Tag Archives: antimicrobial stewardship

“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…

Michael

“A paradigm shift…”

At the moment most antibiotics are initiated without waiting for the microbiological result, if they are thought to be clinically necessary.

Quite right too.

This is so called “empirical therapy”.

There is a good reason for this. Traditionally, microbiology tests have neither been good enough nor fast enough to make the antibiotic prescription dependent on the result.

Take for example the patient who sees his GP with a productive cough and fevers. The GP is not going to say to the patient “Let’s just wait a few days until we get the sputum culture result back. By the way there is a good chance it will be negative even if you do happen to have a pneumonia. And on the flipside, if it does grow something it might just represent the bacteria in your throat.”

No chance…, the GP will simply prescribe an antibiotic based on the most likely pathogens, and also the local antibiotic susceptibility patterns.

Along the same lines, the GP is not going to say to the patient a couple of days later. “Your sputum sample has come back negative, so let’s stop your antibiotic.” Sputum cultures are nowhere near sensitive enough to allow this approach.

On the very odd occasion, the treatment will actually change as a consequence of the microbiology result, if there happens to be an unusual or resistant organism.

And sputa are only one sample type. Ear swabs, peri-anal swabs, & ulcer swabs probably have even less impact on patient management…

In fact for the vast majority of  samples (probably > 95%) that get processed by the microbiology laboratory, the impact on patient management is rather small indeed.

However change is coming on to the horizon. The newer microbiological tests, and in particular the polymerase chain reaction (PCR) assays, are both fast enough and sensitive enough to start genuinely impacting on patient management right at the time of prescribing.

Take the following potential examples:

  • Macrolide antibiotics could be witheld in a patient with suspected whooping cough until the Bordetella pertussis PCR is back.
  • Patients with urethral discharge and suspected gonorrhoea would only be treated if the Neisseria gonorrhoeae PCR result comes back positive.
  • Patients with meningo-encephalitis could have acyclovir to cover HSV, dependent on the CSF viral panel result.
  • Legionella cover in a patient with moderate to severe community acquired pneumonia could be dependent on the result of the Legionella PCR in a sputum sample.

These are all tests which, if performed quickly enough, can significantly reduce the amount of antibiotics given to the tested cohort, so they all have potential to play a big part in any antimicrobial stewardship program.

So we need to get such assays into our microbiology laboratories, whatever it takes.

Microbiology matters, but we need to ensure that we utilise new tests and technology to make it matter even more…

Michael

 

“To err is human”

Those that know me, will be aware that I am a passionate believer in having clinical rationale and clinical context as pre-requisite for all microbiology samples that are processed by the laboratory.

Exactly the same principles should apply for antibiotic prescriptions…

There are various reasons why a clinician might prescribe an antibiotic:

  • Fear: That if an antibiotic is not prescribed, then any suspected infection might increase in severity or even be potentially life threatening.
  • Pressure: Pressure to prescribe an antibiotic from the patient or their relatives.
  • Action: To be seen to be doing something positive for the patient.
  • Justification: That prescribing an antibiotic justifies the cost or time of the consultation.
  • Loyalty: If an antibiotic is not prescribed then the patient may go elsewhere to get what they want.
  • Bacterial infection: That there is a genuine suspicion of a bacterial infection where the evidence shows that antibiotics are indicated in that particular clinical scenario.

It would be foolish to think that the real prescribing reason is always the last one on this list.

Humans are subject to all sorts of internal biases, and external pressures. We are in essence, fundamentally flawed. It is therefore wrong to expect us to always prescribe antibiotics for the right reasons as opposed to the “not so right” ones.

In other words we need tight controls on our decision making behaviours.

At the moment a clinician can write a prescription for most antibiotics without including any indication as to why the antibiotic was prescribed.

This needs to change.

It is my belief that all antibiotic prescriptions should have the clinical indication for prescribing included on the prescription form as a pre-requisite for dispensing, in both community and hospital settings.

Otherwise the pharmacist is essentially dispensing blindly.

Once such a system is in place, then specific criteria can start to be applied for certain infections in order for an antibiotic prescription to be valid/approved.

Then we can start getting some real controls in place for the purposes of antibiotic stewardship.

The days of clinicians being able to request laboratory tests and prescribe antibiotics without providing a clinical rationale are numbered.

I hope…

Michael