Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis

Costelloe, C.; Metcalfe, C.; Lovering, A.; Mant, D.; Hay, A. D.

doi:10.1136/bmj.c2096

Cited by 1,981Antibiotic Use and ResistanceAntibiotic Resistance in BacteriaUrinary Tract Infections Management

Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis

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Costelloe, C., Metcalfe, C., Lovering, A., Mant, D., Hay, A. D.·2010·BMJ

DOI 10.1136/bmj.c2096

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Abstract

OBJECTIVE: To systematically review the literature and, where appropriate, meta-analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Observational and experimental studies identified through Medline, Embase, and Cochrane searches. Review methods Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta-analyses were conducted for studies presenting similar outcomes. RESULTS: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months. CONCLUSIONS: Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection 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 carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.

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The major driver for the rapid development and spread of antibiotic resistance is the total volume of antibiotic use, which exerts unnatural selective pressure on bacteria and potentiates the development of AMR.
“The major driver for the rapid development and spread of antibiotic resistance is the total volume of antibiotic use, which exerts unnatural selective pressure on bacteria and potentiates the development of AMR [6].”
From Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers’ Perspectives across Two States (2021) · cites this paper as [6]

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Authors: Costelloe, C., Metcalfe, C., Lovering, A., Mant, D., & Hay, A. D.
Affiliations: National Institute for Health and Care Research (GB)
University of Bristol (GB)
Southmead Hospital (GB)
University of Oxford (GB)
Corresponding author: Hay, A. D.
ORCID: Costelloe, C.
Metcalfe, C.
Lovering, A.
Hay, A. D.
Venue: BMJ
Publisher: BMJ
Published: 2010-05-18
Volume: 340
Issue: may18 2
Pages: c2096-c2096
ISSN: 0007-1447 (ISSN-L)
0959-8138
1468-5833
DOI: 10.1136/bmj.c2096
OpenAlex: W2158264979
Cited by: 1,981
References: 51
Citations by year: 2026: 66 · 2025: 90 · 2024: 119 · 2023: 127 · 2022: 147 · 2021: 159 · 2020: 194 · 2019: 163 · 2018: 160 · 2017: 142 · 2016: 127 · 2015: 127 · 2014: 120 · 2013: 85 · 2012: 67
FWCI: 10.01
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by-nc
Locations: BMJ (publishedVersion, cc-by-nc)
PubMed (publishedVersion)
Bristol Research (University of Bristol) (submittedVersion, other-oa)
Spiral (Imperial College London) (submittedVersion, cc-by-nc)
Funders: National Institute for Health and Care Research (PC6/PDA04/10)
Topics: Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Medicine › Antibiotic Resistance in Bacteria
Health Sciences › Medicine › Epidemiology › Urinary Tract Infections Management
Keywords: antibiotic prescribing, antimicrobial resistance, primary care, urinary tract infection, respiratory infections, bacterial resistance, antibiotic duration, second-line antibiotics
MeSH terms: Anti-Bacterial Agents, Drug Resistance, Microbial, Family Practice, Humans, Practice Patterns, Physicians', Respiratory Tract Infections, Urinary Tract Infections

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Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis

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