News Release

Reducing antibiotic use in primary care may be insufficient alone to curtail antimicrobial resistance

Peer-Reviewed Publication

Imperial College London

Strategies to reduce antibiotic prescribing in primary care are insufficient alone to halt the rise in drug resistant E. coli infections in England, a new report concludes.  

The first evaluation of NHS England’s Quality Premium intervention on antimicrobial resistance (AMR) is published in The Lancet Infectious Diseases. The Quality Premium scheme was introduced in 2015 and rewarded groups of general practitioners (GPs) for improvements in quality of care, including reducing inappropriate antibiotic prescribing in primary care.

Led by researchers at Imperial College London, the new report finds 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). The study’s authors conclude that a single intervention in one sector is not enough; a more radical, multi-sectoral approach is needed to tackle the growing threat of AMR. 

AMR is a substantial and growing health issue, which globally causes around 700,000 deaths a year. E. coli is of particular concern because of its widespread resistance to antibiotics. It is the most common drug resistant infection, and in the UK more than half of drug-resistant bacterial blood stream infections, which can lead to sepsis, are caused by E. coli

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 per cent 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 tried 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, and colleagues 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 says: “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 per cent  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 per cent 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 per cent 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 says: “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.”

Co-author Professor Azeem Majeed, GP, and Head of the Department of Primary Care and Public Health, Imperial College London, says: “My colleagues in primary health settings have done the right thing and responded to the focus on their prescribing of antibiotics, but to combat the devastating impacts of antimicrobial resistance, we need global, coordinated efforts and new drugs to treat resistant infections. If the COVID-19 pandemic has taught us anything, it is that we can move fast in the face of large-scale epidemics. If we apply some of the recent lessons learned and work together, we can achieve a great deal in a short time. I hope this is possible.” 

For more information, please contact:
Maxine Myers
AHSC Communications Manager
Imperial College London 
Tel:  +44 (0) 7561 451724
Duty press officer mobile: +44 (0) 7803 886248

Notes to editors

To download the paper before the embargo lifts:

Claim ID: HWUSupwQnf5GyW82
Claim Passcode: S8SARihSaaYQ7Mfx

About Imperial College Academic Health Science Centre (AHSC) 
The AHSC is a partnership between Imperial College London, The Institute of Cancer Research (ICR) Imperial College Healthcare NHS Trust, Chelsea and Westminster NHS Foundation Trust and the Royal Marsden NHS Foundation Trust, based in West London. 

Established in 2007, it was the first AHSC to be created in the UK and was formally designated by the Department of Health in 2009. 

The partnership brings together multi-disciplinary research and education from across all faculties at the College with the resources and critical mass of the three Trusts to advance discovery and innovation within healthcare. 

The purpose of Imperial College AHSC is to utilise excellence in research and education to transform health outcomes, and support the UK's globally competitive position in healthcare related industries by increasing societal and economic gain. 

The AHSC is nested within Imperial College Health Partners, the Academic Health Science Network for North West London, which will ensure that discoveries and innovations are applied on a national and global scale. 

About Imperial College London
Imperial College London is one of the world's leading universities. The College's 16,000 students and 8,000 staff are expanding the frontiers of knowledge in science, medicine, engineering and business, and translating their discoveries into benefits for society. 

Founded in 1907, Imperial builds on a distinguished past - having pioneered penicillin, holography and fibre optics - to shape the future. Imperial researchers work across disciplines to improve health and wellbeing, understand the natural world, engineer novel solutions and lead the data revolution. This blend of academic excellence and its real-world application feeds into Imperial's exceptional learning environment, where students participate in research to push the limits of their degrees. 

Imperial collaborates widely to achieve greater impact. It works with the NHS to improve healthcare in west London, is a leading partner in research and education within the European Union, and is the UK's number one research collaborator with China. 

Imperial has nine London campuses, including its White City Campus: a research and innovation centre that is in its initial stages of development in west London. At White City, researchers, businesses and higher education partners will co-locate to create value from ideas on a global scale. 

Imperial College London is a world-class university with a mission to benefit society through excellence in science, engineering, medicine and business.   


Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.