WAAW and time to reconsider amoxicillin in childhood LRTIs

18th-24th November this year marks World Antibiotic Awareness Week (WAAW) - an important yearly reminder about the impact antibiotic resistance has on global health and the crucial role we have in General Practice to help stem the tide of antibiotic resistance. It feels a bit like the yearly dentist appointment to remind me to brush and floss my teeth better - although I do (mostly) try hard with that, I always know I can do better! But the fact remains that antibiotic resistance remains one of the top 10 global threats to health identified by the WHO, coming in at number 5 on the list (worth noting that weak primary care is identified as no. 7 on the list - something that seems to have bypassed many senior politicians…). 

But, it’s important to start with a positive note - we are doing well in primary care in the UK. The latest Nuffield Trust data published in September of this year, shows that in General Practice in England our antibiotic prescribing rates reduced by 16% between 2014 and 2019, and on the back of that, we have contributed to a substantial reduction in high risk antibiotics such as cephalosporins and quinolones. However, overall General Practice still prescribes >70% of the total amount of antibiotics, so we remain the key group to make the biggest impact on (safely) reducing antibiotic prescribing. 

We also know that RTIs remain one of the largest volume areas of antibiotic prescribing, despite the increasing evidence that for many of these RTIs antibiotics will be ineffective. I well remember one of my ex-colleagues joking (I think!) when I joined my practice 15 odd years ago, that the solution to managing winter RTIs (and demand) was to simply put a massive bucket of amoxicillin just outside the Practice entrance and invite patients to grab a handful as and when they saw fit! But times change, and we are all much more aware of the risks of over-prescribing antibiotics and how that drives antibiotic resistance. However, to reduce unnecessary prescribing we need good evidence to underpin our management. 

And bang on cue, just as the winter RTIs really ramp up, we have the ARTIC PC trial to help focus our mind on antibiotic prescribing in childhood RTIs. This was a well-conducted double-blind, placebo controlled RCT, importantly based in UK General Practices, so is highly relevant to our day to day practice. Children aged 6 months to 12 years with acute lower respiratory tract infection were recruited (acute cough <3 weeks with signs localised to the lower respiratory tract e.g. SOB, sputum, chest pain, but with pneumonia not suspected). Just over 200 in each group were assigned to either 7 days of amoxicillin or placebo, with the primary outcome being the duration of moderately bad symptoms. There was no difference between the 2 groups in the primary outcome, and importantly there were low rates of complications or subsequent hospital admissions which were similar between both groups. A useful secondary endpoint was that outcomes were similar irrespective of the 5 pre-specified clinical subgroups (chest signs, fever, physician rating of unwell, sputum/chest rattle, shortness of breath). 

So for me, the take home message is that as long as we don’t suspect a pneumonia, even if we think the child has some lower respiratory tract symptoms or signs (e.g. some creps or wheeze) or other features such as fever they are still unlikely to benefit from antibiotics.

One final caveat is that this study deals with acute cough <3 weeks. If children (especially younger ones under 6 years of age) have protracted wet cough for >4 weeks we need to consider protracted bacterial bronchitis, and if so antibiotics may be indicated in this group.

In summary, this feels like an important study - we’ve known for a long period of time that antibiotics rarely help with upper respiratory tract infection, and we now have some good evidence they don’t work in children 6months-12 years with lower respiratory tract infection (as long as pneumonia is not suspected). So what did we do for Amy? We discussed with Mum that although Amy does have a chest infection, it is likely to be viral and she is unlikely to benefit from antibiotics, while giving clear safety netting advice and the excellent RCPCH safety netting information.

Oh, and if you were wondering what is No 1 on the WHO global threats to health? Yup, you got it - air pollution and climate change. And on that note (if you haven't already done so), do look at Neal's excellent FREE Green GP course/webinar which you can download and watch on catch-up here.