ArticlePDF Available

Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates? Retrospective cross-sectional analysis of national primary care prescribing data in England in 2016

Authors:

Abstract

Objective To determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative medicine (CAM) (referred to as IM GPs) working within National Health Service (NHS) England. Design Retrospective study on antibiotic prescription rates per STAR-PU (Specific Therapeutic group Age–sex weighting Related Prescribing Unit) using NHS Digital data over 2016. Publicly available data were used on prevalence of relevant comorbidities, demographics of patient populations and deprivation scores. Setting Primary Care. Participants 7283 NHS GP surgeries in England. Primary outcome measure The association between IM GPs and antibiotic prescribing rates per STAR-PU with the number of antibiotic prescriptions (total, and for respiratory tract infection (RTI) and urinary tract infection (UTI) separately) as outcome. Results IM GP surgeries (n=9) were comparable to conventional GP surgeries in terms of list sizes, demographics, deprivation scores and comorbidity prevalence. Negative binomial regression models showed that statistically significant fewer total antibiotics (relative risk (RR) 0.78, 95% CI 0.64 to 0.97) and RTI antibiotics (RR 0.74, 95% CI 0.59 to 0.94) were prescribed at NHS IM GP surgeries compared with conventional NHS GP surgeries. In contrast, the number of antibiotics prescribed for UTI were similar between both practices. Conclusion NHS England GP surgeries employing GPs additionally trained in IM/CAM have lower antibiotic prescribing rates. Accessibility of IM/CAM within NHS England primary care is limited. Main study limitation is the lack of consultation data. Future research should include the differences in consultation behaviour of patients self-selecting to consult an IM GP or conventional surgery, and its effect on antibiotic prescription. Additional treatment strategies for common primary care infections used by IM GPs should be explored to see if they could be used to assist in the fight against antimicrobial resistance.
A preview of the PDF is not available

Supplementary resources (2)

... There is a growing amount of evidence that GP surgeries employing doctors with additional qualification in Integrative Medicine (IM doctors) prescribe fewer antibiotics overall and for RTIs than conventional GP surgeries. This could be because IM doctors have additional treatments to offer for infections, and/or patients who do not want to use antibiotics visit these IM surgeries [3,8]. ...
Article
Full-text available
Introduction Most Complementary & Alternative Medicine (CAM) interventions have not been tested in clinical trials and systematic reviews (SRs). It is therefore important to collect knowledge from experienced practitioners to identify (lower level) evidence to support their use and to prioritize interventions for future research. This study aimed to document the CAM treatments for cough and sore throat as part of uncomplicated, acute respiratory tract infections (RTI), most frequently recommended by experienced integrative medical practitioners; and to assess whether these approaches have been tested in clinical trials and SRs. Methods Data on treatment approaches were collected by means of (1) a SR on prescription rates of CAM treatments for RTIs in CAM practice by searching Pubmed and CINAHL databases; and (2) a survey among integrative medical doctors and TCM practitioners in five European countries. Results The SR identified 336 articles. After screening five studies were included (Anthroposophic Medicine (AM): two and homeopathy (HOM): three). The survey resulted in 262 responses (including 99 AM and 95 HOM experts). Of 19 products that were described in both the SR and the survey, two (22%) AM (Hustenelixier, Echinacea) and three (30%) homeopathic products (Belladonna, Hepar sulphuris, Mercurius solubilis) had been studied in a clinical trial and one AM treatment (Echinacea) in a SR for this indication. Conclusions CAM treatments for RTI related cough and sore throat were identified (medicinal products, syrup, external applications, tea and acupuncture). These treatments have hardly been studied in clinical trials (26%) and SRs (5%) and require further evaluation.
... Interestingly, many whole medical systems, for instance anthroposophic medicine, traditional Chinese medicine and Ayurveda have developed clinical practices that make use of far less antibiotics than modern medicine [2]. Furthermore, there is evidence that general practitioners additionally trained in integrative medicine practices prescribe fewer antibiotics [3]. However, it appears that the chances offered by integrative medicine practices have not yet been considered by the WHO global action plan. ...
... Besides these classic assessments of untoward effects of interventions, also other safety issues are related to the whole field of T&CM as well as AM and can be investigated with different methodologies: for instance the impact of AM on patients' adherence to conventional medicine treatments (e.g., compliance with scheduled chemotherapy protocol [93]) and associated treatment effectiveness or the impact of AM on decreasing unjustified overuse of conventional drugs (nonindicated antibiotics prescriptions, analgesics overuse, etc. [51,62,94,95]), to reduce drug-associated adverse effects, morbidity, and health costs [59,71,[96][97][98]. A further safety issue necessitating also exploratory research relates to patients who adopt "alternative" health belief models that they (wrongly) associate with AM, expressed by negation of evidence-based conventional treatments or prevention recommendations (e.g., certain vaccinations, antibiotics, chemotherapy, steroids). ...
Article
Full-text available
Background: Whole medicine and health systems like traditional and complementary medicine systems (T&CM) are part of healthcare around the world. One key feature of T&CM is its focus on patient-centered and multimodal care and the integration of intercultural perspectives in a wide range of settings. It may contribute to good health and well being for people as part of the Sustainable Development Goals of the United Nations. The authentic, rigorous, and fair evaluation of such a medical system, with its inherent complexity and individualization, imposes methodological challenges. Hence, we propose a broad research strategy to test and characterize its possible contribution to health. Methods: To develop a research strategy for a specific T&CM system, Anthroposophic Medicine (AM), applying multimodal integrative healthcare based on a four-level concept of man, we used a three-phase consensus process with experts and key stakeholders, consisting of (1) premeeting methodological literature and AM research review and interviews to supplement or revise items of the research strategy and tailor them to AM research, (2) face-to-face consensus meetings further developing and tailoring the strategy, and (3) postmeeting feedback and review, followed by finalization. Results: Currently, AM covers many fields of medical specialties in varied levels of healthcare settings, such as outpatient and inpatient; primary, secondary, and tertiary care; and health education and pedagogy. It is by definition integrated with conventional medicine in the public healthcare system. It applies specific medicines, nursing techniques, arts therapies, eurythmy therapy, rhythmical massage, counseling, and psychotherapy, and it is provided by medical doctors, nurses, therapists, midwives, and nutritionists. A research strategy authentic to this level of complexity should comprise items with a focus on (I) efficacy and effectiveness, divided into (a) evaluation of the multimodal and multidisciplinary medical system as a whole, or of complex multimodal therapy concept, (b) a reasonable amount of methodologically rigorous, confirmatory randomized controlled trials on exemplary pharmacological and nonpharmacological therapies and indications, (c) a wide range of interventions and patient-centered care strategies with less extensive formats like well-conducted small trails, observational studies, and high-quality case reports and series, or subgroup analyses from whole-system studies, or health service research; (II) safety; (III) economics; (IV) evidence synthesis; (V) methodologic issues; (VI) biomedical, physiological, pharmacological, pharmaceutical, psychological, anthropological, and nosological issues as well as innovation and development; (VI) patient perspective and involvement, public needs, and ethics; (VII) educational matters and professionalism; and (IX) disease prevention, health promotion, and public health. Conclusion: The research strategy extends to and complements the prevailing hierarchical system by introducing a broad "evidence house" approach to evaluation, something many health technology assessment boards today support. It may provide transparent and comprehensive insight into potential benefits or risks of AM. It can serve as a framework for an evidence-informed approach to AM for a variety of stakeholders and collaborating networks with the aim of improving global health.
... Traditional Chinese medicines served as alternatives to antimicrobials for doctors. Similarly, in the UK, a retrospective study which included 7283 general practice (GP) surgeries suggested that GPs additionally trained in integrative medicine or complementary and complementary medicine had lower antibiotic prescribing rates compared with conventional GPs.30 ...
Article
Full-text available
Objectives: To explore doctors' knowledge, willingness, concerns and the countermeasures to the most stringent antimicrobial stewardship regulations of China which implemented in August 2012. Design: Cross-sectional survey. A pretested 32-point structured questionnaire was distributed to doctors by sending a web link via the mobile phone application WeChat through snowball sampling methods and email groups of medical academic societies. Setting: China. Participants: Doctors. Primary and secondary outcome measures: The questionnaire inquired about the doctors' experiences, knowledge, willingness, concerns and the countermeasures to the stewardship policies. Results: Total of persons in the groups was 19 791, among them 1194 submitted the answers, within them, 807 were doctors. Doctors had a mean age of 39.0 years. The majority (78.9% in 2012, 89.1% in 2016) reported that they were willing or very willing to accept the regulations. Almost all respondents (93.2%) felt the stewardship regulations had the potential to adversely affect the prognosis of patients who would have been prescribed antimicrobials before they were implemented, and >65% (65.7% in 2012, 66.9% in 2016) of doctors were often or always concerned about the prognosis of these patients. In 2012, 32% of doctors prescribed restricted antimicrobials or suggested patient self-medication with restricted antimicrobials to address doctors' concerns, and this number decreased to 22.6% in 2016. Although compulsory antimicrobial stewardship training was frequent, less than half of respondents (46.8%) responded correctly to all three knowledge questions. Conclusion: Antimicrobial stewardship regulations had some positive effect on rational antimicrobial use. Willingness and practice of doctors towards the regulations improved from 2012 to 2016. Knowledge about rational antimicrobial use was still lacking. Doctors found ways of accessing restricted antibiotics to address their concerns about the prognosis of patients, which undermined the implementation of the stewardship regulations.
... As discussed in the introduction, the use of non-specific treatments among GPs seems more prevalent in the United Kingdom than in Germany [5][6][7] while CAM use is certainly higher in Germany. Some studies found that GPs using CAM therapies prescribe antibiotics for upper respiratory tract infections less often than those not using CAM [30,31]. However, such differences can also be explained by other factors (such as differences in patient populations, time, communication training or health system differences). ...
Article
Full-text available
Background In routine practice, general practitioners (GPs) see many patients for whom treatment might not be necessary, or evidence-based treatments are not available, yet often a treatment is prescribed. We denote such situations as therapeutically indeterminate. We aimed to investigate 1) whether therapeutically indeterminate situations play a role in the accounts of GPs in their practical work; 2) the role of complementary and alternative medicine (CAM) modalities or non-specific therapies, and of other strategies used in handling therapeutically indeterminate situations; and 3) factors associated with preferences for specific strategies. Methods We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs from Bavaria, Germany. A grounded theory approach was used for data analysis. Results Participants reported that therapeutically indeterminate situations recur often in their daily practice. Professionally legitimate strategies such as empathetic consultations without providing a treatment intervention did not seem to suffice for coping with all of these situations. CAM treatments were used frequently, but motives varied. While some participants were convinced that these treatments were active and effective, others were uncertain or had doubts and used them as a relational tool, as a non-specific treatment or as a beneficial placebo. Conventional drugs were also used in a non-specific manner or despite doubts regarding the risk-benefit ratio. The extent to which GPs felt responsible for offering solutions in therapeutically indeterminate situations seemed to influence their preference for specific strategies. Conclusion Our results demonstrate the important role of CAM and the somewhat smaller role of non-specific therapies for German general practitioners in dealing with therapeutically indeterminate situations. The concept of therapeutically indeterminate situations may be helpful in better understanding why many general practitioners treat patients in situations where treatment does not appear to be clearly indicated. Electronic supplementary material The online version of this article (10.1186/s12875-019-0945-4) contains supplementary material, which is available to authorized users.
Article
The Homeopathy Research Institute (HRI) welcomed more than 450 people from 35 countries to their first online event on June 25, 2022. The one-day programme featured an excellent line-up of international speakers and provided a unique interactive platform in keeping with the theme of the event – Key Collaborations in Homeopathy Research. Scientists from a range of different research fields gave an exceptional insight into the current status of homeopathy research. Here we give an overview of the most significant findings in both clinical and basic research presented during HRI Online 2022.
Article
Background Unnecessary antibiotic prescribing and use are most common for uncomplicated acute respiratory infections (ARIs). Some Complementary and Alternative Medicine (CAM) treatments have evidence of effectiveness for symptom relief and could be used instead of antibiotics. Aim To understand views of the general public and health professionals regarding use of CAM for uncomplicated ARIs. Design and Setting Systematic review and thematic synthesis of qualitative studies. Method We systematically searched MEDLINE, EMBASE, AMED, COREHOM, CINAHL, Dissertation and theses global and Web of Science Core Collection. We included studies which reported qualitative data on the use of CAM for uncomplicated ARIs where participants were either patients or parents of patients, health professionals or the general public. Analysis followed thematic synthesis. Results Twenty-two studies were included from four high-income and ten low-and-middle income countries; almost all focussed on non-White populations. Nineteen concerned parents’ treatment of ARIs in their children. In all settings, treatment decisions were influenced by beliefs about the illness (cause, severity), beliefs about treatments (efficacy, safety), availability of treatments and of trustworthy advice. Participants mostly thought CAM is an acceptable option for treatment of mild ARIs but felt that they need trustworthy advice on which treatments to use and when. Conclusion Treatment decisions depend on beliefs about the illness and treatments, availability of treatments and advice. CAM treatments appear to be acceptable to people from many different settings as a possible alternative to antibiotics for mild ARIs. There is a need for reliable, evidence-based advice on which treatments to use.
Article
Résumé L’antibiorésistance (AR) est depuis longtemps un problème pour les médecins et les associations de soignants dans le monde entier. Récemment, l’inquiétude à ce sujet s’est aggravée : le “Global Antimicrobial Surveillance System” (GLASS), mis en place par l’Organisation mondiale de la Santé (OMS) en 2015, a mis l’accent sur l’émergence croissante de micro-organismes résistants aux antibiotiques. En Italie, les taux d’antibiorésistance sont parmi les plus élevés d’Europe. Cela est probablement dû à l’usage excessif des antibiotiques. Selon le récent Rapport italien de surveillance nationale des bactériémies, l’incidence moyenne de l’antibiorésistance pour les bactéries les plus répandues avoisine les 25-30 %. Les causes de cette AR sont complexes, elles incluent sans l’ombre d’un doute l’usage excessif et inapproprié des antibiotiques, et toute stratégie visant à corriger ce mésusage sera donc efficace. La médecine alternative et complémentaire (CAM) représente une alternative conceptuelle à l’usage des traitements conventionnels, mais pourtant ces dernières années, c’est plutôt un autre modèle que celui de la Médecine Intégrée (MI) qui a été privilégié. Plusieurs études ont montré que les CAM peuvent réduire le recours aux antibiotiques dans le traitement des affections respiratoires, sans augmentation du risque de complications. Une étude récente conduite par notre Société homéopathique pédiatrique italienne s’est penchée sur l’efficacité de l’homéopathie dans le traitement de l’otite aigue chez les enfants. 90 enfants ont été inclus et randomisés en un groupe traité par homéopathie et un groupe contrôle, chacun avec 45 patients. Des antibiotiques ont été prescrits à 33.3 % des enfants dans le groupe traité contre 62.2 % des enfants dans le groupe contrôle (p = 0.006). En conclusion, il y a donc des preuves dans la littérature que l’usage des CAM en général et de l’homéopathie en particulier permet de réduire le recours aux antibiotiques, avec toutes les répercussions positives que cela peut avoir dans le combat contre l’antibiorésistance.
Article
Antibiotic resistance (AR) has long been a problem for doctors and healthcare organizations worldwide. In recent years the issue has become even more pressing: the Global Antimicrobial Surveillance System (GLASS), launched by the World Health Organization in October 2015, bears witness to the growing emergence of antibiotic-resistant microorganisms. In Italy, AR levels are still among the highest in Europe. This is presumably due to over-use of antibiotics. According to the recent Italian National Surveillance Report on bacteriemia, the incidence of AR is on average, for the most widespread bacteria, 25-30%. The causes of the development of AR are complex, but undoubtedly include the excessive and inappropriate use of antibiotics then each strategy to correct these misconducts will be effective. Complementary and alternative medicine (CAM) offers a conceptual alternative to the use of conventional treatments, but in recent years a different model, that of integrated medicine (IM), has been gaining ground. Several studies show that CAM can allow to reduce the recourse to antibiotics in the treatment of respiratory symptoms, without increasing the incidence of complications. A recent study conducted by our Italian Paediatric Society's CAM research group investigated the efficacy of homeopathy in the treatment of acute otitis in children. Ninety children were enrolled and randomized to a homeopathy treatment group or to a control group, each of 45 patients. Antibiotics were prescribed in 33.3% of children in the treatment group and 62.2% of children in the control group (p = 0.006). In conclusion, there is evidence in the literature demonstrating that the use of CAM in general, and homeopathy in particular, can reduce recourse to antibiotics, with positive repercussions for strategies to combat antibiotic resistance.
Article
Objective: Our review summarizes published literature of complementary and alternative medicine (CAM) used for the treatment of acute bronchitis in children. Background: Acute bronchitis is one of the most frequent pediatric diseases and has high prevalence for in- and outpatient care. Acute bronchitis is mainly a viral-caused infection, but a high and inappropriate use of antibiotics has been demonstrated in many countries. As CAM therapies might reduce the use of antibiotics and can complement conventional therapies in children, they could be an appropriate treatment option. Methods: A systematic literature search was conducted using general and complementary and alternative medicine (CAM)-specific databases. A search term including 65 CAM-associated definitions was applied. Results: Literature search revealed 309 articles, whereby 18 articles hit search criteria. These clinical trials were subgrouped into the categories herbal medicine, anthroposophic medicine and homeopathy. The most often studied approaches are herbal remedies, in particular the Pelargonium sidoides extract, EPs® 7630. Its efficacy was demonstrated in three placebo-controlled trials and two observational studies. Anthroposophic approaches (mainly ribwort-containing remedies) were investigated in two controlled trials and three observational studies. Two studies were found investigating the homeopathic remedies Monapax® and Droperteel®. Conclusion: Study results indicate a favorable effect of investigated CAM approaches. However, only three of 18 studies were randomized controlled trials (RCTs), so a reliable statement on effectiveness was not possible and further RCTs are indispensable.
Article
Full-text available
Background: Reducing inappropriate antibiotic prescribing for acute upper respiratory tract infections (AURIs) requires a better understanding of the factors associated with this practice. Objective: To determine the prevalence of antibiotic prescribing for nonbacterial AURIs and whether prescribing rates varied by physician characteristics. Design: Retrospective analysis of linked administrative health care data. Setting: Primary care physician practices in Ontario, Canada (January-December 2012). Patients: Patients aged 66 years or older with nonbacterial AURIs. Patients with cancer or immunosuppressive conditions and residents of long-term care homes were excluded. Measurements: Antibiotic prescriptions for physician-diagnosed AURIs. A multivariable logistic regression model with generalized estimating equations was used to examine whether prescribing rates varied by physician characteristics, accounting for clustering of patients among physicians and adjusting for patient-level covariates. Results: The cohort included 8990 primary care physicians and 185 014 patients who presented with a nonbacterial AURI, including the common cold (53.4%), acute bronchitis (31.3%), acute sinusitis (13.6%), or acute laryngitis (1.6%). Forty-six percent of patients received an antibiotic prescription; most prescriptions were for broad-spectrum agents (69.9% [95% CI, 69.6% to 70.2%]). Patients were more likely to receive prescriptions from mid- and late-career physicians than early-career physicians (rate difference, 5.1 percentage points [CI, 3.9 to 6.4 percentage points] and 4.6 percentage points [CI, 3.3 to 5.8 percentage points], respectively), from physicians trained outside of Canada or the United States (3.6 percentage points [CI, 2.5 to 4.6 percentage points]), and from physicians who saw 25 to 44 patients per day or 45 or more patients per day than those who saw fewer than 25 patients per day (3.1 percentage points [CI, 2.1 to 4.0 percentage points] and 4.1 percentage points [CI, 2.7 to 5.5 percentage points], respectively). Limitation: Physician rationale for prescribing was unknown. Conclusion: In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States. Primary funding source: Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute.
Article
Full-text available
Objectives To systematically review studies investigating the prevalence of antibiotic resistance in urinary tract infections caused by Escherichia coli in children and, when appropriate, to meta-analyse the relation between previous antibiotics prescribed in primary care and resistance. Design and data analysis Systematic review and meta-analysis. Pooled percentage prevalence of resistance to the most commonly used antibiotics in children in primary care, stratified by the OECD (Organisation for Economic Co-operation and Development) status of the study country. Random effects meta-analysis was used to quantify the association between previous exposure to antibiotics in primary care and resistance. Data sources Observational and experimental studies identified through Medline, Embase, Cochrane, and ISI Web of Knowledge databases, searched for articles published up to October 2015. Eligibility criteria for selecting studies Studies were eligible if they investigated and reported resistance in community acquired urinary tract infection in children and young people aged 0-17. Electronic searches with MeSH terms and text words identified 3115 papers. Two independent reviewers assessed study quality and performed data extraction. Results 58 observational studies investigated 77 783 E coli isolates in urine. In studies from OECD countries, the pooled prevalence of resistance was 53.4% (95% confidence interval 46.0% to 60.8%) for ampicillin, 23.6% (13.9% to 32.3%) for trimethoprim, 8.2% (7.9% to 9.6%) for co-amoxiclav, and 2.1% (0.8 to 4.4%) for ciprofloxacin; nitrofurantoin was the lowest at 1.3% (0.8% to 1.7%). Resistance in studies in countries outside the OECD was significantly higher: 79.8% (73.0% to 87.7%) for ampicillin, 60.3% (40.9% to 79.0%) for co-amoxiclav, 26.8% (11.1% to 43.0%) for ciprofloxacin, and 17.0% (9.8% to 24.2%) for nitrofurantoin. There was evidence that bacterial isolates from the urinary tract from individual children who had received previous prescriptions for antibiotics in primary care were more likely to be resistant to antibiotics, and this increased risk could persist for up to six months (odds ratio 13.23, 95% confidence interval 7.84 to 22.31). Conclusions Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E coli is high, particularly in countries outside the OECD, where one possible explanation is the availability of antibiotics over the counter. This could render some antibiotics ineffective as first line treatments for urinary tract infection. Routine use of antibiotics in primary care contributes to antimicrobial resistance in children, which can persist for up to six months after treatment.
Article
Full-text available
Identifying and tackling the social determinants of infectious diseases has become a public health priority following the recognition that individuals with lower socioeconomic status are disproportionately affected by infectious diseases. In many parts of the world, epidemiologically and genotypically defined community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged to become frequent causes of hospital infection. The aim of this study was to use spatial models with adjustment for area-level hospital attendance to determine the transmission niche of genotypically defined CA- and health-care-associated (HA)-MRSA strains across a diverse region of South East London and to explore a potential link between MRSA carriage and markers of social and material deprivation. This study involved spatial analysis of cross-sectional data linked with all MRSA isolates identified by three National Health Service (NHS) microbiology laboratories between 1 November 2011 and 29 February 2012. The cohort of hospital-based NHS microbiology diagnostic services serves 867,254 usual residents in the Lambeth, Southwark, and Lewisham boroughs in South East London, United Kingdom (UK). Isolates were classified as HA- or CA-MRSA based on whole genome sequencing. All MRSA cases identified over 4 mo within the three-borough catchment area (n = 471) were mapped to small geographies and linked to area-level aggregated socioeconomic and demographic data. Disease mapping and ecological regression models were used to infer the most likely transmission niches for each MRSA genetic classification and to describe the spatial epidemiology of MRSA in relation to social determinants. Specifically, we aimed to identify demographic and socioeconomic population traits that explain cross-area extra variation in HA- and CA-MRSA relative risks following adjustment for hospital attendance data. We explored the potential for associations with the English Indices of Deprivation 2010 (including the Index of Multiple Deprivation and several deprivation domains and subdomains) and the 2011 England and Wales census demographic and socioeconomic indicators (including numbers of households by deprivation dimension) and indicators of population health. Both CA-and HA-MRSA were associated with household deprivation (CA-MRSA relative risk [RR]: 1.72 [1.03-2.94]; HA-MRSA RR: 1.57 [1.06-2.33]), which was correlated with hospital attendance (Pearson correlation coefficient [PCC] = 0.76). HA-MRSA was also associated with poor health (RR: 1.10 [1.01-1.19]) and residence in communal care homes (RR: 1.24 [1.12-1.37]), whereas CA-MRSA was linked with household overcrowding (RR: 1.58 [1.04-2.41]) and wider barriers, which represent a combined score for household overcrowding, low income, and homelessness (RR: 1.76 [1.16-2.70]). CA-MRSA was also associated with recent immigration to the UK (RR: 1.77 [1.19-2.66]). For the area-level variation in RR for CA-MRSA, 28.67% was attributable to the spatial arrangement of target geographies, compared with only 0.09% for HA-MRSA. An advantage to our study is that it provided a representative sample of usual residents receiving care in the catchment areas. A limitation is that relationships apparent in aggregated data analyses cannot be assumed to operate at the individual level. There was no evidence of community transmission of HA-MRSA strains, implying that HA-MRSA cases identified in the community originate from the hospital reservoir and are maintained by frequent attendance at health care facilities. In contrast, there was a high risk of CA-MRSA in deprived areas linked with overcrowding, homelessness, low income, and recent immigration to the UK, which was not explainable by health care exposure. Furthermore, areas adjacent to these deprived areas were themselves at greater risk of CA-MRSA, indicating community transmission of CA-MRSA. This ongoing community transmission could lead to CA-MRSA becoming the dominant strain types carried by patients admitted to hospital, particularly if successful hospital-based MRSA infection control programmes are maintained. These results suggest that community infection control programmes targeting transmission of CA-MRSA will be required to control MRSA in both the community and hospital. These epidemiological changes will also have implications for effectiveness of risk-factor-based hospital admission MRSA screening programmes.
Article
Full-text available
Background: Identifying and tackling the social determinants of infectious diseases has become a public health priority following the recognition that individuals with lower socioeconomic status are disproportionately affected by infectious diseases. In many parts of the world, epidemiologically and genotypically defined community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged to become frequent causes of hospital infection. The aim of this study was to use spatial models with adjustment for area-level hospital attendance to determine the transmission niche of genotypically defined CA- and health-care-associated (HA)-MRSA strains across a diverse region of South East London and to explore a potential link between MRSA carriage and markers of social and material deprivation. Methods and findings: This study involved spatial analysis of cross-sectional data linked with all MRSA isolates identified by three National Health Service (NHS) microbiology laboratories between 1 November 2011 and 29 February 2012. The cohort of hospital-based NHS microbiology diagnostic services serves 867,254 usual residents in the Lambeth, Southwark, and Lewisham boroughs in South East London, United Kingdom (UK). Isolates were classified as HA- or CA-MRSA based on whole genome sequencing. All MRSA cases identified over 4 mo within the three-borough catchment area (n = 471) were mapped to small geographies and linked to area-level aggregated socioeconomic and demographic data. Disease mapping and ecological regression models were used to infer the most likely transmission niches for each MRSA genetic classification and to describe the spatial epidemiology of MRSA in relation to social determinants. Specifically, we aimed to identify demographic and socioeconomic population traits that explain cross-area extra variation in HA- and CA-MRSA relative risks following adjustment for hospital attendance data. We explored the potential for associations with the English Indices of Deprivation 2010 (including the Index of Multiple Deprivation and several deprivation domains and subdomains) and the 2011 England and Wales census demographic and socioeconomic indicators (including numbers of households by deprivation dimension) and indicators of population health. Both CA-and HA-MRSA were associated with household deprivation (CA-MRSA relative risk [RR]: 1.72 [1.03-2.94]; HA-MRSA RR: 1.57 [1.06-2.33]), which was correlated with hospital attendance (Pearson correlation coefficient [PCC] = 0.76). HA-MRSA was also associated with poor health (RR: 1.10 [1.01-1.19]) and residence in communal care homes (RR: 1.24 [1.12-1.37]), whereas CA-MRSA was linked with household overcrowding (RR: 1.58 [1.04-2.41]) and wider barriers, which represent a combined score for household overcrowding, low income, and homelessness (RR: 1.76 [1.16-2.70]). CA-MRSA was also associated with recent immigration to the UK (RR: 1.77 [1.19-2.66]). For the area-level variation in RR for CA-MRSA, 28.67% was attributable to the spatial arrangement of target geographies, compared with only 0.09% for HA-MRSA. An advantage to our study is that it provided a representative sample of usual residents receiving care in the catchment areas. A limitation is that relationships apparent in aggregated data analyses cannot be assumed to operate at the individual level. Conclusions: There was no evidence of community transmission of HA-MRSA strains, implying that HA-MRSA cases identified in the community originate from the hospital reservoir and are maintained by frequent attendance at health care facilities. In contrast, there was a high risk of CA-MRSA in deprived areas linked with overcrowding, homelessness, low income, and recent immigration to the UK, which was not explainable by health care exposure. Furthermore, areas adjacent to these deprived areas were themselves at greater risk of CA-MRSA, indicating community transmission of CA-MRSA. This ongoing community transmission could lead to CA-MRSA becoming the dominant strain types carried by patients admitted to hospital, particularly if successful hospital-based MRSA infection control programmes are maintained. These results suggest that community infection control programmes targeting transmission of CA-MRSA will be required to control MRSA in both the community and hospital. These epidemiological changes will also have implications for effectiveness of risk-factor-based hospital admission MRSA screening programmes.
Article
Background: The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care. Objectives: To assess the effects of antibiotics in improving outcomes and assess adverse effects of antibiotic therapy for patients with a clinical diagnosis of acute bronchitis. Search methods: We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January week 1, 2014), EMBASE (1974 to January 2014) and LILACS (1982 to January 2014). Selection criteria: Randomised controlled trials (RCTs) comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in patients without underlying pulmonary disease. Data collection and analysis: At least two review authors extracted data and assessed trial quality. Main results: Seventeen trials with 3936 participants were included in the primary analysis. The quality of trials was generally good. There was limited evidence to support the use of antibiotics in acute bronchitis. At follow-up, there was no difference in participants described as being clinically improved between antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15; number needed to treat for an additional beneficial outcome (NNTB) 22. Participants given antibiotics were less likely to have a cough (four studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; NNTB 6); have a night cough (four studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7) and a shorter mean cough duration (seven studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance. Antibiotic-treated patients were more likely to be unimproved according to clinician's global assessment (six studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 25); have an abnormal lung exam (five studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6); have a reduction in days feeling ill (five studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and a reduction in days with limited activity (six studies with 767 participants MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants) (RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional adverse effect 5). Authors' conclusions: There is limited evidence to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self-limiting condition, increased resistance to respiratory pathogens and cost of antibiotic treatment.
Article
Background: Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it. Objectives: To assess the benefits of antibiotics for sore throat for patients in primary care settings. Search methods: We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013). Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications. Data collection and analysis: Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information. Main results: We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. SymptomsThroat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complicationsThe trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complicationsAntibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reductionAntibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs. Authors' conclusions: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.
Article
Background: The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care. Objectives: To assess the effects of antibiotics in improving outcomes and to assess adverse effects of antibiotic therapy for people with a clinical diagnosis of acute bronchitis. Search methods: We searched CENTRAL 2016, Issue 11 (accessed 13 January 2017), MEDLINE (1966 to January week 1, 2017), Embase (1974 to 13 January 2017), and LILACS (1982 to 13 January 2017). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 5 April 2017. Selection criteria: Randomised controlled trials comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in people without underlying pulmonary disease. Data collection and analysis: At least two review authors extracted data and assessed trial quality. Main results: We did not identify any new trials for inclusion in this 2017 update. We included 17 trials with 5099 participants in the primary analysis. The quality of trials was generally good. At follow-up there was no difference in participants described as being clinically improved between the antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15). Participants given antibiotics were less likely to have a cough (4 studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 6) and a night cough (4 studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7). Participants given antibiotics had a shorter mean cough duration (7 studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated participants were more likely to be improved according to clinician's global assessment (6 studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 11) and were less likely to have an abnormal lung exam (5 studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6). Antibiotic-treated participants also had a reduction in days feeling ill (5 studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and days with impaired activity (6 studies with 767 participants, MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants, RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional harmful outcome 24). Authors' conclusions: There is limited evidence of clinical benefit to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self limiting condition, increased resistance to respiratory pathogens, and cost of antibiotic treatment.
Article
Importance The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. Objective To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. Design, Setting, and Participants Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. Exposures Ambulatory care visits. Main Outcomes and Measures Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. Results Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. Conclusions and Relevance In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.
Article
This second edition of Hilbe's Negative Binomial Regression is a substantial enhancement to the popular first edition. The only text devoted entirely to the negative binomial model and its many variations, nearly every model discussed in the literature is addressed. The theoretical and distributional background of each model is discussed, together with examples of their construction, application, interpretation and evaluation. Complete Stata and R codes are provided throughout the text, with additional code (plus SAS), derivations and data provided on the book's website. Written for the practising researcher, the text begins with an examination of risk and rate ratios, and of the estimating algorithms used to model count data. The book then gives an in-depth analysis of Poisson regression and an evaluation of the meaning and nature of overdispersion, followed by a comprehensive analysis of the negative binomial distribution and of its parameterizations into various models for evaluating count data.