Supporting patients will influence antibiotics overuse as much as medical advances

So the nation has spoken. Antibiotics - specifically the immediate challenge of increasing antibiotic resistance in bacteria - is to be the focus of the Longitude Prize 2014 following a public vote.

My first reaction was one of surprise.

Why did we choose antibiotics over challenges for science as fundamental as food and water?

Why not dementia – we know there is an epidemic of dementia in ageing populations like ours – or paralysis or flight?

The emphasis for medicine in developed economies has changed in the past 70 years, from cure to care.

‘We face the prospect of infections caused by multiresistant organisms. Perhaps we should be scared’

The vast majority of activity and resource is directed at looking after people living with chronic disease, not curing people of life threatening infection. The dementia challenge is a natural consequence of this, as people live longer.

But it was not that long ago that we were all far less secure. Infections - bacterial and viral - wreaked havoc in ways we no longer see: tuberculosis, polio, pneumonia are now all killers with diminished frequency.

Scarlet fever and epiglottitis are bacterial diseases that have become very rare, within my working lifetime. Antibiotics have contributed to this, but vaccinations, improved nutrition, housing and sanitation have had at least as much effect.

Does this vote reveal a societal memory, a collective subconscious for a relatively recent time when infections scared us more than cancer or heart attacks? As individuals, could every fever we experience remind us of a vulnerability that remains real and very frightening?

As Dame Sally Davies reminded us, in her annual chief medical officer’s report of 2011, infections are still an important cause of illness and accounted for 7 per cent of deaths in England in 2010.

We have been warned that we face the prospect of infections caused by multi-resistant organisms. Perhaps the nation is right. We should be scared. This is a priority.

• GPs feel pressured over antibiotics
• The prize striving to solve some of the biggest health challenges of our time

Prescribed with abandon

Dame Sally’s report goes on to describe in detail the complex and multifarious contributors to the emergence of antibiotic resistance. An important one is the overuse of antibiotic prescriptions by doctors.

So why does this happen? What leads us as a profession to use these precious and potent drugs with such abandon?

In community settings, GPs and nurse prescribers rarely have definitive evidence to guide the use or otherwise of antibiotics. This came out clearly in new survey responses from Nesta in which three-quarters of GPs in the UK said they prescribed antibiotics at least once a month when they were not sure they were medically necessary.

‘Doctors frequently make decisions that are wrong’

We rely on assessment of the clinical picture, a notoriously inexact science. Increasingly guidelines from National Institute of Health and Care Excellence, the National Prescribing Centre and many other attempts to rationalise the decisions that we make, are often encouraging us to use delayed or no prescription of antibiotics.

In hospital settings, however, watchful waiting is rarely used.

Decisions need to be made quickly, though doctors here are far more likely to have culture results or images that may help indicate the presence of a bacterial cause. It is equally clear, however, that doctors in both settings frequently get it wrong.

Doctors feel the pressure

About 80 per cent of antibiotics are prescribed in primary care, most frequently for respiratory tract infections. A large proportion of these will be of limited or no value. Many will be associated with harm, whether unwanted effects or the potential encouragement of resistant bacterial strains.

A recent meta-analysis described an increased risk of developing resistant bacteria: “Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months.”

‘A large proportion of antibiotics prescribed in primary care have limited or no value’

Frequently, doctors feel pressured to prescribe by anxious patients or their families, which again can be seen in Nesta’s survey of GPs. However, there is plenty of evidence to suggest that doctors overestimate this.

In the most successful encounters we, the healthcare professionals, will have sufficient time to explore the hopes and fears of patients, understand their health beliefs and come to a shared view on whether there is a need for an antibiotic.

If the Longitude Prize can find that the hard pressed health service does some time do this that would be a breakthrough.

For now, though, the emerging policy is to look at education - of professionals and public alike - and the use of evidence based decision making tools and many similar efforts, described together as antibiotic stewardship.

Gather stronger evidence

The Longitude Prize focuses on the development of point of care tests that will help gather stronger evidence, for clinicians and patients, on when we should and should not use antibiotics. That would be very helpful.

But we should consider the possible unintended consequences that such a test could generate.

For instance, could it lead to an increased demand for contacts with the hard pressed NHS?

‘The overuse of antibiotics will be influenced by patient support as much as by advances in medical science’

Will it make people with self-limiting symptoms think twice about visiting their GP?

Will having extra data help people with limited understanding of antimicrobials want antibiotics any less?

Technological advances may help but it must be coupled with an increasing focus of the NHS towards supporting patients with high quality information, more personalised decisions and better self-care, which diagnostics can help with if the data they collect is clinically useful.

For a behaviour that is largely socially determined, overuse of antibiotics will be influenced by this, at least as much as advances in medical science.

Dr Guy Pilkington is clinical chair of Newcastle West Clinical Commissioning Group