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March 2019

Studies ‘critical of antibiotic prescribing’

Delaying or withholding antibiotics for over 65s with urinary infection linked to heightened sepsis risk

Delaying or withholding antibiotics for over 65s with symptoms of urinary tract infection (UTI) appears to be associated with higher risk of sepsis and death, a study published by The BMJ has revealed.1

The findings suggest that older adults (especially men aged over 85) should start taking antibiotics as soon as possible after diagnosis to prevent serious complications.

UTI is the most common bacterial infection in older patients. But concerns about the spread of antibiotic resistance have led to reductions in antibiotic use in England.

Such a decline in antibiotic use, however, may harm vulnerable older patients who are already more likely to develop UTI-related complications, and there is a lack of good evidence about the treatment of UTIs in primary care.

So a team of UK researchers compared outcomes for the 87% of patients who were prescribed immediate antibiotics (on the day of diagnosis), the 6% who had deferred antibiotics (prescription within seven days), and the 7% who had no antibiotics (no record of a prescription within seven days).

Sepsis and mortality rates were significantly higher in the groups with no or deferred prescriptions, compared with immediate prescriptions.

The rate of hospital admissions was around double (27%) in patients with no and with deferred prescriptions, compared with immediate prescriptions (15%).

Older men, especially those aged over 85 years, were most at risk.


In contrast, a second study found that many courses of antibiotics prescribed for common infections exceed guideline recommendations.2

In total, treatment courses were prescribed for 1.3 million days beyond the durations recommended by guidelines, with most excess days due to treatment for respiratory conditions.

There has been little research on reducing antibiotic overuse by cutting back on prolonged treatment.

So this study compared the durations of antibiotic courses prescribed for 13 common infections including acute sinusitis, sore throat, bronchitis, pneumonia and cystitis with the guidelines recommended by Public Health England in 2013.

In respiratory conditions, 80% or more of antibiotic courses exceeded guidelines, but only 1 in 10 (9.6%) of acute sinusitis prescriptions were longer than the recommended 7 days. More than half (54.6%) of the antibiotic prescriptions for acute cystitis in women were for longer than recommended.

There was significant under-treatment for acute prostatitis and cystitis among men. For example, 52.3% of courses were shorter than the recommended 28 days for prostatitis.

The findings indicate ‘substantial scope’ for reducing antibiotic prescribing through better adherence to recommended durations of treatment, the authors said.

RCGP chair Professor Helen Stokes-Lampard, said prescribers were ‘in an incredibly difficult position when it comes to antibiotics prescribing.

‘We are under huge pressure not to prescribe – and publicly vilified when we are deemed to do so too readily – yet, we know that in some cases antibiotics are a matter of life or death.

‘Getting the balance right every time is extremely challenging.

‘Growing resistance to antibiotics is a huge threat globally, and it’s essential we all – not just GPs and other healthcare professionals – work to curb it, by realising they are not a cure-all for every illness. But antibiotics are also important, life-saving drugs and it’s vital that [we] are not deterred from using them when it’s appropriate to do so.’


Meanwhile, a GP-led patient survey reveals over half (53%) of patients in the UK go to see a doctor with the intention of being prescribed antibiotics, despite almost a quarter (23%) not knowing what antibiotics are intended to treat.

Out of the 200 patients surveyed, 53% said they would only deem the appointment a success if they were prescribed antibiotics, although 25% had a viral illness, which cannot be treated with antibiotics. Men were less well-informed than women: 28% of males thought that antibiotics could treat a virus, compared with 14% of female patients who said the same.

The study also revealed that 36% demanding antibiotics had no idea about any of the side effects associated with taking antibiotics.

The survey was conducted by GPs working for the GP on-demand app GPDQ in January and February 2019.

1. Gharbi M, et al. BMJ 2019;364:l525

2. Pouwels KB, et al. BMJ 2019;364:l440