GPs the target in the fight against antimicrobial resistance
GPs have had success in cutting antibiotics prescribing yet remain the focus of the public health message. Elisabeth Mahase asks why?
Fighting antimicrobial resistance is a global health priority – and GPs have been more than playing their part.
In England, they have successfully cut antibiotics prescriptions; in hospitals and other community services rates are rising.
But the Government is demanding more. It had already called on GPs to cut antibiotics prescribing by 10% from March 2018 to 2020, and to educate patients about antimicrobial resistance.
But in the past two months, the Government has announced two new initiatives – the first is to cut antibiotics prescribing by a further 15%. The second is to prescribe shorter courses. New research commissioned by Public Health England claims 80% of GP antibiotics prescriptions for respiratory conditions are longer than recommended by PHE.
GPs are now asking when they will stop being targeted in the fight against antimicrobial resistance and start getting the support they need.
West Kent LMC representative Dr Zishan Syed says: ‘GPs are often targeted unfairly regarding antibiotics. The impression I get is it’s a political issue and it’s fashionable to blame GPs.
‘The present strategy is flawed. Self-management needs to be more heavily promoted. A clear message of the limitations of medicine in distinguishing between viral and bacterial infection is crucial. A fairer approach would be a national campaign to educate the public not to insist on antibiotics for self-limiting viral illness.’
The UK’s new 20-year vision for antimicrobial resistance, published in January, commits to ‘lower the burden of infection’, ensure ‘optimal use of antimicrobials’ and use ‘new diagnostics, therapies, vaccines and interventions’.
GPs know antimicrobial resistance is a major problem, and 80% of antibiotics are prescribed in primary care. Nevertheless, the burden for reducing their use falls disproportionately on GPs’ shoulders.
In 2016, then Prime Minister David Cameron said he wanted GPs to ‘halve’ inappropriate prescribing of antibiotics within four years. PHE finally clarified this in March 2018, when research it commissioned said between 8% and 23% of antibiotics prescriptions in primary care between 2013 to 2015 were not needed.1
PHE controversially used this to claim ‘at least’ 20% of all primary care antibiotics prescriptions in England were inappropriate, and called for the figure to be halved by 2020 – effectively re-announcing Mr Cameron’s earlier target.
In January, as part of the 20-year vision on antimicrobial resistance, the Government announced NHS antibiotics prescribing was to be cut by a ‘further 15%’, a reduction PHE suggests should mainly come from GP practices.
Speaking exclusively to Pulse, PHE antibiotics lead Dr Susan Hopkins says: ‘We want GPs, in the new action plan, to reduce prescriptions by a further 15% from where they are at now by 2024.
‘In 2019, that’s about 2-3% per year, so we’re not asking for a massive push.’
But this sounds like preaching to the converted, as GPs have been steadily reducing antibiotics prescribing in recent years. A PHE report last year found that, between 2013 and 2017, the overall number of individual antibiotics prescriptions written in primary care fell by 13.4%. Similarly, the defined daily dose (DDD) – which is the average amount of antibiotics being used – fell by 9.2% in general practice. But in all other settings the DDD increased – by 27.5% in community services, 10.5% in hospitals and 0.4% in dental services (see chart).
But Dr Hopkins argues general practice can still make the most impact: ‘We know 80% of antibiotics prescribing occurs in general practice – that is clearly where we can make the greatest wins.’
At the same time, PHE is now focusing on the length of antibiotics courses, following an analysis in the BMJ of around a million consultations, which suggested a cumulative 1.3 million excess days in terms of course length.2
Researchers have started to show that clinicians can safely decrease the length of antibiotics courses if a patient has significantly improved, contradicting the previous public message that courses must be finished to avoid resistance.
In 2016, a paper in JAMA Internal Medicine found a five-day course of antibiotics was as effective as 10 days in fighting infection in hospitalised patients with pneumonia.3 A year later, a group of infectious disease experts argued in the BMJ that taking antibiotics for longer than necessary increases the risk of resistance.4 They said certain opportunistic bacteria species that often already exist in the body develop resistance, so the longer they are exposed to antibiotics, the greater the risk.
Dr Hopkins says: ‘We’re asking clinicians to prescribe the shortest duration possible. In many situations, that’s gone from prescribing seven to 10 days of antibiotics right down to five days, and even three in some scenarios.
‘We understand that it’s difficult for GPs – they can’t review those patients every day – but they can prescribe short durations, and if the patient is not well after three or four days, then it’s about contacting the GP again.’
But GPs are not convinced this approach is feasible, and say it will add to workload. As Dr Syed puts it: ‘Often we find the shorter courses don’t work, so patients come back and we end up prescribing for a longer period of time than we would have previously.
‘If we started telling people with these very common infections to come back, we would end up doubling waiting times.’
Liverpool LMC secretary Dr Rob Barnett says patients will also lose out if they have to pay for two prescriptions. ‘We need a discussion and the Government needs to look at this,’ he says.
It’s not just the drive to shorten courses that is causing concern. GPs say the Government’s whole antibiotics strategy puts them in an impossible situation.
When PHE released its research showing GPs were prescribing antibiotics for too long, RCGP chair Professor Helen Stokes-Lampard responded, saying: ‘GPs are in an incredibly difficult position with antibiotics prescribing.
‘We are under huge pressure not to prescribe and publicly vilified if deemed to do so too readily. Yet, in some cases antibiotics are a matter of life or death.’
The Think Sepsis campaign, which implores GPs to spot the signs of sepsis and treat it with antibiotics as quickly as possible, is indicative of this.
GPs have witnessed the treatment of clinicians who did not prescribe antibiotics in cases later confirmed to be sepsis – notably Dr Hadiza Bawa-Garba, the Leicester paediatrician controversially struck off by the GMC.
Dr Syed says: ‘The sepsis campaign provides a drive to prescribe antibiotics, yet we have authorities wanting to do audits to effectively name and shame “high” prescribers.’
These concerns are shared by Walsall LMC medical secretary Dr Uzma Ahmad: ‘It’s very difficult to get the balance right, especially amid pressure and a lack of resources. We’re not in a hospital where we can do tests and get confirmation.’
There is also a concern the requirement for GPs to offer more digital consultations will make it harder to refuse antibiotics because of the lack of a physical examination. Dr Hopkins says: ‘The RCGP has developed a set of tools for sepsis and clearly it involves seeing the patient, so I think that’s going to be a challenge when we’re using more digital technology to do consultations.’
NHS England is exploring the possibility of introducing point-of-care testing into practices, focusing initially on the use of C-Reactive Protein (CRP).
GPs who have trialled CRP testing have found it helped reduce prescribing, but CCGs have been reluctant to fund the technology. So when NHS England decided to look at CRP, GPs raised concerns about funding and also fitting it into a 10-minute appointment. Some also questioned the test’s reliability.
For many GPs, though, the solution is to focus on patient demand. The Government has tried initiatives, including PHE’s awareness campaign featuring animated pills and asking patients to ‘keep antibiotics working’. PHE has also issued GPs with ‘non-prescription pads’ to help them talk to patients about whether antibiotics are appropriate.
Yet despite the best efforts of GPs and other clinicians, a Department of Health and Social Care report last year revealed antimicrobial resistance ‘continues to increase’. It said despite increased public awareness and lower prescribing, resistance and incidence of bloodstream infections had continued to rise.5
Dr Ahmad says the focus needs to be on education at a younger age: ‘I think there needs to more education around antibiotics, for example in schools, and especially when it comes to teenagers and those in college.’
An even more effective strategy would be longer GP appointments, says south London GP, Professor Azeem Majeed, head of primary care at Imperial College London: ‘Trying to assess a patient, take a history, perform a clinical examination, formulate a management plan and explain this to the patient is difficult in the typical 10-minute consultation.’
The new GP contract for England does make a commitment to move towards 15-minute consultations, but fails to explain how this will be achieved.
Professor Majeed says there also needs to be an emphasis on preventing the conditions that require antibiotics. He cites the example of urinary tract infections in care homes: ‘The main use for antibiotics in nursing homes is for UTIs resulting from poor hydration. I don’t see any approaches to tackle this, and thereby reduce the need to prescribe.’
Others highlight that many antimicrobials are prescribed for animals. Dr Jackie Applebee, chair of Tower Hamlets LMC in east London, says: ‘[Many] antibiotics are used in animal husbandry and enter humans via the food chain, not by being prescribed.
‘So while it is important for doctors and dentists to reduce antibiotic use, there is little point if the agricultural industry is not doing the same.’
But GPs simply want the Government to recognise that the responsibility must be shared. Dr Barnett says: ‘ I think it is right that GPs are targeted, but in the scheme of things, we only make up a small part of the use of antibiotics.
‘Yes, we have a responsibility but you can’t blame us for everything.’
1 Smieszek T et al. Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother, 2018;73;suppl2:ii36–ii43
2 Duration of antibiotic treatment for common infections in English primary care. BMJ 2019;364:l440
3 Uranga A et al. Duration of antibiotic treatment in community-acquired pneumonia. JAMA Intern Med. Arch Intern Med 2016;176(9):1257-1265.
4 Llewelyn M et al. The antibiotic course has had its day. BMJ 2017;358:j3418
5 House of Commons Health and Social Care Committee. Antimicrobial Prescribing. October 2018