conjunctivitis (the red eye which has all too commonly disappeared by the time it has reached your consulting room). With conjunctivitis there seems to be an expectation from nurseries that children should be treated with antibiotics and we have much re-education to do in this respect. I also feel that we give out too many delayed scripts, e.g., for a developing tonsillitis – perhaps swayed by the patient’s view that “it is Friday and things may develop over the weekend”.
I hope that having national guidelines will promote prescribing consistency. We have all seen the case where an antibiotic may not be prescribed one day, only for the patient to visit a different doctor the next day who dutifully prescribes. Patients know this, and (especially in larger practices) can “shop around” to get what they feel they need. I would hope that national guidelines might help reduce this trend and promote consistency.
If we are to reduce antimicrobial prescribing down to 2013/14 levels, educating patients, relatives and carers is going to play a crucial role. I feel that national prescribing guidelines for common infections may help facilitate the discussion and would welcome them in this respect. Sometimes it’s easiest to sign a script. But if you consider that antimicrobial resistance is currently estimated to cause 50,000 deaths in Europe and the US, and 700,000 deaths worldwide, signing that script really could cause more harm than good.