More than a fifth of antibiotic prescriptions in primary care in England could be ‘inappropriate’, researchers find

There is “substantial” inappropriate antibiotic prescribing in primary care in England, particularly for respiratory tract conditions, according to research by Public Health England^[1]
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The research, published in a five-article supplement for the Journal of Antimicrobial Chemotherapy, attempted to quantify the extent of inappropriate prescribing in primary care in the UK, and identify the contributory factors, such as different clinical syndromes and conditions.

In the most conservative scenario, it was found that 8.8% of all antibiotic prescriptions in primary care in England were deemed inappropriate. In the least conservative scenario, 23.1% of prescriptions were found to be inappropriate.

It was found that most antibiotics were prescribed for conditions that only sometimes require antibiotic treatment, depending on patient-specific indicators. The majority of these prescriptions in primary care in England were for respiratory or urinary tract infections.

No clinical justification was documented in a third of all prescriptions, and prescribing of antibiotics varied substantially between practices.

The researchers also found that the majority of practice-level variation in antibiotic prescribing could not be explained by variation in the prevalence of comorbidities. They highlighted that factors, such as high consultation rates for respiratory tract infections and high prescribing rates for corticosteroids, could explain much of the variation, and as such may be considered in determining a practice’s potential to reduce prescribing.

According to the researchers, this work demonstrates the existence of substantial inappropriate antibiotic prescribing and poor diagnostic coding in English primary care. All GP practices, not just the high prescribers, should engage in efforts to improve antimicrobial stewardship.

Better diagnostic coding, more precise prescribing guidelines and a deeper understanding of appropriate long-term uses of antibiotics would allow identification of further potential for reductions, they said.

Elizabeth Beech, antimicrobial resistance spokesperson for the Royal Pharmaceutical Society, said that finding variation in antibiotic prescribing was not new, and that the responsibility for reducing inappropriate antibiotic prescribing does not lie solely with GPs.

“There is no single solution — it’s a bundle — we need an educated healthcare workforce, clear guidelines and implementation of those guidelines, and good data on what prescribing should look like,” she said.

“It’s not about ‘bad GPs’; we need a system-wide approach engaging all clinicians — including pharmacists and those working in community services, out-of-hours and urgent-care services and A&E. We need engagement right across the whole healthcare system to help deliver this reduction.

“And we need consistent messaging on antibiotics wherever a patient meets a healthcare professional, educating patients and their families about appropriate use of antibiotics.”

Beech added that since the NHS England Quality Premium (QP) improvement scheme for AMR was introduced in 2015–2016, clinical commissioning group pharmacists had introduced antimicrobial stewardships resources across a range of healthcare settings.

This resulted in a large reduction of inappropriate antibiotic prescribing, with four million fewer antibiotic items prescribed and dispensed — a 10.8% reduction since the start of the QP initiative, she said.

Helen Stokes-Lampard, chair of the Royal College of General Practitioners, described the findings as “extremely disappointing”, but said they must not be used as an excuse to criticise GPs.

“Antimicrobial resistance is now a major global health threat and responsibility for tackling this does not lie solely at the door of GPs — the whole of society must play its part,” she added.