There is clear evidence of uncertain benefit in NICE's inconsistencies
Look, it’s just a hobby, OK - this tendency of mine to forensically scrutinise NICE guidance and point out its inconsistencies and errors and non sequiturs. You have hobbies, too, right, whether it’s stamp collecting, yoghurt making or toad sexing. That’s fine. Mine’s NICE-picking.
So, the latest NICE guidance I’ve just wasted another chunk of my life over is a draft one on antibiotic prescribing in acute exacerbations of COPD. And it’s a pedantic NICE picker’s dream.
First, we have to put to one side the overarching message, which is that we should be trying to reduce our antibiotic prescribing in acute exacerbations of COPD.
Yes, that’s right. Just in case you thought you didn’t read that correctly - to get onto the nit-picky bits, we have to ignore the key message; we should be reducing our prescribing of antibiotics in acute COPD.
This, in turn, means ignoring the fact that this would drive a coach and horses through traditional practice. This also means ignoring the fact I have just employed nurses whose job descriptions include organising rescue packs for COPD patients.
In addition, it means ignoring the fact that patients never complain when you do something (eg prescribe antibiotics), but they most certainly will if you don’t, especially if they go on to become very unwell/hospitalised/dead.
But, ignoring all that, I want to focus on two of the minutiae of the guidance because that’s my hobby, remember?
First, in the treatment section of the guidance NICE says we should offer an antibiotic for a severe exacerbation. But if it’s not severe we are told we should only consider antibiotics - that is to say, if it’s a moderate or mild attack.
Still with me? Good. Because here’s the funny bit. How do you suppose NICE defines a moderate attack? As an episode ‘that requires treatment with systemic corticosteroids and/or antibiotics’.
In other words, consider antibiotics if the severity of an exacerbation of COPD is such that it requires antibiotics.
That line is so marvellous that I’m jotting it down in my NICE-spotting notebook. Swiftly followed by the other teensy detail I’d like to highlight from the guidance - that, when we’re considering antibiotics for those moderate exacerbations that by definition require antibiotics, then we should bear in mind ‘That for people with less severe or fewer symptoms who are having treatment in the community there is evidence of uncertain benefit of antibiotics’.
Yes. ‘Evidence of uncertain benefit’. I’ve been mulling that for over 48 hours now, and the only thing I’m certain about, because I’ve checked in the mirror, is that trying to figure out what it means makes me pull the kind of face my bowels insist on after a couple of days of co-codamol.
Anyhow, I realise I am now in danger of labouring the point about this latest NICE gripe of mine. Even I can recognise that this is probably not healthy and that I need a different hobby. So how do you sex a toad, exactly?
Dr Tony Copperfield is a jobbing GP in Essex