All posts by 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.

“Face to face”

Sometimes your chair can be just too comfortable

It can be all too easy to sit in front of a computer all day, allowing yourself to be sucked in by a vortex of emails, playing to the tune of other people’s agendas, and from which it is difficult to escape as work fatigue sets in. We become hypnotised by the screen and frozen to our chairs.

Or if you are a scientist, you might feel compelled to sit all morning at the bench reading agar plates, without any hope of reprieve…

So one of my resolutions for 2018 is more face to face time. Less time in front of a screen and more time talking to people, building relationships, and breaking down barriers. By this I don’t mean more formal meetings, just more informal chats, and not necessarily about work!

Sure, there will always be periods where I need to be in front of a computer:- reading articles, reviewing or writing laboratory policy, checking emails, analysing data, etc. But I want to ensure that this is the minority of my working day, not the majority.

The same applies if you are working at a bench. If you have a mountain of culture plates to read, or samples to set up, then the risk of boredom and consequent errors is a genuine one. Make sure such work is punctuated by occasional wandering and chats to your colleagues. Discuss possible ways to make the laboratory process more efficient, or just talk about what you got up to at the weekend! And never, ever feel compelled to stay at your bench just because your boss is sitting in the office nearby. This is not school anymore!

Being an introvert, I am not a natural conversationalist, but this year I am going to force myself out of my comfort zone. Disagreements with colleagues, which are inevitable from time to time,  are so much easier to navigate through if you have a good working relationship with them.

To quote the often used cliche. “Nobody has ever said on their deathbed ‘I wish I had spent more time in the office/at the bench.‘”

But it’s absolutely true.

So in 2018 I will endeavour to seek more face to face time, assuming I can find somebody who is not busy sending emails or reading plates…

Michael

 

“The Annual Ritual”

A lot of diagnostic clinical microbiology laboratories create an annual antibiogram at the start of each year in order to inform laboratory users of local susceptibility rates for common microbe/antibiotic combinations. Here is a link to the one for my own laboratory.

It is a time honoured tradition, a ritual of sorts… There would be uproar from the clinicians if we didn’t produce it.

And yet such antibiograms are fundamentally flawed…

They are overly simplistic because resistance rates can vary markedly in different patient cohorts and different sample types.

Take the following examples (based on my local data searches):

  • Antibiotic resistance rates for urinary isolates differ markedly according to age and sex. Urinary isolates from young women have much lower resistance rates to uropathogens than old men, with the difference being up to 25% depending on what microbe/antibiotic is being tested. This has very obvious implications for empirical antibiotic choices for UTI in different population cohorts.
  • Staphylococcus aureus resistance rates to mupirocin are much higher in young people with recurrent skin infections than in the (elderly) cohort about to go elective  joint replacement.
  • MRSA rate as a percentage of total Staphylococcus aureus isolates is significantly higher in superficial wound swabs than it is in blood cultures.

These are just a few examples of many, but the common theme here is that different exposure rates to particular antibiotics in different population cohorts lead to different resistance rates.

So I suspect the days are numbered of static antibiograms shown in table form on an A4 sheet of paper.

So last year!

I see the future being an electronic interactive antibiogram, possibly in the form of a smartphone “app”. The clinician enters a few important variables, such as patient age, sex, sampling site, and community/hospital patient, along with the microbe isolated. The app then calculates a more accurate antibiogram based on the particular cohort that this patient falls into.

This is the future, I am sure of it.

The only downside to such an approach is by splitting the total susceptibility data available into different cohorts, the sample size for analysis goes down, which can then lead to bigger margins of error in the results for less common microbe/antimicrobial combinations. This however could be addressed in the app by adding a disclaimer to resistance rates calculated from small sample numbers.

And maybe an interactive electronic antibiogram is in existence already, in an ultra-progressive laboratory somewhere… If so, please let me know!

I had better get started on creating that app!

Michael