Oh dear, we’re all going to die from resistant bacteria and it’s all the doctor’s fault … again!

At least, that’s the message from the recent newspaper headlines. Apparently, overprescribing GPs will be struck off, or at least disciplined by the GMC. However, the media brouhaha, as usual, obscures the real picture.

If you believe the press reports, every patient in the UK with a sore throat is automatically provided with bucket-loads of the newest antibiotics by malicious GPs. But before we start listening to the media’s calls to discipline these ‘offending’ GPs, we should look at the wider picture.

The media coverage was sparked by the publication in August of the NICE guidance on ‘antimicrobial stewardship’. Professor Mark Baker, director of the NICE Centre for Clinical Practice is on record as saying that antibiotics must be used ‘more sensibly’ and suggesting that GPs who prescribe too many antibiotics should face sanctions [1].

There is no doubt that GPs are under considerable pressure to prescribe antibiotics. A survey commissioned by Nesta in 2014 found that 90% of GPs say they feel pressure from patients to prescribe antibiotics and 70% say they prescribe because they are unsure whether the infection is bacterial or viral [2]. Other research reinforces the impact of patient pressure: 44% of GPs have admitted to prescribing antibiotics just to get a patient to leave the surgery [3].

So two things are going to help GPs to meet the recommendations in the NICE document:

• Accurate point-of-care diagnostic tools
• Help with communication skills and strategies to help educate patients

Improved point-of-care diagnostics can help the physician to be sure that the patient’s symptoms are caused by bacteria that will respond to antimicrobials. There are some diagnostic tools already available in some countries but these tend to be time consuming and not terribly accurate. The Nesta Longitude Prize 2014 has set a challenge to create cost-effective, accurate, rapid and easy-to-use tests for bacterial infections that will help health professionals worldwide [4]. The prize fund is £10m and entries for the prize are already being submitted – the final closing date is 2019 but the first entry to successfully meet the criteria will win the prize.

Feedback and education

There have already been several programmes that have proved successful in reducing overprescribing and provided insight into the factors that influence primary care physicians in their prescribing. For example, in 1995 the Swedish Strategic Programme against Antibiotic Resistance (STRAMA) was launched and demonstrated the importance of providing information feedback to GPs and allowing them to reflect on their own prescribing. The guiding principle underlying STRAMA was to provide prescribers with feedback on local prescribing or resistance patterns so that they can compare their own prescribing with anonymised data for their colleagues. The programme brought about a steady reduction in antibiotic use in Sweden between the mid1990s and 2004 [5].

The NICE guidance also acknowledges the importance of patient education to the success of antimicrobial stewardship but doesn’t suggest how this can be achieved. Physicians constantly face patients who ‘know that antibiotics is what I need, Doctor’ and the 8-10 minute typical consultation can easily lead to defensiveness and frustration. Media campaigns to educate patients about antibiotics are typically unsuccessful but there are model interventions that have been shown to work. For example, a recent study in Wales shows that actively supporting the GP with up-to-date education and enhanced communication skills can help to make the consultation itself a successful patient education initiative. The STAR programme (Stemming the Tide of Antimicrobial Resistance) achieved a 4.2% reduction in total oral antibiotic prescribing in 34 practices in Wales without significant changes in admissions to hospital, reconsultations or costs. The programme comprised five sessions of web-based training and an expert-led, face-to-face seminar [6]. The online training included case-based scenarios, provision of up-to-date research evidence and guidelines, and training in the communication skills to help educate the patient without conflict. Participants were happy with the programme and reported an increased awareness of the issues of antibiotic resistance and increased insight into the patient expectations, which in turn improved the consultation [7].

Not the whole story

However, even if the NICE guidance does have the desired effect, there is still an elephant in the room: resistance resulting from animal and environmental antibiotics.

Across Europe and the US, at least as much tonnage of antibiotics is used in agriculture as is used in human medicine. Although there is still dispute, there is a considerable weight of evidence that agricultural antibiotic use is the main source of resistance in Salmonella and Campylobacter infections and contributes significantly to E.coli and entrococci infection [8].

There are many routes for antibiotic resistance to be transferred from sources outside the healthcare system:

• Direct contact: farm and slaughterhouse workers can be infected by resistant bacteria [9 and references therein] enabling transmission to the community
• Through the food chain: this is challenging to prove but the weight of evidence is accumulating with an increasing number of reports in the literature
• Through exposure to bacteria in the environment: in addition to hospital waste, 75-90% of antibiotics used in food animals are excreted unmetabolised into the environment [9]

Actions taken so far include the banning of non-therapeutic use of antibiotics in farming (although some countries still permit the use of antibiotics as growth enhancers)

The WHO has established a list of antimicrobial agents essential for human health – agents that should not be used for treating animals. However, compliance with the WHO regulations is neither mandatory nor regulated [10]!

The environmental risks should be mitigated by improving industrial systems for sanitation and decontamination of hospital sewage water.

So although GPs undoubtedly carry a responsibility for the careful prescription of antibiotics within the healthcare system, the things they aren’t responsible for include:

• Implementation of linked AMR surveillance systems that will provide accurate monitoring and reporting of resistance
• Educating farm workers and everybody involved in ‘farm-to-fork’ food chain
• Policing which antibiotics can be used for treating animals, avoiding all those that have been identified as essential for human health
• Developing strategies for reducing the risks of environmental exposure
• Discovering new antibiotics – the pipeline is currently empty!

I guess that once governments and global agreements have solved all these issues, not just alleged overprescribing, it will be OK to consider striking off GPs. But not until then!

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. GPOnline (2015): http://www.gponline.com/gps-face-sanctions-inappropriate-antibiotic-prescribing-says-nice/article/1360344. Accessed August 2015
2. Nesta, Antibiotic prescribing survey (2014): http://www.nesta.org.uk/news/%E2%80%98benefit-doubt%E2%80%99-basis-prescribing-antibiotics-finds-longitude-survey. Accessed August 2015
3. Cole A. GPs feel pressurised to prescribe unnecessary antibiotics, survey finds. BMJ. 2014;349:g5238.
4. Nesta Longitude Prize (2014). http://www.nesta.org.uk/news/ps10m-longitude-prize-opens-today-tackle-antibiotic-resistance. Accessed August 2015
5. Molstad S, Cars O, Struwe J. Strama–a Swedish working model for containment of antibiotic resistance. Euro Surveill. 2008 Nov 13;13(46).
6. Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, et al. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ. 2012 Feb 2;344:d8173.
7. Bekkers M-J, Simpson SA, Dunstan F, Hood K, Hare M, Evans J, et al. Enhancing the quality of antibiotic prescribing in Primary Care: Qualitative evaluation of a blended learning intervention. BMC Fam Pract. 2010 May 7;11:34.
8. ASOS (Alliance to Save Our Antibiotics (2015) ‘Antimicrobial resistance – why the irresponsible use of antibiotics in agriculture must stop’: http://www.ciwf.org.uk/media/7247793/antibiotics-alliance-40pp-report-2015.pdf. Accessed August 2015
9. Marshall BM, Levy SB. Food Animals and Antimicrobials: Impacts on Human Health. Clin Microbiol Rev. 2011 Jan 10;24(4):718–33.
10. WHO (2012): Critically important antimicrobials for human medicine. http://www.who.int/foodsafety/publications/antimicrobials-third/en/. Accessed August 2015.