Seasonal variation in fluoroquinolone prescribing

J Antimicrob Chemother 1999; 43: 315–316

S. Abella, S. Chapmana,*, L. Nadina and R. Warrenb

a Department of Medicines Management, Keele University, Keele, Staffordshire ST5 5BG; b Public Health Laboratory, Royal Shrewsbury Hospital, Shrewsbury, UK

Sir,

National prescribing data for general practice in the UK (obtained from Prescribing Analysis and Cost (PACT) data provided by the Prescriptions Pricing Authority) are not amenable to interpretation in relation to clinical usage. None the less, there is widespread concern that the overall levelof antibiotic prescribing is excessive. We recently analysed PACT data for antibiotic usage in the West Midlands and concluded that seasonal analysis might contribute to interpreting and setting targets for appropriate prescribing.

Early fluoroquinolones (ciprofloxacin, ofloxacin and norfloxacin) have limited activities against pneumococci, streptococci, enterococci, anaerobes and methicillin-resistant Staphyloccocus aureus. 1 For these reasons, it is widely regarded that these drugs should not be used routinely as treatment of patients with respiratory tract, soft tissue or bone infections without clear bacteriological indications; in contrast to ciprofloxacin and ofloxacin, norfloxacin is licensed solely for use astherapy of patients with urinary tract infections.

The Figure shows the prescribing trends for fluoroquinolones in the West Midlands Health Authorities over a 3 year period between March 1995 and January 1998. As expected from the usage of norfloxacin being limited to the treatment of patients with urinary tract infections, there wasno evidence of seasonal fluctuation in the prescribing of this agent, whereas fluctuations in prescriptions for ciprofloxacin and ofloxacin are consistent with them being administered as therapy of patients with seasonal infections, particularly those of the respiratory tract. While the quinoloneshave potent activities against Haemophilus influenzae, they exhibit only modest activities against pneumococci and there are several antibiotics that should be used in preference in patients with respiratory tract infections; these include the tetracyclines, co-amoxiclav, trimethroprim and second- and third-generation cephalosporins. Thenewer fluoroquinolones, grepafloxacin and levofloxacin, have superior activities against pneumococci, compared with earlier agents, but it should not be construed from this that either drug should be used routinely as first-line therapy.



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Figure. Prescribing trends in the West Midlands (March 1995-January 1998) for ciprofloxacin ({blacklozenge}), norfloxacin (µ), ofloxacin (µ), and ciprofloxacin and ofloxacin combined (x).

 
Fluoroquinolones are used widely in both human and veterinary medicine; indeed, ciprofloxacin is currently one of the world's most frequently administered antibiotics. 2 In order to minimize the emergence of resistant strains, cross-resistance being a feature of these agents, 3 they should be used rationally. Fluoroquinolones are described in the ninth World Health Organisation Model List of Essential Drugs as being among `the most important reserve agents'. 4 Thus, the use of these antibiotics in patients with respiratory tract infections, as implied by the data reported here, and the rapid increase in ciprofloxacin prescribing in the West Midlands during 1997 are causes for concern. Ongoing education of both physicians and the public is essential,given that most episodes of upper and lower respiratory tract infections do not require antibiotic therapy. A public health policy on appropriate prescribing must be a priority and the ethics of promoting antibiotics in clinical settings where they are unnecessary should be given seriousconsideration. 4 Meanwhile, we suggest that a low seasonal fluctuation in fluoroquinolone prescribing is a good marker of restrained use.

Notes

* Corresponding author. Tel: +44-(0)1782-584-131; Fax: +44-(0)1782-713-586. Back

References

1 . Warren, R. (1995). Antibacterial agents: the fluoroquinolones. Prescriber's Journal 35, 95–101.

2 . Acar, J. F. & Goldstein, F. W. (1997). Trends in bacterial resistance to fluoroquinolones. Clinical Infectious Diseases 24, Suppl. 1, S67–73.[ISI][Medline]

3 . Eliopoulos, G. M. (1995). In-vitro activity of fluoroquinolones against Gram-positive bacteria. Drugs 49, Suppl. 2, 48–57.[Medline]

4 . Couper, M. R. (1997). Strategies for the rational use of antimicrobials. Clinical Infectious diseases 24, Suppl. 1, S154–6.[ISI][Medline]





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