Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis

Published 18 May 2010, doi:10.1136/bmj.c2096
Cite this as: BMJ 2010;340:c2096

Research
Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis

Céire Costelloe, research associate1, Chris Metcalfe, senior lecturer in medical statistics2, Andrew Lovering, consultant clinical scientist3, David Mant, professor of general practice4, Alastair D Hay, consultant senior lecturer in primary health care1

1 Academic Unit of Primary Health Care, NIHR National School for Primary Care Research, Department of Community Based Medicine, University of Bristol, Bristol BS8 2AA, 2 Department of Social Medicine, Canynge Hall, University of Bristol, Bristol BS8 2PS, 3 Department of Microbiology, Bristol Centre for Antimicrobial Research and Enterprise, Southmead Hospital, Bristol BS9 3HU, 4 Department of Primary Health Care, NIHR National School for Primary Care Research, Oxford University, Headington, Oxford OX3 7LF

Correspondence to: A Hay alastair.hay@bristol.ac.uk
Objective To systematically review the literature and, where appropriate, meta-analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care.
Design Systematic review with meta-analysis.

Data sources Observational and experimental studies identified through Medline, Embase, and Cochrane searches.

Review methods Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta-analyses were conducted for studies presenting similar outcomes.

Results The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months.

Conclusions Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.

© Costelloe et al 2010
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