All posts by michael

“Susceptibility to Influenza”

If you live in the Northern Hemisphere you may have found that your laboratory was swamped by incoming influenza tests this season?

You would not be alone.

Influenza is an unpredictable beast. In my own neck of the woods, New Zealand, the 2015 season was busier than usual, the 2016 season was almost non-existent, and the 2017 season was very average.

Nobody knows what will happen with influenza during 2018.. (Note that as NZ is in the Southern Hemisphere, our winter is June, July , August, right in the middle of the year).

Often you will see Influenza “experts” on TV making predictions about how severe the forthcoming influenza season will be. However such predictions come with huge pinches of salt. You might well be better off predicting the stock market…

The truth is that we don’t really know how bad the forthcoming influenza season is going to be, whether you are an expert or just an interested bystander.

And as a result we have no idea how much each influenza season is going to cost a diagnostic laboratory that performs influenza testing.

Let’s say a bog standard Influenza/RSV PCR costs approximately $30. In a quiet season 1000 tests might get performed in a medium sized hospital. However in a busy season 5000 tests might be required, with an excess cost of $120000. This would of course cause the laboratory manager some sleepless nights!

I am glad I am not a laboratory manager..

And then there might be an influenza pandemic…

The same goes for Public Health Laboratories. The numbers of samples coming in for antigenic sub-typing will be closely related to the severity of the influenza season.

Contracts that laboratory providers have with healthcare funders need to take this unpredictability into account. Some sort of clause like “The diagnostic laboratory will perform up to X Influenza PCRs during the Influenza season. If this number is exceeded, further funding will be negotiated”. Unfortunately this is often not the case. Often laboratory providers will be so desperate to get the contract signed and sealed that they will accept these risks, and manage such problems reactively.

From a financial point of view, microbiology laboratories are very susceptible to influenza test volumes, just like they are susceptible to emerging diseases and MDROs, cohorts where “unexpected testing” may need to take place.

There will of course be some laboratories who are reimbursed per test performed (fee for service). Those places of course would be hoping for a pandemic every year!, but such laboratories/funding arrangements are getting less and less common. The funders are not daft!

I hope for a quiet influenza season this year, and that is nothing to do with my personal risk! (I look forward to receiving the quadrivalent vaccine in the next couple of months).

Michael

“Use and Abuse”

You can produce sophisticated and comprehensive antimicrobial resistance surveillance data.

You can adhere to the best infection control policies in the country.

You can have a “search and destroy” policy for multi-resistant organisms.

and you can even develop and bring out a new antibiotic every couple of years….

But unless you control antibiotic consumption (usage), you will always be fighting an uphill battle.

In order to control antibiotic consumption you need to know how  many antibiotics are being used in the first place.

One of the problems is that antimicrobial resistance surveillance data is produced by microbiologists. Antibiotic consumption data is produced by pharmacists. Antibiotic consumption data even in this day and age can still be difficult to get hold of. Sometimes I wonder if the companies selling the antibiotics to the hospitals have a much better handle on consumption data than the microbiologists do!

Microbiologists and pharmacists need to talk to each other more. It is such a key relationship in the antimicrobial stewardship world.

Antibiotic usage needs to be surveyed and controlled not only at an individual level, but at a national level. Communities and hospitals, humans and animals. It all adds up… Too often I have sat in conferences and seen pretty graphs of antimicrobial resistance data, without complementary antibiotic consumption data to put the resistance data into context. I find it all a bit frustrating…

If reducing antibiotic usage was easy it would already have happened. It’s not easy , and there are good reasons for this. (See this article). This is where objective data is key to monitoring and measuring change. Feedback to the “prescriber” is critical.

Every antimicrobial stewardship committee in the world needs to be aware of their consumption data. Otherwise they are simply not doing their job. Surveillance of antibiotic consumption does not seem to get the same profile as resistance data. This is a shame. I would actually argue that it is the more important of the two….

Michael

“Back pocket antibiotic prescriptions: Good or Bad?”

Whenever my children get taken to the GP for a suspected chest/ear/throat/sinus infection, more often than not we are given a “back pocket”/delayed antibiotic prescription to be used only if the child does not improve over the next couple of days.

Is this a good policy?

My analytical way of thinking deduces the following assertions from the decision to prescribe a “back pocket” antibiotic prescription.

  • The doctor has decided that based on the current clinical presentation, the patient doe not require an antibiotic immediately.
  • The patient/guardian now has the primary responsibility as to whether the antibiotic is actually given or not. Is this really a good thing?

Studies have shown that back pocket prescriptions are acted upon about half the time, maybe a bit less than that. Whether or not a back pocket policy reduces antibiotic prescribing depends entirely on what you are comparing it against. If you say that all these patients would otherwise have received an antibiotic straightaway, then of course you can demonstrate a reduction! (Lies, damned lies and statistics…)

So what seems like a good idea may in reality may not be so perfect after all.

Given that only a small minority of such infections ever really need an antibiotic I prefer an educational approach (check out this leaflet), along with advice to come back if not settling in a couple of days’ time for clinical reassessment.

I remain to be convinced that back pocket prescriptions are a truly effective means of antimicrobial stewardship. To me it is more a way of the GP showing that they are doing something for the patient, a bit of a halfway house as such. It may even give out the completely wrong message to the patient. i.e. “I am not interested in seeing you again.”

If we are really serious about antimicrobial stewardship, then I think we need to review the back pocket policy. I think antibiotic prescribing for minor infections needs much tighter regulation. I also think including the clinical indication for the antibiotic on the prescription should be mandatory.

So the antibiotic prescription in my back pocket hardly ever comes out, and my gut feeling is that it shouldn’t even be there in the first place…

Michael

Here is an article with a bit more detail on this debate.