Reducing antibiotics

– what are the positive options?

Self-care support from the College of Medicine

Doctors would prefer not to give you antibiotics unless really needed. The hope is to reserve antibiotics for life-threatening bacterial infections. There are three good reasons not to use them for everyday problems:

  • antibiotics do not work for viral infections, which are the most common;
  • the more antibiotics that are prescribed the more likely we will get infections resistant to them, and may find they are less effective if we need them;
  • antibiotics can upset our natural healthy gut flora (‘microbiome’).

This is all very well but what can we do instead? If we or our children go down with colds, flu, coughs, sinus, earache or sore throats – or get cystitis or urinary infections – what other options are there? Usual advice is to turn to paracetamol or ibuprofen to relieve discomforts and keep drinking fluids, but there are few suggestions for other remedies.

In this site we look at simple home care remedies that either have independent evidence for being effective in managing infections or have a long track record of being useful. They are all safe and generally inexpensive.

 

Before starting check this SAFETY NOTICE. Then consider looking first through the information on home remedies for the common cold. These are often useful for a wider range of infections. Then look at any other symptom you need help with.

UPDATE: As Coronavirus spreads around the world it is important both to heed current current advice about reducing spread and exposure, and to look for ways to improve your defences. There is a new Coronavirus page to cover likely options.

For each treatment option you will see a row with a choice of three symbols. This is what they mean.

Would you like to read more about the antibiotic question?

The evidence against routine use of antibiotics

Acute respiratory infections (ARIs) are one of the most common reasons for consulting in family practice/primary care. Systematic reviews of the benefits of antibiotics conclude that they have little benefit for reducing symptom duration or complications in sinusitis [Ahovuo‐Saloranta. 2014], bronchitis [Smith, 2014], sore throat [Spinks, 2013], and acute otitis media [Venekamp, 2015], and no benefit for laryngitis [Gonzales, 2001] or colds [Kenealy, 2013]. Any limited benefits of antibiotics for ARIs may be further outweighed by unnecessary exposure to common adverse reactions, such as diarrhoea, candidiasis, rash, abdominal pain, diarrhoea, nausea and/or vomiting [Gillies, 2015].

Patients prescribed an antibiotic for respiratory infection may 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 of organisms resistant to first line antibiotics, but also leads to increased use of second line antibiotics in the community [Costelloe 2010].

In the case of urinary tract infections antibiotic therapy is still the best treatment option. However up to a quarter of sufferers a left with recurrent infections and there are rising levels of antimicrobial resistance [McLellan, 2016; Waller 2018].

There may be other unintended consequences of antibiotic prescription. The recent advent of genome sequencing techniques has revealed the presence of communities of organisms inhabiting many spaces in or on the human body – the microbiota. These appear to have a major influence on the development of immune responses. There is increasing awareness of the importance of the respiratory microbiota in supporting defences, with ‘risk-‘ or ‘resilience-microbiota’ identified, with particular relevance in the vulnerability of children to respiratory infections. For example it has been postulated that children with higher levels of Moraxella and Haemophilus species in their airways during infancy have a higher incidence of ARI in early childhood, while those with more Lactobacillaceae (e.g., Corynebacterium, Alloiococcus) are associated with a lower incidence of ARIs [Hasegawa, 2015]. It seems likely that antibiotic prescription could upset these microbiota.

References

References

Ahovuo‐Saloranta A, Rautakorpi UM, Borisenko OV, et al (2014). Antibiotics for acute maxillary sinusitis in adultsCochrane Database of Systematic Reviews 2014, Issue 2

Link to Abstract and Full Text

Costelloe C, Metcalfe C, Lovering A, et al (2010). Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta‐analysis. BMJ 340: c2096

Link to Abstract and Full Text

Gillies M, Ranakusuma A, Hoffmann T, et al. (2015) Common harms from amoxicillin: a systematic review and meta‐analysis of randomized placebo‐controlled trials for any indication. Canadian Medical Association Journal 187 (1): 21‐31.

Link to Abstract and Full Text

Gonzales R, Malone DC, Maselli JH, Sande MA. (2001) Excessive antibiotic use for acute respiratory infections in the United States. Clinical Infectious Diseases 33: 757‐62

Link to Abstract and Full Text

Hasegawa K, Camargo CA Jr. (2015) Airway microbiota and acute respiratory infection in children. Expert Rev Clin Immunol. 11(7): 789-92

Link to Abstract and Full Text

Kenealy T, Arroll B. (2013) Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews 2013, Issue 6

Link to Abstract and Full Text

McLellan LK, Hunstad DA. Urinary Tract Infection: Pathogenesis and Outlook. Trends Mol Med. 2016;22(11):946–957.

Link to Abstract and Full Text

Smith SM, Fahey T, Smucny J, Becker LA. [2014] Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2014, Issue 3

Link to Abstract and Full Text

Spinks A, Glasziou PP, Mar CB (2013). Antibiotics for sore throatCochrane Database of Systematic Reviews 2013, Issue 11

Link to Abstract and Full Text

Venekamp RP, Sanders S, Glasziou PP, et al. (2015) Antibiotics for acute otitis media in childrenCochrane Database of Systematic Reviews 2015, Issue 6.

Link to Abstract and Full Text

Waller TA, Pantin SAL, Yenior AL, Pujalte GGA. (2018) Urinary Tract Infection Antibiotic Resistance in the United States. Prim Care. 2018;45(3):455–466

Link to Abstract

Delayed antibiotic prescriptions?

In a 2017 update to the Cochrane review comparing different antibiotic prescribing strategies [Spurling, 2017], the authors concluded that where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections, “no antibiotics” with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction. Where clinicians are not confident in using a “no antibiotic” strategy, a “delayed antibiotics” strategy may be an acceptable compromise. There were no significant differences in symptom control and disease complications between the different approaches. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics although delay was favoured over no antibiotics.

However explanation of the rationale for delayed prescription is needed [McDermott, 2017] and care taken to minimise mixed messages about the severity of illnesses and causation by viruses or bacteria. Better access is needed to good natural history information, and the signs and symptoms requiring or not requiring general practitioner advice. Significant concerns about paracetamol, ibuprofen and steam inhalation are likely to need careful exploration in the consultation.

References

References

McDermott L Leydon GM, Halls A et al. (2017) Qualitative interview study of antibiotics and self-management strategies for respiratory infections in primary care. BMJ Open.7(11): 016903

Link to Abstract and Full Text

Spurling GKP, Del Mar CB, Dooley L, et al (2017) Delayed antibiotic prescriptions for respiratory infections Cochrane Database Syst Rev. 2017 Sep; 2017(9): CD004417.

Link to Abstract and Full Text

Other prescribing options?

Unfortunately standard pharmaceutical alternatives to antibiotics do not sustain research scrutiny well.

For example there is limited evidence to support the agents currently available to treat acute cough due to upper respiratory infection. There are no published, well-designed, contemporary research studies supporting the efficacy of narcotics (codeine, hydrocodone) and over-the-counter oral antitussives and expectorants (dextromethorphan, diphenhydramine, chlophedianol, and guaifenesin) [Paul, 2012]. Even the default use of paracetamol and ibuprofen has been shown to be ineffective in managing otitis pain in children [Sjoukes, 2016].

Other approaches may be more productive. Compared to usual care a 2016 meta-analysis indicated that there is moderate quality evidence showing that trained GPs providing written information to parents of children with acute upper respiratory infections in primary care can reduce the number of antibiotics used by patients without any negative impact on re-consultation rates or parental satisfaction with consultation [O’Sullivan, 2016]. A key study reviewed involved 61 practices in England and Wales [Francis, 2009], and the use of an interactive booklet on respiratory tract infections in children within primary care (‘When Should I Worry’). This led to significant reductions in antibiotic prescribing and intention to consult, without reducing satisfaction with care.

In a wider review [Coxeter, 2015], interventions that aim to facilitate shared decision making were found to reduce antibiotic prescribing for acute respiratory infections in primary care in the short term by almost 40% compared with usual care, without an increase in patient‐initiated re‐consultations for the same illness or a decrease in patient satisfaction.

It has also been shown that GPs who have had additional training in complementary approaches prescribe less antibiotics than their colleagues [van der Werf, 2018].

References

References

Coxeter P, Del Mar CB, McGregor L, et al (2015) Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015(11): CD010907

Link to Abstract and Full Text

Francis NA, Butler CC, Hood K, et al. (2009)  Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 339: b2885.

Link to Abstract and Full Text

O’Sullivan JW, Harvey RT, Glasziou PP, McCullough A (2016) Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. Cochrane Database Syst Rev. 2016(11): CD011360

Abstract and Full Text

Paul IM. (2012) Therapeutic options for acute cough due to upper respiratory infections in children. Lung. 2012 Feb;190(1): 41-4

Link to Abstract

Sjoukes A, Venekamp RP, van de Pol AC et al (2016) Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev. 2016 Dec 15;12:CD011534

Link to Abstract and Full Text

van der Werf ET, Duncan LJ, Flotow P, et al. (2018)  Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates? Retrospective cross-sectional analysis of national primary care prescribing data in England in 2016. BMJ Open 8

Link to Abstract and Full Text