Antibiotic Prescriptions Often Exceed Recommended Treatment Durations

By Will Boggs MD

NEW YORK (Reuters Health) - Many antibiotic prescriptions for common infections in primary care exceed durations recommended by guidelines, according to a new study.

"Given that we excluded chronic and recurrent episodes, I expected that only a small percentage of prescriptions would exceed the guideline recommendation," said Dr. Koen B. Pouwels of Public Health England, in London.

"The fact that results were very similar after excluding patients with comorbidities or prior use of corticosteroids or immunosuppressive drugs suggests that longer courses may not have been driven by individual patient factors indicating a clinical need for prolonged treatment," he told Reuters Health by email.

Much of the effort to support antibiotic stewardship has aimed at starting antibiotic treatments only when clearly indicated or changing the choice of drug for specific conditions. Little attention has been given to minimizing unnecessarily prolonged treatment, Dr. Pouwels and his colleagues note in The BMJ, online February 27.

The team used data from The Health Improvement Network, a U.K. primary-care electronic database, to assess the durations of antibiotic courses prescribed for common infections.

They included 13 indications whose recommended treatment durations ranged from three days (acute cystitis in nonpregnant females) to 28 days (acute prostatitis).

Among more than 900,000 consultations for these indications that led to antibiotic prescriptions, the most common were acute cough and bronchitis (41.6%), acute sore throat (25.7%), acute otitis media (8.9%), acute sinusitis (8.2%), cellulitis (5.9%) and acute cystitis (5.7%).

For all conditions combined, about 1.3 million days beyond the durations recommended by guidelines were prescribed, mostly due to respiratory indications (approximately 1.1 million excess days).

Prescriptions for acute cough and bronchitis and acute otitis media exceeded the recommended durations by a median of two days, those for acute sinusitis by three days, those for cellulitis by seven days and those for acute cystitis by four days for females and seven days for males.

There was also evidence of undertreatment: 52.3% of prescriptions for acute prostatitis were for less than the recommended 28 days (and 26.0% for less than 14 days), and 31.8% of prescriptions for acute cystitis in males were for less than the recommended seven days.

The percentage of prescriptions beyond the recommendation was substantially lower for conditions where guidelines recommend longer durations than for conditions where guidelines recommend a relatively short duration.

"Poor guideline adherence may be a result of several factors," Dr. Pouwels said. "This may include lack of awareness and skepticism of specific guideline recommendations."

"It is therefore important that GPs are aware of the recently published new NICE guidelines that were developed in collaboration with Public Health England," he said. "These guidelines are based on the best available evidence, which increasingly indicates that for many conditions shorter durations than previously recommended are safe and effective to use. I would encourage GPs to take the revised guidelines (https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/antimicrobial-prescribing-guidelines) into account when prescribing antibiotics."

"Another factor that may play a role, and has been observed to play a role in certain hospital settings, is that software automatically suggests a longer duration than necessary when prescribing certain antibiotics," Dr. Pouwels said. "In addition, pack sizes, i.e., the number of pills per package, could influence treatment durations. Such system factors could be addressed by changing standard pack sizes and using software in smarter ways to suggest durations that are in line with the most recent guidance."

He added, "Furthermore, in follow-up work we are currently trying to better understand the reasons why prescribers are deviating from guideline recommendations. The results of that work could potentially be used to develop interventions and support tools that could potentially help in reducing unnecessary long antibiotic courses."

Dr. Bent Hakan Lindberg of the University of Oslo and Hamar Out-of-Hours primary-care center, in Norway, recently examined factors correlated with antibiotic prescribing for acute respiratory tract infections in Norwegian primary-care after-hours service. He told Reuters Health by email, "More research is needed on why doctors don't adhere to guidelines."

"For government and other stakeholders," Dr. Lindberg, who was not involved in the study, recommended "a mandatory diagnosis field on each prescription, with an automatically generated question from the computer about duration of treatment if it exceeds the recommended duration."

In an accompanying editorial, Dr. Alastair D. Hay from Bristol Medical School at the University of Bristol, U.K., writes, "Both clinicians and patients may need convincing to abandon longer courses of antibiotics, and future campaigns by Public Health England to 'Keep Antibiotics Working' could usefully emphasize that when antibiotics are needed, shorter courses are sufficient to kill bacteria and less harmful than longer courses. Also, that some symptoms should be expected to persist beyond the end of the course, in some cases for up to four weeks."

SOURCE: https://bit.ly/2UqlaZk and https://bit.ly/2ISFVLR

BMJ 2019.

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