Antibiotic resistance – a problem for everyone
Published in MedicineWise News
Date published: About this date
- Recent antibiotic use increases the risk of antibiotic resistance in individuals
- Effective patient communication can improve antibiotic prescribing
- Respiratory tract infections: when is medical imaging appropriate?
- Case Study 72: Management of rhinosinusitis
- Symptomatic management pad and patient communication tool orders page (or you may wish to use our interactive PDF)
Few people are better placed to address the problem of antibiotic resistance than GPs. Continued improvements in prescribing practice and a positive influence on individual and community beliefs will be essential to limit the spread of antibiotic resistance. In this issue of NPS News, we review the latest evidence about individual antibiotic resistance and using patient-centred communication to improve prescribing.
Antibiotic resistance is a public health issue…
The widespread use of antibiotics promotes antibiotic resistance. As a consequence standard treatments become ineffective, and infections persist and may spread to others.1
The burden of antibiotic resistance is shared by the community. Infections caused by resistant bacteria need to be treated with costly second- and third-line antibiotics. Surgical procedures, cancer chemotherapy and organ transplantation may be compromised. In emphasising the scale of the problem, the World Health Organization recently warned of a return to the pre-antibiotic era if bacterial resistance to antibiotics continues to develop unabated.1
Resistance can persist within populations.2,3 So to preserve the effectiveness of antibiotics, and minimise the prevalence of resistance when it does emerge, prescribers are advised to use an antibiotic:
- when benefits to the patient are likely to be substantial
- of the narrowest spectrum to treat the likely pathogen, as recommended by local guidelines and pathology providers
- at the appropriate dose and for the appropriate duration.4
…but does it influence your decision to prescribe?
Qualitative data suggest that antibiotic resistance ranks low on the list of factors influencing GPs' decisions to prescribe an antibiotic.5-7They may question the importance of resistance because it falls beyond the realm of their personal experience.
In the UK, interviews with GPs revealed that more than a quarter were unclear about what they, as individuals, could do about antibiotic resistance.7 Some felt that there is a lack of evidence linking their prescribing behaviour to emerging antibiotic resistance.
But results from studies examining patient data make the case clearer. Prescribing a routine course of antibiotics significantly increases the likelihood of an individual carrying a resistant bacterial strain.8,9
An observational study in Australia found that recent use of antibiotics increased the carriage of resistant strains of pneumococcus in young children.8 Those prescribed a penicillin or cephalosporin in the two months before a nasal swab were twice as likely to carry penicillin-resistant respiratory bacteria as children not prescribed an antibiotic (odds ratio [OR] 2.03; 95% confidence interval [CI] 1.15 to 3.56). Among the children who had not taken an antibiotic in the previous six months, 12% carried penicillin-resistant pneumococci, which the authors suggest were acquired in the community.
Resistance genes compound the risk
An observational study conducted in the UK demonstrated increased carriage of a transferable resistance gene in bacterial isolates from children prescribed a beta-lactam antibiotic in the community.9
About one third of children presenting with otitis media or a suspected respiratory infection tested positive for a resistance gene (ICEHin1056) that circulates among nasopharyngeal Haemophilus species. After two weeks, the resistance gene was present in 67% of children prescribed an antibiotic, primarily amoxycillin (relative risk 1.9; 95% CI 1.2 to 2.9). This coincided with a nearly fourfold increase in the mean inhibitory concentration for ampicillin. The prevalence of the gene did not change with time in children not prescribed an antibiotic at the initial consult (38% initially and 36% two weeks later).
Individual effects impact on the community
Antibiotic resistance persisted for two months in children who took a beta-lactam antibiotic.8 This residual antibiotic resistance could lead to individual treatment failure if antibiotic therapy is required in the near future. Furthermore, even a transient effect on antibiotic resistance is likely to be sufficient to maintain such resistance in the community.
Combining study results confirms association
A recent systematic review summarises the evidence of an association between antibiotic prescribing in primary care and resistance in individual patients.10 The authors carried out a meta-analysis of studies of resistance in respiratory tract bacteria. A randomised controlled trial examining antibiotic resistance in respiratory tract streptococci of healthy volunteers was analysed separately.10,11
Meta-analysis of the respiratory pathogen studies found that individuals were twice as likely to test positive for antibiotic resistance within one month (OR 2.1; 95% CI 1.04 to 4.23) and within two months (OR 2.37; 95% CI 1.42 to 3.95) of antibiotic exposure.
Results from the randomised trial support a causal relationship between macrolide use and bacterial resistance.11 Compared with placebo, treatment with azithromycin 500 mg once daily for three days or clarithromycin 500 mg twice daily for seven days significantly increased the carriage of resistant streptococci one week after completing the course (OR 12.22; 95% CI 6.76 to 22.1).10 The effect was still significant at six months (OR 2.16; 95% CI 1.3 to 3.61).
Convey individual risk to patients
Increasingly, studies provide evidence that individuals carry transmissible antibiotic resistance after a course of antibiotics.9-11 Prescribers are well placed to convey the importance of these findings. Inform patients that they are twice as likely to carry resistant bacteria after a course of antibiotics as someone who has not taken them.8-10 It may help to explain that antibiotics are less likely to be effective if they need them to treat a severe infection in the near future.
Evidence from general practice demonstrates that patient satisfaction is more likely to be influenced by good communication than a prescription for an antibiotic.12-14 The benefits of patient-centred communication skills training and implementationcan persist for at least 12 months, and do not appear to compromise repeat consultation rate, patient recovery or patient satisfaction.15-17
A randomised controlled trial found that GPs trained in communications skills prescribed antibiotics significantly less often for patients with lower respiratory tract infections than GPs without training (27% vs 54%).17 A second intervention, C-reactive protein point-of-care testing, reduced prescribing compared with no test (31% vs 53%).
Of 10 GPs familiar with using both interventions, 9 preferred communication skills training.18 They described communications skills as 'crucial' or 'essential' and thought that they had a role in all consultations for lower respiratory tract infection. Point-of-care testing, however, was only thought to be helpful in managing a subgroup of patients.
Provide written information as well as verbal advice
Written patient information materials, along with interventions to improve communication during consultations, reduced antibiotic prescribing for respiratory tract infection in two randomised trials.15,19
The first study found a reduction in antibiotic prescribing for acute cough when patients received an information booklet and read a waiting room poster.15 Prescribers asked patients about their worries and expectations, and discussed antibiotics in the consultation. The information booklet encouraged patients to ask their doctor about the limited role of antibiotics in treating acute cough. Six weeks after the intervention, the likelihood of an antibiotic being prescribed was significantly reduced compared with the group assigned to usual care (OR 0.38; 95% CI 0.26 to 0.56). The effect of the intervention persisted for at least 12 months, with some attenuation over time (OR 0.55; 95% CI 0.38 to 0.8).
The second study examined the effect of an interactive booklet on antibiotic prescribing and repeat consultations.19 When talking with parents of children with an acute respiratory tract infection, prescribers used the booklet to facilitate discussion about expectations and concerns, treatment options and when a repeat consultation is needed. Parents were encouraged to take the booklet home as a reference resource. Using the booklet significantly reduced antibiotic prescribing at the initial visit (20% vs 41% receiving usual care, p < 0.001), and antibiotic consumption during the subsequent two week period (22% vs 43% receiving usual care, p < 0.001). Parental satisfaction remained high despite the reduction in antibiotic prescribing.
Repeat consultation rates did not differ significantly between the intervention group and usual care (13% vs 16%, respectively). In addition, the number of parents who said they would consult if their child had a similar illness in the future decreased after the intervention (55% vs 76% receiving usual care, p < 0.001).
|interactive pdf version)|
Will consultations take longer?
Using patient-centred communication skills did not increase consultation time in one study.16 In another study, prescribers thought that they added 2–3 minutes to the consultation.20 Clinicians in the latter study felt that the extra time was well spent because it reduced or prevented future consultations. With practice, communication skills are likely to improve quality of care without imposing an excess burden on consultation time.
Chest X-ray usually establishes the diagnosis of pneumonia in patients presenting with severe illness.4 Otherwise, there is a limited role for medical imaging in the diagnosis of respiratory tract infection. Prescribers should consider if the potential benefit outweighs the risk, and whether the results of diagnostic radiology will alter patient management.21
Computed tomography (CT) may be considered when atypical, severe or chronic (lasting more than 12 weeks) sinusitis has failed to respond to medical treatment.4,22 Discuss each case with, or refer the patient to, a specialist.4
Radiation exposure can be considerable
A CT scan of the head may expose a patient to about 2.3 millisieverts of ionising radiation, which is equivalent to about 115 chest X-rays.23 Risk to the individual is compounded by age (children and young adults are particularly susceptible), number of scans (cumulative risk) and radiation dose.24
Prof Chris Del Mar, Professor of Public Health, Faculty of Health Sciences and Medicine, Bond University, QLD
Prof Nigel Stocks, Head, Discipline of General Practice, University of Adelaide, SA
Dr John Dowden, Editor, Australian Prescriber
Dr Graham Emblen, GP, Toowoomba
Dr Sarah Gani, GP and Medical Educator, Blacktown
Benafsha Khariwala, Managing Editor, Journal of Pharmacy Practice and Research
A/Prof Jennifer Martin, Head PA-Southside Clinical School
Deborah Norton, QUM Pharmacist, West Vic DGP
Simone Rossi, Managing Editor, Australian Medicines Handbook
Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been soughtfrom all reviewers.
- World Health Organization. Combat antimicrobial resistance: fact sheet. 2011. (accessed 14 November 2011).
- Enne VI, Livermore DM, Stephens P, et al. Persistence of sulphonamide resistance in Escherichia coli in the UK despite national prescribing restriction. Lancet 2001;357:1325–8.
- Sundqvist M, Geli P, Andersson DI, et al. Little evidence for reversibility of trimethoprim resistance after a drastic reduction in trimethoprim use. J Antimicrob Chemother 2010;65:350–60.
- Antibiotic Writing Group. Therapeutic Guidelines: Antibiotic. 14th ed. Melbourne: Therapeutic Guidelines Ltd, 2010.
- Bjornsdottir I, Kristinsson KG, Hansen EH. Diagnosing infections: a qualitative view on prescription decisions in general practice over time. Pharm World Sci 2010;32:805–14.
- McNulty CA, Francis NA. Optimizing antibiotic prescribing in primary care settings in the UK: findings of a BSAC multi-disciplinary workshop 2009. J Antimicrob Chemother 2010;65:2278–84.
- Simpson SA, Wood F, Butler CC. General practitioners' perceptions of antimicrobial resistance: a qualitative study. J Antimicrob Chemother 2007;59:292–6.
- Nasrin D, Collignon PJ, Roberts L, et al. Effect of beta lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002;324:28–30.
- Chung A, Perera R, Brueggemann AB, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007;335:429.
- Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- Malhotra-Kumar S, Lammens C, Coenen S, et al. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet 2007;369:482–90.
- Butler CC, Rollnick S, Pill R, et al. Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ 1998;317:637–42.
- Welschen I, Kuyvenhoven M, Hoes A, et al. Antibiotics for acute respiratory tract symptoms: patients' expectations, GPs' management and patient satisfaction. Fam Pract 2004;21:234–7.
- Kallestrup P, Bro F. Parents' beliefs and expectations when presenting with a febrile child at an out-of-hours general practice clinic. Br J Gen Pract 2003;53:43–4.
- Altiner A, Brockmann S, Sielk M, et al. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother 2007;60:638–44.
- Cals JW, Scheppers NA, Hopstaken RM, et al. Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice. Patient Educ Couns 2007;68:270–8.
- Cals JW, Butler CC, Hopstaken RM, et al. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374.
- Cals JW, Butler CC, Dinant GJ. 'Experience talks': physician prioritisation of contrasting interventions to optimise management of acute cough in general practice. Implent Sci 2009;4:57.
- Francis NA, Butler CC, Hood K, et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:b2885.
- Bekkers MJ, Simpson SA, Dunstan F, et al. Enhancing the quality of antibiotic prescribing in primary care: qualitative evaluation of a blended learning intervention. Fam Pract 2010;11:34.
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Requesting imaging investigations: General principles.(accessed 18 October 2011).
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Chronic sinusitis. (accessed 18 November 2011).
- Government of Western Australia Department of Health. Diagnostic imaging pathways - Ionising radiation. (accessed 18 October 2011).
- Brenner DJ, Hall EJ. Computed tomography - an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84.