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A Million more Antibiotic Prescriptions than expected in December

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A Million more Antibiotic Prescriptions than expected in December

Tales from the Front Line

Carl Heneghan
and
Tom Jefferson
Mar 15
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A Million more Antibiotic Prescriptions than expected in December

trusttheevidence.substack.com

“How's it going,” I say.

“It’s manic, there are hundreds on the phone, and every child with a sore throat is coming into base,” she replied. “And I’ve used more antibiotics this month than the whole year.”

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Sore throat is a common primary care presentation and can occasionally lead to scarlet fever, which usually affects young children - but not always. It presents with a sore throat, high fever and a skin rash; it can usually be treated with an antibiotic (penicillin) targeted to the causative pathogen - strep A. However, in rare cases, scarlet fever can lead to an invasive infection which can cause life-threatening complications. 

But in the Autumn of last year, cases rocketed: a substantial scarlet fever outbreak occurred across Europe from September 2022 onwards - up to 30 UK children died by the end of the year. 

You'd be hard-pushed to have missed the outbreak as its reporting was in every news outlet. As the death toll rose - parental anxiety was heightened - the usual approach of riding out the illness went out the window, and a massive increase in children presenting to primary care ensued. At one point in the month, half of all the urgent care base visits were filled by children under 12. 

When they did get to be seen, GPs lowered their threshold for treatment, and as a consequence, antibiotic prescribing rose dramatically. Data from Open Prescribing shows that roughly 1.3 million more antibiotics were prescribed in December compared to the previous month. 

The substantial increase was driven by additional prescribing of Penicillin V. The antibiotic of choice for Strep A sore throat in those not allergic. However, stocks of Penicillin V rapidly ran out; alternatives such as Amoxicillin and Clarithromycin were used, and they also showed marked increases. 

There has been a push to reduce antibiotic prescriptions for two decades, given the concerns over resistance, particularly in children.

A 2006 systematic review showed that antibiotics confer relative benefits in treating sore throat but modest absolute benefits. You have to accept that many people require treatment to prevent serious complications. The effectiveness of antibiotics is increased in people with identified streptococcal infection. By the end of December, rapid strep A tests were available, but it was too late to prevent the prescribing deluge. 

In 1945, Alexander Fleming warned that the misuse of penicillin could result in the selection of resistant bacteria. True to his word, resistance emerged within ten years of penicillin's wide-scale introduction. 

The dramatic increase in prescribing risks unravelling the national action plan to reduce unintentional exposure to antimicrobials. 

The targeting of antibiotics for those most likely to benefit remains a priority. Online home-testing kits for Strep A sold out as parents scrambled to diagnose their children's sore throats. Making available rapid tests could have averted much of the panic and overprescribing antibiotics. Instead, the health service was caught playing catch up, and the damage had been done.

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Open Prescribing Link https://openprescribing.net/bnf/0501/

Antibiotic data: 

Penicillin V: https://openprescribing.net/chemical/0501011P0/

Amoxicillin: https://openprescribing.net/chemical/0501013B0/

Clarithromycin:  https://openprescribing.net/chemical/0501050B0/

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A Million more Antibiotic Prescriptions than expected in December

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2 Comments
Nik
Mar 15

And during lockdown, dentists had to hand out antibiotics as were ordered to cease treatment and refer to specialist units,instead of inciting abscesses and draining pus

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norstadt
Writes about data
Mar 15·edited Mar 15

Why would only the "misuse of penicillin" drive evolution of antibiotic resistance? The correct usage of penicillin could impact bacterial populations even more, as there are then bacteria in the body fighting against penicillin, and the resistant ones would have a distinct survival advantage.

Anyway, this subject of bacterial evolution seems to be less well understood than is commonly thought.

https://www.nature.com/articles/s41586-021-04265-w

"Discussion

This research shows that hedgehogs are a natural reservoir of zoonotic mecC-MRSA lineages that predate the antibiotic era, which is inconsistent with the commonly accepted view that widespread resistance in clinical pathogens is a modern phenomenon that is driven by our use of antibiotics in human and veterinary medicine."

Edit: What is the proposed mechanism of action when antibiotics are overused in people? Do sewer rats get exposed to a hugely diluted antibiotic concentration and develop resistant infections?

Edit #2: Interestingly, two of the three Cochrane Review authors disclosed funding to study antibiotic resistance. Yet they wrote (in the 2013 update): "it is unclear if changes in bacterial resistance in the community may have affected the effectiveness of antibiotics [since 1975]."

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