During a recent meeting to discuss the increasing threat of antimicrobial resistance, a GP member of the audience asked why those with the real responsibility for this problem: the vets, the dentists and secondary care weren’t being tackled for their irresponsible prescribing. There seems to be a “them and us” blame culture, rather than each of us taking collective responsibility for our part in the problem.
There is good evidence that in primary care there is a wide national[1] as well as international[2] variation in antibiotic prescribing and antimicrobial resistance rates[3]. There is no evidence that case-mix is responsible for these differences, and no evidence for any increase in complication rates in those areas that prescribe less.[4] The evidence seems to suggest that our choice of antibiotic may be improving but we are actually prescribing more antibiotics overall.[5]
The threat of antimicrobial resistance is real and is here and now. Both the World Health Organisation (WHO) and the Royal College of General Practitioners (RCGP) have flagged the global threat of increasing antimicrobial resistance as a major priority. With few new antibiotics in the development pipeline we will soon see the impact of increasing resistance in the community; it will no longer be a hospital phenomenon. This is a particularly relevant for multi-resistant E coli and gram negative infections.
The Department of Health has established an advisory panel with input from all the interested parties (primary care, secondary care, microbiology, public health, veterinary medicine, dentistry, nursing and pharmacy) under the umbrella term; ARHAI - Antimicrobial Resistance and Healthcare Associated Infection.[6] This panel meets to discuss current trends in antimicrobial use and resistance, recent advances in the field and also advises the Government. Other groups involving many professional societies are working together to make a difference.[7] This has started to happen with the Start Smart and Focus initiative in secondary care,[8] and European Antibiotics Awareness Day (EAAD) (http://www.dh.gov.uk/health/tag/eaad/). This year will see the launch of the TARGET website (Treat Antibiotics Responsibly; Guidance, Education, Tools) - a primary care toolkit hosted on the RCGP website to help inform improved antibiotic prescribing decisions in primary care.
Not taking any responsibility, or doing nothing because you think that what others are doing is more harmful, is not unique to this topic. It mirrors reactions to global warming and protecting the environment: “I don’t need to do anything because someone else is a greater offender than I am”, “whatever I do won’t make a difference.” However, if all the interested parties continue to take this attitude, then the situation for us and our patients will continue to deteriorate.
We are often criticised for prescribing too many antibiotics for many common general practice consultations (sore throats, coughs, urinary tract infections). There are many reasons why this is often the case. There is a fear that not prescribing an antibiotic could result in a complaint if subsequently the condition deteriorates while many antibiotics are prescribed in the hope of preventing complications[9]. There is good evidence that they do neither [10] and in fact can cause harm (diarrhoea, vomiting rashes, to name a few). Other reasons for prescribing include time pressures or patient expectations. Perhaps some of us are not as aware of the effects of resistant infections as our secondary care colleagues, who see the consequences more frequently.
So, GPs are up against it. We have to decide whether a patient in front of us needs an antibiotic, often without evidence of benefit, [4] with few tools to call upon.[11] [12] [13] Some strategies seem to help doctors to reduce prescribing: interactive booklets,[14] communication skills training,[15] delayed antibiotic prescribing,[16] and point of care tests[17]. However, these interventions are probably not being used as widely as they might be. On the plus side, GPs rise to a challenge; we are used to dealing with uncertainties and balancing risks and benefits with shared decision making.
The answer is that we can’t change prescribing habits on our own. We need to engage with patients and empower them. We need to win the argument that if antibiotics are to remain effective for future generations, we cannot prescribe them as readily as previously. We can’t always predict the course of the illness. We can provide information about symptoms of deterioration so that patients are confident to seek help when needed. In the hectic pace of modern society there is no time to feel unwell and patients often forget that illnesses are inconvenient and that sometimes time is the only cure.
Resistant infections when they occur take longer to treat, may require multiple courses of treatment, cause more morbidity and result in a greater chance of hospitalisation and poorer outcomes.[18] Faced with this situation, what would you choose to do – hope that someone else takes some responsibility and changes behaviour, or lead the way and start making small changes yourself?
So if you would like to be in the vanguard of this movement or would like more information to help you make better use of your time and prescribing decisions then you could undertake an on-line course on antibiotic prescribing in respiratory tract infection. Courses are available on the RCGP website www.RCGP.org.uk/TARGETantibiotics/which are free to all. Other useful resources to share with patients can be accessed through these pages.
Dr Naomi Stanton is the GP representative on the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection and a GP in Gilfach Goch in Wales
1. Ashworth, M., et al., Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995-2000. Br J Gen Pract, 2005. 55(517): p. 603-8.
2. Elseviers, M.M., et al., Antibiotic use in ambulatory care in Europe (ESAC data 1997-2002): trends, regional differences and seasonal fluctuations. Pharmacoepidemiol Drug Saf, 2007. 16(1): p. 115-23.
3. Goossens, H., et al., Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet, 2005. 365(9459): p. 579-87.
4. Butler, C.C., et al., Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. Bmj, 2009. 338: p. b2242.
5. Meropol, S.B., Z. Chen, and J.P. Metlay, Reduced antibiotic prescribing for acute respiratory infections in adults and children. Br J Gen Pract, 2009. 59(567): p. e321-8.
6. Finch, R., Current challenges in antimicrobial resistance and healthcare-associated infections: role and organization of ARHAI. J Antimicrob Chemother, 2012. 67 Suppl 1: p. i3-10.
7. McNulty, C.A. and N.A. Francis, Optimizing antibiotic prescribing in primary care settings in the UK: findings of a BSAC multi-disciplinary workshop 2009. J Antimicrob Chemother, 2010. 65(11): p. 2278-84.
8. Ashiru-Oredope, D., et al., Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart—Then Focus. J Antimicrob Chemother, 2012. 67 Suppl 1: p. i51-63.
9. Kumar, S., P. Little, and N. Britten, Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. Bmj, 2003. 326(7381): p. 138.
10. Petersen, I., et al., Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. Bmj, 2007. 335(7627): p. 982.
11. Ewig, S. and T. Welte, CRB-65 for the assessment of pneumonia severity: who could ask for more? Thorax, 2008. 63(8): p. 665-6.
12. Fine, A.M., V. Nizet, and K.D. Mandl, Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med, 2012. 172(11): p. 847-52.
13. Little, P., et al., Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women. Br J Gen Pract, 2010. 60(576): p. 495-500.
14. Francis, N.A., et al., Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. Bmj, 2009. 339: p. b2885.
15. Butler, C.C., et al., Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. Bmj, 2012. 344: p. d8173.
16. Little, P., Delayed prescribing of antibiotics for upper respiratory tract infection. Bmj, 2005. 331(7512): p. 301-2.
17. Cals, J.W., et al., Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. Bmj, 2009. 338: p. b1374.
18. Butler, C.C., et al., Antibiotic-resistant infections in primary care are symptomatic for longer and increase workload: outcomes for patients with E. coli UTIs. Br J Gen Pract, 2006. 56(530): p. 686-92.
