Antibiotic prescribing – one small cheer?

First we had the apocalypse scenario – the ‘ticking time bomb’ of antibiotics resistance that could push medicine back into the dark ages. Now – finally – for some better news. New figures show that antibiotic prescribing in the UK has gone down by 7% in the last year, from 36.6 million prescriptions to 34 million. Better still, prescribing of the ‘last resort’ antibiotics, the last line of defence against untreatable infections, has dropped by even more.

Most of that drop has been in GP prescriptions – and it’s been hard work. I’m the prescribing lead for my practice, in charge of monitoring not just cost but safety. We have targets for the number of antibiotics we prescribe – I’m proud to say we were well within our targets from the start. We also have targets for limiting the types of antibiotics used for more severe conditions, and these have been tougher. There’s no doubt that some patients, such as those with COPD or other chronic lung diseases are at much higher risk of bacterial infections. Good practice dictates that we give them antibiotic prescriptions to have at home, to take at the first sign of symptoms worsening.

But the vast majority of coughs, colds, sore throats and ear infections are caused by viral infections – and antibiotics have no effect on them whatsoever. In fact, even if your bronchitis or ear infection is caused by bacteria, antibiotics are unlikely to get you better any quicker than your body’s own immune system. A recent study on children with chest infections treated with antibiotics showed that unless they had pneumonia, antibiotics didn’t help. They can also cause side effects such as diarrhoea, sickness and tummy pain that may be as bad as the condition we’re trying to treat. If you develop an allergy to an antibiotic you can never have it again, making it harder to treat infections in the future. And that’s before we’ve even started on the wider problem of worldwide antibiotic resistance.

Over the years, I’ve regularly been accused of not prescribing because I’m trying to save money (most antibiotics cost pennies – believe me, I could prescribe hundreds and not make a dent in my area’s drug budget); because I don’t think they ‘deserve’ them (every patient deserves the best treatment – and the best treatment is one that will work, which antibiotics won’t for viral infections); or because I’m too lazy to prescribe. Prescribing antibiotics takes a few seconds – taking a full history, excluding a bacterial infection and giving a full explanation to the patient takes far longer, and is far harder work.

Patients have often told me they understand all the reasons why I need to keep prescribing of antibiotics to essential cases. All too often, though, they’ve promptly gone on to explain earnestly that in their case I need to make an exception because … (‘I’ve got a wedding I have to be well for’/’I have a heck of a week coming up at work’/’I know my own body and I know when I need them’/’you don’t understand, colds always go to my chest’ – delete as applicable).

10 days ago I spent 15 minutes with a patient explaining all the reasons why antibiotics wouldn’t do her any good and could cause her harm. She walked out, went right out to reception, demanded to see another doctor and, when told she would have to wait until the end of surgery for a second opinion, went straight to A&E. She waited there for three hours and was told exactly what I’d explained. Will it stop her pushing for antibiotics next time she gets a cold? I sincerely hope so. I suspect junior doctors working in A&E departments find it harder to resist pressure from patients, and I regularly see letters from A+E with clear documentation of a viral infection but a prescription ‘just in case’ as the outcome.

But in the last couple of years I’ve seen a shift. My GP/A&E shuttler is the exception, rather than the rule these days. Patients are much more likely to come in saying ‘I need checking out, and I’m really hoping I won’t need antibiotics’ – a statement which wouldn’t have crossed their minds a couple of decades ago. These days, the vast majority of my patients do understand if they don’t get a prescription – although admittedly it can still take a long discussion.

I take my hat off to all of you – we live in a fast-paced, demanding world, and it’s hard to let go of the idea of a magic bullet which will get you back to normal in hours. It’s been particularly tough for older patients, who for years were handed antibiotics freely by GPs who didn’t know there was a down side. I know one prescription for you is nothing compared to the millions of antibiotics poured into animals to keep them healthy. But I’m not in charge of veterinary practice – my job is doing the best for my patients, and for all the patients who might ever need antibiotics in the future. I – even every GP in the country – can’t do it on our own. We need your help and understanding – and we’re grateful to you.

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