Tag Archives: antimicrobial stewardship

“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.

“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