Explaining socioeconomic inequalities in antibiotic prescribing for common infections in English primary care: a population-based study

OBJECTIVES To quantify socioeconomic inequalities in antibiotic prescribing for common infections in primary care, and assess whether these inequalities arise from differences in consultation frequency, prescribing behaviour, or variation in vaccination uptake, smoking, and body mass index. DESIGN Population based cohort study. SETTING Primary care data from Clinical Practice Research Datalink, England. PARTICIPANTS 17,195,399 children and adults estimated to have been registered with a general practice in 2019. MAIN OUTCOME MEASURES Antibiotic prescribing rates (prescriptions per person-year), consultation rates (consultations per person-year), and probability of receiving an antibiotic prescription following consultation. RESULTS Higher deprivation was associated with higher antibiotic prescribing rates for most respiratory tract indications. In children, prescribing rates were 44.8% (95% confidence interval [CI] 41.9% to 47.7%) higher for upper respiratory tract infections and 47.6% (95% CI 44.2% to 51.3%) higher for lower respiratory tract infections in the most versus least deprived twentile. In adults, prescribing rates for lower respiratory tract infections were 22.7% (95% CI 21.4% to 24.1%) higher in the most deprived twentile. Prescribing rates for other indications showed weak, U-shaped, or negative associations with deprivation. Prescribing inequalities were primarily driven by inequalities in consultation rates rather than probability of receiving antibiotics once consulted. Lower influenza vaccination uptake partly accounted for higher consultation rates for respiratory infections among more deprived children, while smoking prevalence contributed to inequalities among adults. CONCLUSIONS Socioeconomic inequalities in antibiotic prescribing vary by indication type and are largely explained by consultation frequency. Reducing inequalities may require interventions that decrease the need to consult, e.g. improving influenza vaccination coverage in children and reducing smoking among adults, rather than focussing solely on prescribing behaviour.