Children with acute coughs and respiratory tract infections (RTIs) are the most frequent patient group seen by GPs. Most RTIs are caused by viruses but up to half of patients are treated with antibiotics. This constitutes a large amount of inappropriate antibiotic prescribing in primary care, with the risk of contributing to antimicrobial resistance, a major public health threat.

The intervention had three components: GPs asking parents about their concerns during the consultation; use of an algorithm to identify children at very low risk of hospital admission within 30 days of the consultation (in whom antibiotics might be safely withheld); and a leaflet for parents and carers explaining what to do should their child’s condition not improve or deteriorate.

The trial had an ‘efficient’ design, in that practices rather than individual patients were recruited with the help of the NIHR Clinical Research Network, and primary outcomes were measured using data routinely collected by Clinical Commissioning Groups (now Integrated Care Boards) and Public Health England (now the UK Health Security Agency), rather than going through individual patient records. This design was used to reduce the burden on practice staff and was found to be both a feasible method of conducting a trial in primary care and good value for money.

Although overall the intervention was not effective in reducing antibiotic prescribing, sub-group analyses suggest that the intervention might have been more effective pre-pandemic; in older children; in affluent or single site GP practices; and those with fewer prescribing nurses. 

The researchers acknowledge that COVID-19 had a negative impact on the trial, affecting both numbers of patients seen and dispensing rates during much of the trial period. Remote consulting may also have impacted on intervention effectiveness.

Pete Blair, Professor of Epidemiology and Statistics at Bristol Medical School who led the research, said: ”Conducting research in primary care is not easy. Avoiding individual recruitment during busy consultations reduces the potential for bias and using routinely collected data at the practice level is viable and cost-effective for large studies. However, more investment in time and effort is needed to make recruitment of practices and data collection more accessible to researchers.”

In a linked editorial, Jerome Leis, Associate Professor in Infectious Diseases at Sunnybrook Health Sciences Centre and the Department of Medicine and Centre for Quality Improvement and Patient Safety at the University of Toronto, said: “The authors should be commended for completing this important quality improvement study in spite of these formidable [pandemic] challenges."

He added: “Importantly, a sensitivity analysis found significantly lower antibiotic dispensing in the practices in the intervention arm before March 2020. Given the significant external factors that blindsided this trial at the start of the pandemic, a post hoc analysis of this kind is justified. This finding suggests that when deployed as designed, this intervention can reduce antibiotic dispensing for respiratory tract infections in primary care, although the full magnitude of this effect remains unknown.”

Alastair Hay, Professor of Primary Care at the Centre for Academic Primary Care, University of Bristol, a senior co-author, and author of a related Opinion article in the BMJ, said: "Given the rigour with which the intervention was developed, combined with the evidence of pre-pandemic effectiveness, we hope that policy makers will consider promoting its adoption as another tool in the armoury against overprescribing of antibiotics in primary care."

Papers:

A multi-faceted intervention to improve management of antibiotics for CHIldren presenting to primary care with acute COugh and respiratory tract infection (CHICO): an efficient cluster randomised controlled trial. Published in BMJ. April 2023.

Linked editorial: Judicious antibiotic prescribing in primary care. Jerome A Leis. Published in BMJ. April 2023.

Twenty five years in the making: new evidence impacted by covid. Alastair Hay. Published in BMJ, May 2023.

Can primary care research be conducted more efficiently using routinely reported practice-level data: a cluster randomised controlled trial conducted in England? Pete Blair et al. Published in BMJ Open. August 2022.