The Downside of Antibiotic Stewardship

There are many advantages to curtailing antibiotic prescribing. Costs are reduced, fewer antibiotic-resistant bacteria are induced, and treatment-associated adverse events are eliminated.

This retrospective, population-based study, however, illuminates the potential drawbacks. Using electronic record review spanning 10 years of general practice encounters, these authors compared infectious complication rates between practices with low and high antibiotic prescribing rates. Spanning 45.5 million person-years of follow-up after office visits for respiratory tract infections, there is both reason for reassurance and reason for further concern.

On the “pro” side, cases of mastoiditis, empyema, bacterial meningitis, intracranial abscess and Lemierre’s syndrome were no different between those who prescribed high rates (>58%) and those with low rates (<44%). However, there is a reasonably clear linear relationship with excess follow-up encounters for both pneumonia and peritonsilar abscess. Incidence rate ratios were 0.70 compared with reference for pneumonia and 0.78 compared with reference for peritonsillar abscess. However, the absolute differences can best be described as “large handful” and “small handful” of extra cases per 100,000 encounters

There are many rough edges and flaws relating to these data, some of which are probably adequately defeated by the massive cohort size. I think it is reasonable to interpret this article as accurately reflecting true harms from antibiotic stewardship. More work should absolutely be pursued in terms of strategies to mitigate these potential downstream complications, but I believe the balance of benefits and harms still falls on the side of continued efforts in stewardship.

“Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records”

3 thoughts on “The Downside of Antibiotic Stewardship”

  1. ANother paper talking in relative risks, but a laudable effort to give something understandable in the abstract:
    “If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade”
    ABsolute risks and NNH/NNTs we’ll have to look up or calculate reading further. As ususal.
    I had a glance : tough task it seems

    When the authors state “We can conclude that the absolute risks of mastoiditis, empyema, intracranial abscess, and Lemierre’s syndrome remain small” they don’t tell us exactly how small is small.

    This is not a blinded prospective randomised trial and even a huge cohort like this cannot provide anything more than an idea to test properly in an RCT.

    Such a tiny teeny difference is not seriously credible. Even if that was an RCT , it would be difficult to infer any causality from suc microscopic figures..

    The Nurse Health Cohort also gave physiologically supported indication hormones were beautiful yet the WOman’s health Initiative, an RCT proved just the opposite as Vinay Prasad and Adam Cifu recently reminded us.

  2. I’m tired of people talking about doctors over prescribing antibiotics. 80% off all antibiotics go to farm animals. If we cut our prescribing in half (never going to happen) you would get a 10% absolute drop in antibiotic use. If you cut antibiotics for animals in half – you would get an 40% absolute drop in antibiotic use. Seems like the obvious place to start making changes is in animals.

    1. Use of antibiotics in animals is absolutely a public health problem – mostly due to induction of antibiotic-resistant bacteria. There are other harms relating to the use of antibiotics in humans relating to their direct toxicity (i.e., fluoroquinolones), medication interactions, allergic reactions, and alterations of natural bacterial colonization (i.e., c. diff, yeast infections). There are still good reasons to focus on reducing antibiotic use in humans, too!

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