A research article published this week in the British Medical Journal has demonstrated that the prescription of antibiotics to children in primary care leads to a short term increase in resistance in the individual that is sufficient to sustain a high level of antibiotic resistance in the population.
The study recruited 119 children who presented in primary care with an acute respiratory tract infection. 71 of the children were prescribed a beta-lactam antibiotic. Antibiotic resistance was assessed at recruitment and after 2 and 12 weeks using two methods; minimum inhibitory concentration of ampicillin and presence of resistance elements in Haemophilus isolates from throat swabs.
Prescription of amoxicillin more than tripled the minimum inhibitory concentration for ampicillin (9.2 µg/ml v 2.7 µg/ml, P=0.005) and doubled the chance of resistance elements being detected (67% v 36%; relative risk 1.9, 95% confidence interval 1.2 to 2.9) at 2 weeks. By 12 weeks resistance had fallen to baseline levels.
The authors conclude that "substantial and sustained changes in antibiotic prescribing in the community" are required to reverse the endemic presence of bacterial resistance in UK children. They also suggest that, if a second course of antibiotic treatment is considered necessary within 12 weeks, a beta-lactamase inhibitor - antibiotic combination (for example co-amoxiclav) may be an appropriate choice.
Action: Clinicians should continue implementing strategies to reduce overall prescribing of antibiotics to minimise the risk of antibiotic resistance. Where repeated courses are considered necessary, antibiotic resistance should be considered during antibiotic selection.
The British National Formulary for Children has been updated, published and made available online.
A press release from the publishers contains more information about the update. Many NHS staff will receive a free hard copy through usual channels and can also access the online version at http://www.bnfc.nhs.uk.
Action: BNFC is the primary source of prescribing information when prescribing to all children up to the age of 18 years.
Aliskiren (Rasilez®) has been approved for use in the European Union according to a media release from the manufacturer. The Summary of Product Characteristics is now available via the Electronic Medicines Compendium.
This new antihypertensive is the first in a new class of drugs that work through direct renin inhibition. The drug has been approved based on data from 44 clinical studies involving over 7,800 patients.
Studies have shown greater blood pressure lowering when compared to ramipril or hydrochlorothiazide. Additional blood pressure lowering has been demonstrated in patients who were already taking angiotensin converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and thiazide diuretics.
The drug has been shown to have a long duration of action and is the subject of ongoing studies in patients with high blood pressure and heart failure or kidney failure.
As with all new products, the evidence supporting use is limited in terms of restricted patient exposure and study endpoints focussing upon disease orientated outcomes (blood pressure in this case). These two factors combined mean that the risk-benefit profile of the drug is not yet fully understood. Increased usage will reveal more side effects and ongoing studies may provide more valuable patient orientated data (for example reduced risk of death or cardiovascular disease).
Action: Clinicians should be aware of the launch of this new antihypertensive agent. It is likely to be heavily marketed in the coming months. Initial use should be restricted to those patients already on maximal therapy, intolerant or contraindicated to established antihypertensive treatments.
An editorial in the British Medical Journal questions the cost effectiveness threshold used by the National Institute for Health and Clinical Excellence (NICE) claiming that is may currently be too generous. The BBC has reported this story.
This editorial was written by John Appleby, chief economist at the King's Fund. The article highlights that the current cost-effectiveness threshold is arbitrary and inconsistent across the NHS; the cost-effectiveness threshold employed by NICE is higher than calculated equivalent thresholds used in Primary Care Trusts. The editorial concludes that the NHS should be given "independence from the Department of Health on the specific matter of setting a cost effectiveness threshold".
The guidance produced by NICE is increasingly coming under critical review. Broader discussion is required to clarify how the NHS should invest a limited budget in order to obtain maximum healthcare benefits.
Action: Clinicians should continue to implement NICE Guidance but may wish to be aware of the ongoing debate regarding the cost-effectiveness threshold.
Thanks to PharmaGossip for spotting this editorial.
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