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Antibiotic use and bacterial complications following upper respiratory tract infections: a population-based study
  1. Thomas Cars1,
  2. Irene Eriksson1,2,
  3. Anna Granath3,4,
  4. Björn Wettermark1,2,
  5. Jenny Hellman5,
  6. Christer Norman5,
  7. Anders Ternhag2,5
  1. 1Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden
  2. 2Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
  3. 3Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
  4. 4Ear, Nose and Throat Clinic, Karolinska University Hospital, Stockholm, Sweden
  5. 5Public Health Agency of Sweden, Solna, Sweden
  1. Correspondence to Dr Thomas Cars;{at}


Objectives To investigate if use of antibiotics was associated with bacterial complications following upper respiratory tract infections (URTIs).

Design Ecological time-trend analysis and a prospective cohort study.

Setting Primary, outpatient specialist and inpatient care in Stockholm County, Sweden. All analyses were based on administrative healthcare data on consultations, diagnoses and dispensed antibiotics from January 2006 to January 2016.

Main outcome measures Ecological time-trend analysis: 10-year trend analyses of the incidence of URTIs, bacterial infections/complications and respiratory antibiotic use. Prospective cohort study: Incidence of bacterial complications following URTIs in antibiotic-exposed and non-exposed patients.

Results The utilisation of respiratory tract antibiotics decreased by 22% from 2006 to 2015, but no increased trend for mastoiditis (p=0.0933), peritonsillar abscess (p=0.0544), invasive group A streptococcal disease (p=0.3991), orbital abscess (p=0.9637), extradural and subdural abscesses (p=0.4790) and pansinusitis (p=0.3971) was observed. For meningitis and acute ethmoidal sinusitis, a decrease in the numbers of infections from 2006 to 2015 was observed (p=0.0038 and p=0.0003, respectively), and for retropharyngeal and parapharyngeal abscesses, an increase was observed (p=0.0214). Bacterial complications following URTIs were uncommon in both antibiotic-exposed (less than 1.5 per 10 000 episodes) and non-exposed patients (less than 1.3 per 10 000 episodes) with the exception of peritonsillar abscess after tonsillitis (risk per 10 000 tonsillitis episodes: 32.4 and 41.1 in patients with no antibiotic treatment and patients treated with antibiotics, respectively).

Conclusions Bacterial complications following URTIs are rare, and antibiotics may lack protective effect in preventing bacterial complications. Analyses of routinely collected administrative healthcare data can provide valuable information on the number of URTIs, antibiotic use and bacterial complications to patients, prescribers and policy-makers.

  • epidemiology
  • epidemiology
  • infection control

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors TC, IE, AG, BW, JH, CN and AT contributed to the design of the study. TC extracted the data, wrote statistical programs and led statistical analyses. TC, IE, AG, BW, JH, CN and AT participated in the interpretation of data. TC had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. TC and IE drafted the paper. TC, IE, AG, BW, JH, CN and AT critically revised the paper for important intellectual content and approved the final version to be published.

  • Funding This study was funded by the Stockholm County Council and the Public Health Agency of Sweden.

  • Competing interests None declared.

  • Ethics approval The study was approved by the regional ethics committee at Karolinska Institutet, Sweden (ref. no 2015/158-31).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional data are available by emailing the corresponding author.

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