Antibiotic Awareness: a round up of Cochrane evidence

In 2017, Professor Dame Sally Davies, England’s Chief Medical Officer at the time, warned that the world could face a “post-antibiotic apocalypse.” She urged that, unless action is taken to halt the practices that have allowed antibiotic resistance to spread and ways are found to develop new types of antibiotics, we could return to the days when simple wounds, infections or routine operations, are life-threatening.

We created this page in 2017 to mark World Antibiotic Awareness Week and we keep it up-to-date. Now, in 2020, the threat of antibiotic resistance – and the need for responsible antibiotic use – are as great as ever. Below, you can find summaries of Cochrane Reviews which have investigated the benefits and harms of antibiotics for a wide range of health problems. This evidence supports decision-making in the appropriate use of antibiotics.


Respiratory infections, illnesses and conditions

Deciding when to start and stop antibiotics in adults with acute respiratory infections: can testing blood procalcitonin levels help?

Using procalcitonin tests to decide when to start and stop antibiotic treatment in adults with acute respiratory infection reduces antibiotic consumption and makes little or no difference to mortality rates compared with usual care (high-certainty evidence). Procalcitonin-guided treatment probably has little or no impact on rates of treatment failure (moderate-certainty evidence). Using procalcitonin to guide antibiotic treatment probably reduces antibiotic-related side effects (moderate-certainty evidence). Cochrane Review (published October 2017); 26 studies with 6708 adults with acute respiratory infections such as pneumonia, bronchitis, exacerbation of chronic obstructive pulmonary disease, and others. Studies took place in different settings (primary care, emergency departments, intensive care units) and compared antibiotic treatment based on a procalcitonin test with usual care.

In children aged 2-59 months with severe pneumonia, what are the benefits and harms of a short course of intravenous antibiotics compared with a long course? 

For children aged 2-59 months with severe pneumonia, it is unclear whether there are any differences in treatment outcomes between short- (two to three days) and long-course (five days) intravenous antibiotics (alone or combined with oral antibiotics). EVIDENCE GAP. It is uncertain how short- and long-course intravenous antibiotics compare in terms of safety and adverse effects. Cochrane Review (published October 2017); no eligible studies found.

What are the benefits and harms of antibiotics for treating cough or wheeze after acute bronchiolitis in children?

Giving antibiotics to children with persistent cough or wheeze within six months of having acute bronchiolitis may make little or no difference to symptoms or to the likelihood of going back into hospital, compared with giving a placebo (all low-certainty evidence). There was not enough information about possible harms. Cochrane Review (published August 2017); 2 studies with 249 children aged 24 months and under, with wheeze or cough more than 14 days after hospital treatment for bronchiolitis, comparing antibiotics with placebo (something that appears the same as the antibiotic preparation but without the active ingredient).

In patients with bronchiectasis, how do oral antibiotics compare with inhaled antibiotics?

There is no high quality evidence on the comparative effectiveness and safety of oral versus inhaled antibiotics for treating people with bronchiectasis. EVIDENCE GAP. Cochrane Review (published March 2018); no eligible studies found. The review aimed to compare the effectiveness and safety of oral versus inhaled antibiotics for treating adults and children with bronchiectasis.

In patients with bronchiectasis, how do continuous antibiotics compare with intermittent antibiotics? 

The risks and benefits of continuous antibiotic therapy compared with intermittent antibiotic therapy for adults and children with bronchiectasis remain uncertain. EVIDENCE GAP. Cochrane Review (published June 2018); no eligible studies found. The review aimed to compare the safety and effectiveness of continuous versus intermittent antibiotics for adults and children with bronchiectasis.


Labour and birth

What are the benefits and harms of prophylactic antibiotics for women undergoing operative vaginal delivery? 

Compared with placebo or no treatment, prophylactic antibiotics reduce serious infectious complications and deep and superficial perineal wound infection (high‐certainty evidence), and probably reduce wound breakdown (moderate‐certainty evidence). Effects on organ or space perineal wound infection, maternal length of stay or endometritis are uncertain (low-certainty evidence). The studies did not report on maternal fever or urinary tract infection. It is uncertain whether prophylactic antibiotics have any impact on maternal adverse reactions (low-certainty evidence). The studies did not report on neonatal adverse reactions. Cochrane Review (published March 2020); two studies with 3813 women undergoing either vacuum or forceps deliveries. One study (3420 women) compared intravenous amoxicillin and clavulanic acid with placebo. The other study (393 women) compared intravenous cefotetan after cord clamping with no treatment.


What are the benefits and harms of routine antibiotic prophylaxis after normal (uncomplicated) vaginal birth?

Routinely giving antibiotics to women after uncomplicated vaginal birth, compared with placebo or no antibiotics, may reduce mothers’ risk of endometritis but may make little or no difference to mothers’ length of hospital stay or risk of wound infection. However these effects are very uncertain (all very low-certainty evidence). Routine antibiotics may make little or no difference to mothers’ risk of urinary tract infection (low-certainty evidence). None of the studies reported information about severe maternal infections. Routine antibiotics may have little or no impact on mothers’ risk of skin rash, but this effect is very uncertain (very low-certainty evidence). None of the studies reported information about antimicrobial resistance. Cochrane Review (published November 2017); three studies with 1779 women. The studies compared routine use of antibiotics with placebo or no treatment after normal (uncomplicated) vaginal birth.


What are the benefits and harms of routine antibiotics for women undergoing episiotomy repair after a normal (uncomplicated) vaginal birth?

The effects of routine antibiotic prophylaxis for episiotomy repair after normal birth are uncertain (very low-certainty evidence or no information reported). EVIDENCE GAP. There is not enough information about the possible harms of routine antibiotic prophylaxis. Cochrane Review (published November 2017); one study with 73 women in a hospital in Brazil, comparing oral chloramphenicol with no treatment.

Dental care

What are the benefits are harms of antibiotics for irreversible pulpitis (severe tissue damage within a tooth, which causes severe tooth ache)?

In people with irreversible pulpitis (when the tissue inside the tooth is damaged beyond repair, causing severe toothache), it is uncertain whether antibiotics reduce pain or the need for painkillers compared with placebo (low-certainty evidence). EVIDENCE GAP. There is not enough information about possible adverse effects of antibiotics. Cochrane Review (published May 2019); one study with 40 adults with irreversible pulpitis, comparing painkillers plus antibiotics with painkillers plus placebo.


Meningococcal disease

What are the benefits and harms of giving antibiotics prior to admission to hospital for suspected meningococcal disease?

There is probably little or no difference between single IM injections of ceftriaxone and long-acting chloramphenicol in reducing deaths or failure to respond to treatment (both moderate-certainty evidence) and there may be little or no difference in the incidence of neurological disabilities (low-certainty evidence). No adverse events were reported with either intervention. Cochrane Review (published June 2017); 1 study with 510 people during an epidemic in Niger, comparing single dose intramuscular (IM) ceftriaxone with IM long-acting chloramphenicol. No studies were found comparing pre-admission antibiotics with no antibiotics or placebo.


Surgical procedures

In women undergoing a cervical excision to reduce the risk of developing cervical cancer, what are the benefits and harms of antibiotics?

In woman undergoing cervical excision, prophylactic antibiotics (taken before the surgical procedure to prevent infection) may make little or no difference to lower abdominal pain, prolonged vaginal discharge or the need for unscheduled medical consultation compared with placebo or no treatment (low-certainty evidence). Prophylactic antibiotics may also make little or no difference to severe vaginal bleeding after the procedure, the risk of having a fever, or the need for additional self‐medication but the evidence is very uncertain (very low-certainty evidence). EVIDENCE GAP. The evidence is very uncertain about antibiotic‐related adverse effects (very low-certainty evidence). Cochrane Review (published January 2017); three studies with 708 women with pre‐cancerous cervical lesions undergoing excisional treatment to the cervix to reduce the risk of developing cervical cancer in the future. Two of the studies tested an antimicrobial vaginal pessary versus no treatment; the other tested oral antibiotics compared with placebo.

Transplants

Can antibiotics given around the time of transplant surgery prevent surgical site infections in organ transplant recipients? 

Can antibiotics given around the time of transplant surgery prevent surgical site infections in organ transplant recipients? In people undergoing organ transplant surgery, it is uncertain whether antibiotics reduce the incidence of surgical site infections compared with no antibiotics. It is also uncertain how an extended course of antibiotics compares with a shorter course of antibiotics. The effect on other outcomes including deaths, graft loss and other infections is uncertain (all very low-certainty evidence). None of the studies reported on adverse effects. Cochrane Review (published August 2020); eight studies with 718 organ transplant recipients, assessing whether antibiotics given around the time of transplant surgery prevent surgical site infections. The studies compared antibiotics with no antibiotics, or compared a short duration of antibiotics with an extended duration of antibiotics.

What are the benefits and harms of antibiotics in kidney transplant recipients who have bacterial infection in the urine but no symptoms? 

Compared with no treatment, the effects of giving antibiotics to kidney transplant recipients with asymptomatic bacteriuria on the incidence of symptomatic urinary tract infection (UTI), on hospitalization for UTI, and on antimicrobial resistance, graft loss, graft function, acute graft rejection and all-cause mortality are uncertain (all low-certainty evidence). EVIDENCE GAP. There was not enough information about harms. Cochrane Review (published February 2018); 2 studies with 212 adult kidney transplant recipients with asymptomatic bacteriuria, comparing antibiotic treatment with no treatment. 3 ongoing studies were also identified.


Prescribing practices

Improving how physicians working in hospital settings prescribe antibiotics

Interventions aimed at physicians to improve antibiotic prescribing practices for hospital inpatients lead to more patients receiving appropriate treatment and shorten the duration of antibiotic treatment compared with usual care (high-certainty evidence). Interventions to improve antibiotic prescribing probably also reduce the length of hospital stay, without increasing patient deaths (moderate-certainty evidence). Restrictive interventions (which apply rules to make physicians prescribe properly) may lead to delays in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence). Cochrane Review (published February 2017); 221 studies, including high-certainty evidence from 29 studies with 23,394 hospital inpatients (adults or children undergoing antibiotic prophylaxis or treatment). Most studies compared the effect of enabling interventions (which provide advice or feedback to help physicians prescribe properly) or restrictive interventions with usual care on antibiotic prescribing decisions.

Can rapid point‐of‐care tests help reduce antibiotic use in people with acute sore throat in primary care?

Rapid testing probably reduces antibiotic prescription rates by 25% (absolute risk difference) (moderate-certainty evidence) but may have little or no effect on rates of antibiotic dispensing (low-certainty evidence). The impact on the number of people who develop complications from the initial infection, or who need to have another consultation, is uncertain (very low- and low-certainty evidence). There was no information about adverse events attributed to the rapid tests. Cochrane Review (published June 2020); 5 studies with 2545 adults and children in primary care settings, comparing the use of rapid tests (alone or with a clinical scoring system) with clinical grounds (with or without a scoring system) to guide antibiotic prescriptions for sore throat.

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Editor’s note: page last updated November 2020.



Antibiotic Awareness: a round up of Cochrane evidence by Selena Ryan-Vig

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

1 Comments on this post

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    It’s quite frightening in a way how little we actually do know about such a ubiquitous treatment.

    Roger Harrison / Reply

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