Responsible use of antibiotics in general practice

People in New Zealand use more antibiotics per head of population, than people in most similar developed countries. Increased antibiotic use exerts a selective pressure for the development of resistance by eliminating antibiotic-susceptible bacteria and leaving antibiotic-resistant bacteria to multiply. The aim of antibiotic stewardship is therefore to limit the use of antibiotics to situations where they are necessary and deliver the most clinical benefit, so that antimicrobial resistance is minimised and the benefits of effective antimicrobials can be sustained.

Implementing antimicrobial stewardship in general practice: from “what’s good on paper” to “putting this into practice”

The June, 2015 edition of Best Practice Journal examined a number of different aspects of incorporating antimicrobial stewardship into practice. For example, although antibiotics should not be prescribed for viral upper respiratory tract infections, it is often difficult during an initial consultation to establish whether an infection is viral or bacterial in origin. In order to assist clinicians navigate this dilemma, we examined whether performing C-reactive protein testing can help to differentiate between a viral or bacterial infection, the evidence behind delayed, “back pocket” prescriptions and a debate on prescribing antibiotics for respiratory tract infections including the viewpoints of primary care clinicians in New Zealand.

Key practice points are summarised below for articles covering whether patients may stop a course of antibiotics early if symptoms improve, the usefulness of delayed prescriptions and whether a topical antiseptic could be used in place of a topical antibiotic.

For further information on these articles, and additional information about the use of antibiotics, see: BPJ 68 (Jun, 2015).

Is it okay to stop antibiotics early, e.g. when symptoms resolve?

Traditionally, clinicians and health authorities advocate that patients should complete their full course of antibiotics as prescribed to prevent relapse of infection and the development of antibiotic resistance. Evidence around this advice is beginning to change. The debate around stopping antibiotics, however, is essentially about ensuring that they are commenced appropriately in the first place.

When prescribing antibiotics, clinicians and patients should agree on clear expectations about:

• Duration of treatment
• Adherence to a regimen
• Whether stopping a course early would be appropriate

Dose and adherence may be more important than duration of antibiotic treatment. Giving the right antibiotic at an adequate dose, along with good patient adherence with the daily regimen, i.e. taking the correct dose at the appropriate intervals, may be more important for treatment success than taking an antibiotic for a long period of time. New treatment guidelines for infections are increasingly recommending shorter courses of antibiotics than were advocated previously.

Shorter courses of antibiotics do not increase bacterial resistance.The association between antibiotic use and resistance is complex. Longer courses of antibiotics, however, have been associated with the greatest risk of antimicrobial resistance at both an individual and community level.^{1, 2}

There are many situations where a patient could stop taking antibiotics early, and this is not likely to lead to relapse or promote antimicrobial resistance (Table 1). However, the decision to stop an antibiotic should ideally take place only after a follow-up discussion between the treating clinician (or designated clinical staff member, e.g. practice nurse) and the patient, to ensure that clinical features of infection have actually resolved and that there are no misunderstandings about the role of the antibiotic.

Table 1: Factors which can influence the decision to stop antibiotics early

For further information, see: “Is it ok to stop antibiotics when symptoms resolve?”, BPJ 68 (Jun, 2015)

Delayed antibiotic prescriptions for respiratory tract infections (RTIs): does the strategy work?

The goals of a delayed antibiotic prescription strategy are to minimise antibiotic use for conditions in which it is suspected that an antibiotic will have little or no benefit, but to do so without increasing symptom duration or rate of serious complications. A number of studies have now evaluated delayed antibiotic strategies, finding that:

• Up to 50% of patients given a delayed prescription for an antibiotic will collect their prescription³
• Patients who do not receive an antibiotic for a RTI are just as satisfied as those who do, provided that the reasons for not prescribing an antibiotic are effectively explained⁴
• Patients who take an antibiotic for a RTI are unlikely to have a shorter duration of symptoms, but they may be less likely to experience suppurative complications; however, the development of complications in a patient with an acute RTI, regardless of antibiotic use, is relatively uncommon (approximately 2–3%)^{5, 6}

Taking all factors into consideration, evidence suggests that not prescribing the patient an antibiotic initially, explaining why this decision has been made and ensuring that patients understand to contact the practice if symptoms do not resolve and that a prescription will be made available to them if appropriate, is likely to reduce antibiotic use and result in similar clinical outcomes and patient satisfaction than using a delayed prescribing strategy. However, giving the patient a “back pocket” prescription to take with them “just in case”, may be considered for some patients.

Delayed prescriptions may be considered for patients who do not need antibiotics at the time of consultation but may need them laterand may not be able or likely to return for a follow-up appointment. This strategy leads to far fewer prescriptions being dispensed compared with immediate prescription of antibiotics and only a few more being dispensed than for patients not initially offered a prescription.

Factors that contribute to the decision to offer a delayed prescription for a patient with a RTI include:

• Concerns about the potential for symptoms to worsen significantly in a patient with serious co-morbidities
• Previous history of complications with RTIs
• Socioeconomic factors such as the ability of the patient to return for a consultation if their condition deteriorates

Delayed prescribing can be a good approach for some patients when combined with careful history and examination, reassurance, symptom-control advice and clear instructions on when to fill the prescription. Giving a delayed prescription can have a positive effect on a patient’s future expectations for receiving an antibiotic for a RTI, especially if their symptoms resolve without filling the prescription. This may be a good strategy for enabling a patient to become familiar with the idea that they do not always need an antibiotic.

Clinicians should keep in mind that delayed prescription strategies will not suit all patients – some patients will require a face-to-face or telephone follow up.

For further information, see:

“Delayed antibiotic prescriptions for respiratory tract infections: does the strategy work?”, BPJ 68 (Jun, 2015).

“Debate: Do you prescribe antibiotics for respiratory tract infections? An everyday conundrum in general practice”, BPJ 68 (Jun, 2015).

Should I prescribe a topical antiseptic cream instead of a topical antibiotic for minor skin infections?

There are increasing rates of resistance to fusidic acid in New Zealand. Combined with high rates of resistance to mupiricin in the 1990s and early 2000s, clinicians may wonder whether they can prescribe a topical antiseptic instead of a topical antibiotic.

Most topical antiseptic products are intended for use on intact skin, e.g. for hand hygiene or for skin preparation prior to a surgical procedure, or surface decontamination; their use in these situations is widely accepted. At present, however, there is a shortage of quality evidence demonstrating any clear benefit for the use of topical antiseptics in minor skin infections. Therefore, their role remains uncertain. A Cochrane review published in 2012 concluded that there was insufficient evidence to recommend the use of topical antiseptics in the treatment of impetigo; this has also been reiterated in more recent review articles.^{7, 8} For children in New Zealand, where antibiotic resistance rates are likely to differ from the countries covered by the Cochrane review, it is not clear whether a topical antiseptic is a feasible alternative to a topical antibiotic for the treatment of minor skin infections such as impetigo.⁹

It is important to keep in mind that most healthy patients with minor skin infections do not require treatment with a topical antibiotic. Therefore, the use of topical antibiotics can be reduced by following clinical practice recommendations as opposed to substituting with a topical antiseptic. Recommendations include:

• Skin infections such as furuncles and carbuncles are usually more appropriately managed by incision and drainage
• For children with infected eczema, expert opinion now suggests that topical fusidic acid should no longer be prescribed.⁹ The preference is for oral antibiotic treatment, selected based on local resistance patterns, and with appropriate coverage for Staphylococcus aureus and Streptococcus pyogenes (Group A ß haemolytic streptococcus).
• Fusidic acid may be considered for children with three or less localised areas of impetigo, an oral antibiotic, however, is likely to be more appropriate¹⁰

Topical antibiotics continue to have a role in patients requiring nasal decolonisation of S. aureus, and in these cases substitution with a topical antiseptic is not appropriate. The choice of topical antibiotic should be made according to culture results.¹¹

For further information, see: “Should I prescribe a topical antiseptic cream instead of a topical antibiotic for minor skin infections?”, BPJ 68 (Jun, 2015).