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The waiting game

The career-ending Catch 22 decision

Dr Zahid Chauhan

It’s apt that Pulse’s piece on the quandary facing GPs over antibiotic prescribing began with the word ‘emotive’, because seldom have I heard my colleagues respond to an article with such passion.

It perfectly articulated the life-destroying, career-ending Catch 22 that we may all face one day. How do we meet international clamour to reduce antibiotic prescribing, while ensuring that one misdiagnosis doesn’t cause organ damage or kill a child?

On the one hand, the World Health Organisation warns of the Armageddon scenario of the greatest health problem facing humankind, the predicted ten million deaths from superbugs by 2050.

This, it states plainly, has been because GPs are frequently bullied by a population that sees antibiotics as the silver bullet to cure all ailments, quickly.

In that, it’s partly right. The charity Antibiotic Research UK (ANTRUK) released information showing that medics are being verbally threatened and warned they’ll get an online panning for refusing to prescribe antibiotics, with over 80% also having their judgement questioned by sneaky patients who see another doctor (frequently out-of-hours) when denied the drugs.

That should enlist some sympathy. But we haven’t exactly done ourselves many favours by not taking the time to get to grips with a problem that could mean operations are cancelled due to a fear of infection. The same survey showed that only a third of healthcare professionals had a proper knowledge of the issue.

Stem the world’s biggest health problem, or chance a child’s life - what an appalling position to leave any prescriber in

But let’s not beat ourselves up too much. It takes more than a frightened GP to cause an international problem. Pharmaceutical companies driven by wealth not health continue to invest nothing in coming up with the modern medications that we need. The Government does little to properly incentivise them, save for announcing yet another strategy.

Farmers use them to fatten up animals, instead of heal them.

Let’s be honest - the whole of society has caused this potential catastrophe, and yet few organisations (bar the likes of ANTRUK) ask that we all solve it. Together.

Set against jibes that we ‘dish them out like sweeties’ and harsh targets to prune prescribing, we have exactly those horror stories Pulse discusses, about where broken-hearted parents overcome with grief and anger wonder: ‘Why weren’t antibiotics prescribed before my child developed sepsis?’

I share their agony. But it’s strange how the stories are never about older folks or others with already compromised immune systems. Perhaps their lives don’t matter as much?

Stem the world’s biggest health problem, or chance a child’s life - what an appalling position to leave any prescriber in.

According to one of the best authorities on the subject, Lord Jim O’Neill, diagnostics are the single most important intervention one can bring to solving antimicrobial resistance (AMR). Both he and the former chief medical officer - now UK special envoy on AMR - Dame Sally Davies, told the House of Commons Health and Social Care Committee that this was pivotal, and yet, of course, little progress has been made on developing them.

And here’s another stumbling block. What’s on the market has been denied to some surgeries by penny-pinching CCGs, which balk at a few pounds to buy the equipment, unaware seemingly, that AMR not only threatens lives, but according to the World Bank, is a direct threat to our economic future.

I think I speak on behalf of every GP when I say: ‘Take this choice out of our hands’. Stop us from having to hedge against the use of antibiotics by disseminating them needlessly and causing resistance.

But also never let us have to face families and tell them our reticence to prescribe antibiotics caused sepsis and loss of life.

Invest in diagnostics. Better still, back research into more effective treatments than the antiquated antibiotics developed before the 1980s that we have now. Because one needless death, whether by sepsis or superbug, is a death too many.

Dr Zahid Chauhan OBE is a GP in Greater Manchester; national campaigner for health equalities; and the founder of the charity Homeless Friendly charity. Follow him on Twitter @ChauhanZahid

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Readers' comments (14)

  • Decisions become easier when you cease to need to be loved or even liked by your patients. Respected is better.

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  • David Banner

    Hmmm, what to choose, a naughty boy letter from the CCG for over prescribing, or struck off and potential prison for “missing” sepsis?

    This is an excellent article, but further issues need exploring...

    -mass use of antibiotics in farming
    - antibiotics freely available OTC in many other countries
    -the cost of diagnostic equipment is important, but don’t forget the hidden costs of staff, longer appointments, follow up responsibilities etc.
    - once a “test” for antibiotics is freely available, the viral hordes will descend on practices instead of sweating it out at home. Who sees them?
    - the tests are not 100% specific/sensitive. Who’s to blame when sepsis kills off a patient told 2 days earlier it was just a virus?

    As the article suggests, the best way out of this mess is a “no fault for missing sepsis” clause in our contracts. But we all know this will never happen in our damned if you do/ damned if you don’t society.

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  • Agree with David and Zahid, but GPs need to get the message out there that what British GPs do has little influence compared with OTC availability overseas, farming use, and Hospital staff who tell patients they must get an antibiotic from the GP for their 'cold' or their operation will be delayed - clinically negligent blackmail!
    So, what is BMA, RCGP, LMCs, doing about this?

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  • Don't forget all those with viral urtis that are also 'at risk' of secondary infection. Apart from the standard diabetes, long term steroids, copd, asthma, ckd, rheumatoid, ihd, pulmonary fibrosis, previous sepsis, previous pneumonia etc we can usually rationalise (conjour up) justification for antibiotics if we are feeling pressurised, or just want to go home. This isn't by any means just a current GP perpetuated thing - my father told me that just after penicillin arrived it was tried for almost any dying patient - but it is now so much part of lay consciousnesses maybe we should try to manage it other ways than just direct confrontation. Perhaps a secret placebo, or a drug that has statistically significant benefit, with very little clinically significant benefit, (you know, like statins) but which also doesn't lead to multiple resistance - let's push that one for urtis, if we can find it. Then the patients would get what they want, and those that actually DO develop secondary bacterial infections would naturally self refer and we would manage those appropriately.

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  • Publics perception on antibiotics - I use domestos every week to scrub down my toilet so whats the fuss if I wnat to claen my dirty self/inside once every week.

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  • The Sepsis problem is not about deciding whether to give a course of placebomoxin capsules, but whether the patient actually needs an immediate big dose of parenteral killkeverythingomycin and an immediate transfer to that big building full of clever doctors and whizzy machines.

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  • Or not.

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  • And almost always they don't, but getting it wrong will be traumatic.

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  • David Banner

    Re Stelvio,

    Placebomoxin may do zilch for the presenting (probably viral) infection, but is a vital legal fig leaf should the hapless punter subsequently succumb to sepsis......

    Placebomoxin issued - “Well Doctor, don’t feel bad, you did everything you could do, it’s not your fault he died”

    Placebomoxin withheld- “You killed my husband, you incompetent quack! You’ll be struck off for this!”

    Either we are provided with immunity from prosecution over sepsis, or the over-prescribing will continue indefinitely.

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  • AMR genes are found in the permafrost and are probably millions of years old. They are activated mostly by farming. 80% of all antibiotics used on the planet is by 2 countries in farms and arrive in ship's ballasts. We GPs use only about .05% of the world' antibiotics.
    If you are worried about sepsis use it, remember Dr HBG

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