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The waiting game

Saying 'no' to antibiotics is easy

‘I think I need antibiotics, doctor!’

Have you heard this opening gambit too often? Well fear not, it is time to wrestle back control of your prescription pad. The evidence in our favour is reaching Everest-like dimensions, the bells have started tolling for antibiotics in modern medicine and, furthermore, evidence shows that helping to save antibiotics can also help save our appointments.

At the end of a multi-problem 10-minute appointment it is easy to feel overwhelmed. Let’s face it, printing a script can seem substantially quicker than having an ‘antibiotic chat’, and saving antibiotics doesn’t make the slightest difference to QOF, DES or our ever-dwindling practice income. But research shows that prescribing fewer antibiotics may reduce the number of future consultations we might unwittingly perpetuate for self-limiting viral illness.

The world is running out of antibiotics. In the first thirty years after the discovery of penicillin, twenty different classes were discovered, but since 1962 only two more classes have been brought to market; the golden age of antibiotic discovery is over. MRSA is now widespread, particularly in the USA, and resistance among the Gram negative bacteria is the latest worry. Even Carbapenem resistant bacteria are increasing, and in 2009 a new superbug plasmid was discovered in India. This codes for an enzyme called NDM-1, which can confer resistance to several antibiotic classes at once. A ‘post-antibiotic era’ looms. 

There is an important new movement in medicine to combat this - Antibiotic Stewardship. But what can GPs do? Guidelines are at hand. The Centor criteria help for sore throat: not to prescribe unless we find at least three out of fever, exudate, lymphadenopathy, and absence of cough, and the RCGP has developed the ‘TARGET’ toolkit with a link to Public Health England quick reference guides, CPD training resources, a patient information leaflet in different languages and, if you need an audit for your appraisal, there is one ready to do on your own practice’s antibiotic prescribing.1

I’d also like to briefly highlight a few key points myself. Firstly, remember a dry viral cough with no fever or other signs of serious illness can last up to eight weeks, and 80% of sinusitis improves spontaneously in two weeks. In children it can be common in viral illness to hear wet sounding crepitations on auscultation, and the NICE Traffic light system should always be used to assess for signs of more serious illness.

Secondly, for skin infections, remember I&D without antibiotics works for boils. If boils are recurrent, rather than giving repeated courses, don’t forget to test for MRSA or PVL carriage, with skin and nasal swabs. For cellulitis do be aware that Flucloxacillin covers both Staph and Strep, but remember to always give sufficient doses in adults of 500mg QDS for five to seven days.

Thirdly, in women with symptoms of UTI a negative dipstick makes bacterial infection unlikely, and for recurrent UTI in non-pregnant women there is still no clear evidence, but consider appropriate post-coital or standby antibiotics to try to reduce resistance.

Importantly there is also now evidence against ‘delayed prescribing’. A recent Cochrane review concluded that, in patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotic prescription with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar clinical outcomes to delayed antibiotics.

In the future we may need something to replace antibiotics, but such research is in its infancy. I no longer feel disempowered when a patient tries to emphasize their impending holiday or work deadlines to try and get antibiotics. I explain that antibiotics may run out in their lifetime. And that every time we use them, we are using them up. I assess them at that point in time, and if they are not clinically unwell I explain in different ways that if they deteriorate it is much better medicine for them to have a repeat assessment. It seems only a matter of time before antibiotics run out for all of us. We can’t yet predict whether these crown jewels of medicine will still work in another two decades, and our own Chief Medical Officer has warned of a ‘catastrophic threat’. But we all have the power to slow the tsunami of resistance. And we might just save some more appointments too.

Dr Sara Ritchie is a GP in Stoke Newington, north London



Further reading

Ashworth M, Charlton J, Ballard K, Latinovic R, Gulliford M. Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995-2000. British Journal of General Practice 2005;55:603-608.

Gulliford M, Latinovic R, Charlton J, Little P, van Staa T, Ashworth M. Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006. J Public Health 2009 Dec;31(4):512-20.

McNulty CA, Nichols T, French DP, Joshi P, Butler CC. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract. 2013 Jul;63(612):e429-36.

Coates ARM, Halls G, Hu Y. Novel classes of antibiotics or more of the same? British Journal of Pharmacology, 2011;163:184-194.

Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW Jr, Makela M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014 Feb 11;2:CD000243.

Leman P, Mukherjee D. Flucloxacillin alone or combined with benzylpenicillin to treat lower limb cellulitis: a randomised controlled trial. Emerg Med J 2005;22:342-346.

Scottish Antimicrobial Prescribing Group. Guidance to improve the management of recurrent lower urinary tract infection in non-pregnant women. Jan 2014.

Spurling GK, Del Mar CB, Dooley L, Foxlee R, Earley R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004417.

Joint Statement on Antimicrobial Resistance by Faculty of Public Health, Royal College of Physicians, Royal Pharmaceutical Society, and RCGP - May 2014.

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Readers' comments (18)

  • thank you - however you have not touched on the medico-legal ramifications of all of this. Will the GMC support doctors if a complaint is made over non prescription of antibiotics or will their expert witness argue that they should have been prescribed...... what do you do then?

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  • Similarly look at comments on NHS choices - many are around conflicts when medications are refused ( ab's and painkillers being the most common).

    Until we have medico legal support, this is a dead issue.

    Also increasingly meds are being ordered online and from abroad - very common for patients to come in and ask which of their supply they should use !

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  • I'm happy to practice prescription pad medicine rather than evidence based medicine. It's to be honest more cost effective (pennies for most antibiotics rather than repeat attendances), less stressful and more time effective. Also screw the prescribing budgets as little support overall from our paymasters. UK is not the problem with antibiotic resistance. You just have to look at the expensive prescribing habits of overseas doctors when patients return from holiday to see this battle is lost.

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  • Crikey, what's the point in engaging brain or even examining the patient at all if we all adopt the attitude of previous post? Do you think this would stand up if a patient developed complications to the antibiotic you prescribed ? (presumably based on your above principles ). Maybe not.
    Perhaps it's better to practice evidence based medicine after all?

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  • practice evidence based medicine - I'd love to be able to!

    Most dr's are practicing pragmatic based medicine - where they're allowed to - do the right thing, when you're not try and survive!

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  • Doing the right thing doesn't necessary mean rigidly following PBM. GPs have to make so many judgements every day, it would be hard for them all to be evidence based or adhering to some form of guidance. How many refer on a two week when all that you really go off is gut many times are you right to do so?
    I don't think I would issue abx as it's the 'cheaper option' though. As the article suggests, the evidence is suggesting maybe it saves appointments in the future through reducing repeat attendances for obviously viral conditions.

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  • This is a national problem - so requires a national DOH response.

    Public Health 'Adverts' on BBC and newspapers etc - Cough/Colds do not need antibiotics, actual almost all do not even need a GP appointment.

    The problem is hugely exacerbated by GPs who practice poor medicine to give antibiotics to families - as much quicker and easier for any cough, sniffle or ear pain - so they attend every time as have 'Recurrent Chest Infections' but when a Real doctor examines them - there are no signs and just a Viral URTI.

    We have a collective responsibility to stop this excess prescribing.

    However until the government stops them being poured en mass in animal food and farming in general, the medical prescribing is a drop in the Ocean in this problem.

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  • I don't like the smug patronising tone of this article.

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  • After my registrar year, I stopped being so rigid with antibiotic prescribing.

    The reality and the RCGP theory are just so far away from each other. And the system of 10 mins, patient satisfaction, medico-legal, availability of "second opinion" A&E etc just mean the reality never will match the theory.

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  • It takes gentle persuassion over years to turn the tide. After being a prtner for 8 years I notice most parents accpet not getting antibiotics for otitis media etc. It is more difficult not to give antibiotics for the elderly or those with CODP diabetes etc. Why are we being singled out when dentists and vets use them too. and what about the antibiotics you can now get straight from the chemist!

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