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Acute respiratory infections are among the commonest conditions managed in primary care. The Department of Health recognises that antibiotic resistance is an increasingly serious public health problem in England, Europe and the world with rising resistance rates for a range of antibiotics, and a clear relationship between primary care antibiotic prescribing (responsible for 80% of prescribing) and antibiotic resistance. The costs of resistance are also often not included in current estimates of cost-effectiveness. Although consultations rates and antibiotic prescription rates for URTI or chest infections declined sharply in the late 1990s until the early 2000s it is clear that antibiotic use is rising again and the volume of antibiotics prescribed has now exceeded the peak in the late 1990s (https://www.gov.uk/government/publications/resources-to-support-the-2012-european-antibiotic-awareness-day-in-england). The Chief Medical Officer of England has recently warned of catastrophic dangers posed by the overuse of antibiotics, with a key proposed solution of the increased quality of decisions about prescribing our existing antibiotics.
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Children have higher consultation rates for respiratory tract infections than adults, and even when antibiotic prescription was at its lowest most children labelled as having URTI or chest infection still were prescribed antibiotics. Data from our current ongoing observational study among children confirms that at least 60% of children are prescribed antibiotics, which translates to 3 million prescriptions for antibiotics for cough in this age group or approximately £41 million annually in direct consultation and dispensing costs, let alone the indirect costs incurred by ‘medicalising’ illness in the family and wider social networks.
Although trials among adults suggest modest benefit even among important clinical subgroups, we are aware of no randomised placebo-controlled trials available to either support or dispute the common use of antibiotics in children with chest infections. A national research priority is to do clinical trials of medicines in children to ensure children are better represented in RCTs and that medicines for children are more evidence based. Because of the lack of evidence in children it is difficult for GPs to go against the rising tide of antibiotic use to reduce prescribing antibiotics for children. It may be that antibiotics in children also have limited benefit, however the differences in immunity and anatomy between adults and children prohibit simply applying evidence derived in adults to the management of children. If reduction in antibiotic prescribing is to be achieved, one of the key issue for patients and clinicians is the difficulty of knowing whether the child presenting is an ‘average’ child: as with adults there is likely to be variation in pathophysiology and disease severity among children with acute cough. It is highly unlikely that antibiotics are never indicated in a child with acute cough but there is very limited evidence to support GPs in targeting antibiotics. Therefore it is not surprising that important prescribing decisions are made by GPs using traditional but non-evidence based clinical signs like sputum production, fever, chest signs and being unwell as indications for antibiotic use.
This is all why ARTIC PC is important.
