Current measures to reduce antibiotic prescribing in primary care are not enough to prevent the rise of drug-resistant infection in England, a new report has revealed.
Led by researchers at Imperial College London, the report is the first evaluation of NHS England’s Quality Premium intervention on antimicrobial resistance (AMR) – a reward scheme brought in in 2015 to encourage improvements in quality of care, including reducing inappropriate antibiotic prescribing in primary care.
The report has been published in The Lancet Infectious Diseases.
Single intervention not enough to combat AMR
The findings from the report suggest that, while the intervention achieved a downward step change in antibiotic prescribing, it only led to a modest reduction in antibiotic-resistant infections from Escherichia coli (E. coli). From this, the study’s authors concluded that a single intervention is not enough, and that a more radical and multi-sectoral approach is required to tackle the growing threat of AMR.
AMR occurs when bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness, and death. Antibiotics are becoming increasingly ineffective as drug-resistance spreads globally, leading to more difficult to treat infections and death, and E. coli is of particular concern because of its widespread resistance to antibiotics.
Antibiotic use in primary care is associated with increased risk of antimicrobial resistant infection and reducing antibiotic prescribing in this setting has been a cornerstone of antibiotic stewardship activity globally. In England, over 70% of antibiotics are prescribed in primary care, and many are considered inappropriate. This increases the chances of bacteria evolving and becoming resistant, so initiatives have been introduced in an attempt to educate and persuade prescribers of antibiotics to follow evidence-based prescribing.
The Global Digital Health unit team at Imperial College London, led by Dr Céire Costelloe, linked data from 6,882 English general practices with Public Health England’s (PHE) national surveillance of bacterial infections over the six-year period from January 2013 to December 2018 when the NHS Quality Premium was in operation. They looked at prescribing of the five most common antibiotics and examined resistance trends in E. coli infections, before and after the implementation of the intervention.
Dr Céire Costelloe, Reader and Director of the Global Digital Health Unit at Imperial College London, said: “We found that, although the NHS England Quality Premium on AMR succeeded in reducing broad spectrum antibiotic prescribing, resistance among E. coli causing bacteraemia remains on an upward trajectory, despite an initial attenuation. This highlights the fact that a single intervention alone is not enough to tackle the growing threat of AMR.
“A multifactor, multisectoral, collaborative and global approach is needed, taking into consideration antibiotic use across the entire healthcare economy, in combination with a wider, ‘One Health’ approach, which involves efforts that work nationally and globally to improve health for people, animals, and the environment.”
GP practices in England prescribed an average of 207 broad-spectrum antibiotic items per 100,000 patients per month before implementation of the Quality premium. A 13% reduction in prescribing rate was observed immediately following implementation of the Quality Premium, which corresponds to a reduction of 26 items per 100,000 patients in the English population. This effect was sustained such that by the end of the study period there was a 57% reduction in rate of antibiotic prescribing observed, compared to predicted rates if the intervention had not occurred.
In the lead up to the implementation of the Quality Premium, a monthly average of 275 resistant E.Coli isolates, per 1000 isolates tested against broad-spectrum antibiotics, were reported to Public Health England. A 5% reduction in resistance rate was observed immediately following the implementation of the Quality Premium, which corresponds to a reduction of 14 resistant E.Coli isolates per 1000 isolates tested. Although this reduction was sustained until the end of the study period, E.Coli resistance remains on an upward, albeit slower, trajectory.
Co-author Shirin Aliabadi, a research postgraduate in the Global Digital Health unit at Imperial College London and NHS Pharmacist, said: “Antimicrobial resistance is predicted to kill 10 million people per year by 2050. Naturally, the nation’s efforts and resources have shifted to responding to the ongoing COVID-19 crisis, but our findings suggest that we must nevertheless consider the growing threat of antimicrobial resistance, which can be a viewed as a silent pandemic.”