Doctors are prescribing antibiotics to patients with common infections at alarmingly high rates, with little regard for the patient’s prognosis or the risk that the infection could worsen, according to a new study led by epidemiologists from the University of Manchester. The research, which scrutinized over 15 million patient records, suggests that there is significant room for reducing unnecessary antibiotic prescriptions and promoting a more targeted approach to prescribing these medications.
Published in the Journal of the Royal Society of Medicine on April 4, this comprehensive study reveals disturbing patterns in the way antibiotics are prescribed, especially for conditions like respiratory tract infections and urinary tract infections (UTIs). The findings challenge the current practice and highlight an urgent need to reconsider how doctors make decisions about when and to whom they should administer antibiotics.
Unjustified Antibiotic Prescribing: A Rising Concern
Antibiotics are incredibly effective in treating bacterial infections, but when used incorrectly or unnecessarily, they contribute to one of the biggest health threats of the 21st century: antimicrobial resistance (AMR). AMR occurs when bacteria evolve to resist the drugs designed to kill them, making infections harder to treat. The new study demonstrates that despite the growing recognition of this threat, antibiotics are still being prescribed in a way that disregards the likelihood of severe complications from infections.
The research team, led by Professor Tjeerd van Staa and Dr. Ali Fahmi from the University of Manchester, analyzed patient-level electronic health records of over 15.7 million adults registered at general practices in England between January 2019 and March 2023. These patients had been diagnosed with common infections, such as upper and lower respiratory tract infections and urinary tract infections.
The researchers found that for many common infections, the likelihood of being prescribed antibiotics was not linked to the patient’s risk of developing complications like sepsis or requiring hospitalization. Specifically, they observed that patients with lower respiratory tract infections or UTIs were prescribed antibiotics regardless of their risk of being admitted to the hospital. Even more concerning, patients who were more vulnerable to infections due to age or pre-existing health conditions were sometimes overlooked when it came to receiving antibiotics.
The Link Between Age and Antibiotic Prescriptions
One of the more surprising revelations of the study was how age influenced antibiotic prescriptions. Elderly patients, who may be less able to fight infections without medical intervention, were found to be 31% less likely to receive antibiotics for upper respiratory infections than younger, typically healthier patients. This discrepancy could be due to an overestimation of the elderly’s ability to recover from infections without antibiotics or an underestimation of the severity of their conditions by healthcare providers.
On the other hand, younger individuals—who generally have stronger immune systems and are better able to recover from infections without antibiotics—were found to be more likely to be prescribed antibiotics. This trend of over-prescribing to those who don’t need it can lead to the development of antibiotic resistance, a growing concern among healthcare professionals worldwide.
The Risk of Over-Prescribing and AMR
The over-prescription of antibiotics, particularly for common infections that are often self-limiting, significantly contributes to the global issue of antimicrobial resistance (AMR). The World Health Organization (WHO) has consistently warned that AMR threatens to undo decades of medical progress. If antibiotics continue to be dispensed without careful consideration of the individual patient’s risk of complications, there will be serious consequences for public health.
Professor van Staa explained, “Antibiotics are effective in treating bacterial infections, but they carry the risks of antimicrobial resistance (AMR) and loss of effectiveness when used inappropriately. Given the threat of resistance, there is a need to better target antibiotics in primary care to patients with higher risks of infection-related complications such as sepsis.”
Older Adults and the Need for Antibiotics
The study also found that patients with multiple chronic conditions were less likely to receive antibiotics for upper respiratory infections, which could have detrimental effects on their health. Those with combinations of health issues were 7% less likely to be prescribed antibiotics compared to individuals without major health problems. This lack of antibiotic treatment for individuals who may be at higher risk of complications or hospitalization could result in worsened health outcomes, including longer recovery times or even hospitalization due to infection progression.
Dr. Ali Fahmi stressed that rather than setting broad targets for reducing overall antibiotic prescriptions, it’s crucial for clinicians to focus on tailoring their prescribing practices based on individual risk factors. “Rather than imposing targets for reducing inappropriate prescribing, we argue that it is far more viable for clinicians to focus on improving risk-based antibiotic prescribing for infections that are less severe and typically self-limiting.”
The Impact of the COVID-19 Pandemic
The research also analyzed the data from the pandemic period, which introduced a new layer of complexity in healthcare delivery. The study found that the likelihood of being prescribed antibiotics for lower respiratory infections was even less related to the risk of complications during the pandemic. However, for urinary tract infections, there were only minor changes in prescription patterns, which may suggest that while the pandemic disrupted many aspects of healthcare, the fundamental issue of over-prescribing antibiotics remained.
Moving Toward More Personalized Prescribing Practices
This study underscores the need for a more nuanced approach to antibiotic prescribing in primary care. Currently, prescribing practices do not sufficiently account for the potential risks and benefits of antibiotics, and the wide use of these drugs for relatively mild or self-limiting conditions contributes to rising rates of AMR.
One potential solution to this issue, as highlighted by the researchers, is the development of more personalized, risk-based prescribing guidelines. These guidelines would help clinicians assess the likelihood of a patient experiencing complications or requiring hospitalization, thus allowing them to better determine whether an antibiotic is truly necessary.
Professor van Staa, who is also leading a Knowledge Support System (KSS) initiative in North-West England, noted, “We hope it could provide a workable solution to the problem of untargeted antibiotic prescribing.” The KSS provides personalized information to clinicians, helping them make more informed decisions and better tailor antibiotic prescriptions to the specific needs of their patients.
A Call for Better Guidelines and Decision-Making
The findings of this study emphasize the need for healthcare systems to update their guidelines and decision-making frameworks to incorporate a more personalized approach to antibiotic prescribing. As Dr. Fahmi pointed out, prognosis and potential harm should be explicitly considered in treatment guidelines, alongside better personalized information for clinicians and patients to support shared decision-making. This could include more robust risk prediction scores and clinical decision support systems to help doctors assess whether antibiotics are truly necessary.
The key takeaway from this study is clear: while antibiotics are vital tools for treating bacterial infections, they are often being prescribed without sufficient regard for the patient’s risk of complications. The result is an overuse of antibiotics, contributing to the global AMR crisis. With better-targeted prescribing practices, informed by a patient’s individual risk factors and clinical prognosis, healthcare providers can reduce unnecessary antibiotic use, improving patient outcomes and preserving the effectiveness of antibiotics for future generations.
As the study concludes, there is a critical need for a shift in how we approach antibiotic prescribing in primary care. By prioritizing personalized care and considering each patient’s unique circumstances, clinicians can significantly reduce the inappropriate use of antibiotics and help combat one of the most pressing public health issues of our time—antimicrobial resistance.