Up to 1 in 5 antibiotics may be prescribed inappropriately

Tuesday February 27 2018

"Antibiotic madness: A fifth of prescriptions given out by GPs are to patients who do not need them," reports the Mail Online.

A new UK study investigated levels of inappropriate antibiotic prescribing by GPs in England. This was defined as prescribing antibiotics where guidelines say they're of little to no benefit.

Researchers also asked independent experts to estimate an "ideal" level of appropriate prescriptions of antibiotics in a consultation.

They looked at GP databases in England for 2013-15 to find out how antibiotics are being prescribed.

They found between 8.8% and 23.1% of all antibiotic prescriptions could be classified as inappropriate.

The highest number of inappropriate prescriptions were for sore throat, cough, sinusitis (inflammation of the sinuses) and ear infections.

These findings highlight the growing problem of antibiotic resistance.

We could reach a point where infections can no longer be treated with antibiotics, and even routine surgical procedures could become hazardous.

Sally Davies, the Chief Medical Officer for England, pointed out: "Antibiotics are unique among drugs since the more they are used, the less effective they become because bacterial resistance is likely to develop."

Antibiotics aren't recommended for minor ailments like coughs, which are likely to get better on their own.

If you're prescribed antibiotics, it's important to make sure you take them as prescribed and always finish the dose, even if you feel better.

Where did the story come from?

The study was carried out by researchers from several institutions across the UK, such as Public Health England and Imperial College London, and the University of Groningen in the Netherlands.

It was funded by Public Health England.

The study was published in the peer-reviewed Journal of Antimicrobial Chemotherapy and can be read for free online.

Generally, the media coverage in the UK was balanced and accurate.

What kind of research was this?

This cross-sectional analysis of data from a GP database aimed to identify and quantify inappropriate antibiotic prescribing by GPs in England.

The researchers hoped their analysis would help determine potential solutions for reducing the overprescribing of antibiotics.

Cross-sectional analyses, where data is collected at one point in time, are useful to look at how common a particular condition or activity is.

But it isn't usually possible to delve into an issue more deeply and confirm why it's the case.

For example, with this study, it may not be easy to determine the exact reasons why antibiotics were prescribed or say it was definitely inappropriate to prescribe them.

And we can't consider all the potential factors that may have influenced a doctor's decision.

What did the research involve?

GP data from 2013-15 was obtained from The Health Improvement Network (THIN) database, a primary care electronic database that contains anonymous patient data on antibiotic prescribing from GP consultations in England.

The researchers identified inappropriate antibiotic prescribing events by:

  • comparing prescriptions against clinical treatment guidelines for the condition
  • comparing the actual proportion of GP consultations that led to antibiotics being prescribed against the ideal proportions, which were derived from expert opinions
  • identifying high prescribers and variations in prescribing practices

The researchers used this information to look at the proportions and rates of inappropriate prescribing across all practices. They also looked at how much certain health conditions contributed to this.

They made 3 different levels of estimates about inappropriate prescribing:

  • conservative – where GPs were given the benefit of the doubt when it came to potential ambiguities in prescribing
  • least conservative scenario – where a stricter approach was taken
  • middle scenario – halfway between these approaches

What were the basic results?

Data from 3,740,186 prescriptions was used in the study, which included 260 out of 349 English practices (75%).

Of all systemic antibiotic prescriptions in English primary care, 8.8% were identified as inappropriate when the most conservative assumptions were applied.

When the least conservative assumptions were used, 23.1% of prescriptions were found to be inappropriate.

Conditions that had the most inappropriate prescriptions were:

  • sore throat (23.0% of all inappropriate prescriptions)
  • cough (22.2%)
  • sinusitis (7.6%)
  • ear infection (acute otitis media, 5.7%)

But this was based on analysis of only 23% of all prescriptions that could be classified as appropriate or inappropriate using treatment guidelines and expert opinion.

The majority couldn't be analysed for a variety of reasons, including lack of treatment guidelines, conditions not being recorded properly in the database, or not enough information on the patient or their symptoms to be sure whether the prescription was appropriate or not.

How did the researchers interpret the results?

The researchers concluded: "This work demonstrates … the existence of substantial inappropriate antibiotic prescribing.

"More precise prescribing guidelines and a deeper understanding of appropriate long-term uses of antibiotics would allow identification of further potential for reductions."


This cross-sectional analysis suggests around 1 or 2 in 10 antibiotic prescriptions issued by GPs may be inappropriate.

Respiratory infections are known to account for the majority of prescriptions in general practice.

These findings support this, identifying the highest number of inappropriate prescriptions being given for sore throat, cough, sinusitis, and ear infection.

Antibiotic resistance is a growing public health concern, and efforts to reduce inappropriate antibiotic prescribing are urgently needed.

The researchers hope this research will allow policymakers and doctors to prioritise their efforts in reducing unnecessary prescribing, focusing on prescriptions for minor ailments such as sore throats, colds and sinusitis.

That said, this study does have some limitations. The analysis only includes a quarter of all available prescriptions.

This highlights the need for better diagnostic coding in general practice, as well as more guidelines outlining the appropriate treatment for wider conditions.

If it had been possible to analyse all prescriptions, we may have found overprescribing rates were higher.

These results are only estimates. Though prescriptions were analysed by experts and compared with guidelines, it may be difficult to understand the exact circumstances in which GPs chose to prescribe.

The analysis is restricted to general practice in England. Although this may be representative, the findings shouldn't be automatically applied to GPs in Wales, Scotland and Northern Ireland, where prescribing practices may differ.

The study also didn't look at antibiotic prescription rates in hospital care, which is equally important for addressing antibiotic resistance and would have added a different dimension to the findings.

And as the authors pointed out, antibiotic prescriptions don't equate to how they're then used by patients.

Most coughs, colds and sore throats are viral, which means they can't be treated with antibiotics and will get better on their own.

If you're prescribed antibiotics, it's important to take the full course as recommended, even if you start to feel better.

Analysis by Bazian
Edited by NHS Choices