Tag Archives: antimicrobial stewardship

“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….


“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…


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

“No Pressure”

Have you ever taken yourself, or one of your children, along to a doctor and then either exaggerated the presenting symptoms in order to increase the chances of being prescribed an antibiotic?

Or have you ever directly asked the doctor to prescribe an antibiotic, either subtly or not so subtly…?

I am guilty as charged, because I am human like everyone else. However I am improving now that a large part of my job is anti-microbial stewardship!

And because doctors are human as well, they often give in to such demands, because they want the patient to leave the consultation having had a positive opinion of them, even if the antibiotic itself will make no difference to the outcome or speed of resolution of infection.

This week is World Antibiotic Awareness Week, an initiative by the World Health Organisation to make people aware of the potential dangers of overuse of antibiotics. There is plenty of useful promotional material available on their website to promote this message.

However, I believe that creating a “No pressure” culture is one of the key elements of antibiotic awareness amongst the general public. This is the concept of allowing your doctor to make an objective decision as to whether an antibiotic is required. I.e. you go to your doctor, relate the symptoms to them as honestly as possible, you do not pressurise the doctor for any particular type of treatment , and accept whatever treatment choices that the doctor makes.

As most of you are aware, antibiotics are completely futile for many of the conditions that a family doctor will see each day.

An antibiotic prescription in general practice should be the exception, not the norm.

Amidst all the various components of antimicrobial stewardship, I believe the key is reducing antibiotic usage by reducing inappropriate or unnecessary antibiotic prescriptions.

This is not just the responsibility of doctors, but of patients as well.

By all means, go to your doctor, but don’t go in the expectation that you will receive an antibiotic. If you end up getting one, so be it, but don’t push for it.

No pressure…