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