A Million more Antibiotic Prescriptions than expected in December

Tales from the Front Line

“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.”

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.

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/