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GP view: Pharmacists must challenge urban myths around antibiotics

“There are various urban myths that we should challenge”

Pharmacists and GPs must work together to challenge inappropriate antibiotic use to prevent deaths from currently treatable infections, says Dr Toni Hazell

The discovery of penicillin in 1928 at the hospital where I trained to be a doctor – St Mary’s Hospital in London – revolutionised medicine. Antibiotics like penicillin saved many lives during World War II and beyond. It’s hard to imagine practicing medicine without them.

However, if we don’t use antibiotics a bit more carefully and resistance continues to rise, then the post-antibiotic era may come sooner than we think. A 2018 report by the Organisation for Economic Co-operation and Development (OECD) noted that antimicrobial resistance to eight high-priority antibiotic combinations increased from 14% in 2005 to 17% in 2015 across 37 countries.

This average hides wide variations, with some countries having resistance rates of up to 35%. Low and middle-income countries around the world have been worse affected, with resistance rates of up to 60%, the OECD says. In the US, more than 35,000 people die annually as a result of antibiotic resistance, according to the Centers for Disease Control and Prevention.

GPs, nurses and pharmacists are stuck between a rock and a hard place when it comes to antibiotics. We are urged to be careful with our antimicrobial stewardship, not to prescribe unnecessarily and to be aware that many infections are self-limiting.

For example, sore throats are usually self-limiting within two weeks. Whether the cause of infection is viral or bacterial, antibiotics are rarely necessary. Similarly, most ear diseases – otitis media – will resolve within three days. Antibiotic treatment for them should only be reserved for those who are systemically unwell or have a high risk of complications. A GP or pharmacist who tries to explain this often won’t be thanked for their careful antibiotic stewardship. In my career I have had more than one complaint linked to my entirely correct refusal to prescribe antibiotics.

Only last week, a patient told me that she “always gets antibiotics” when she has a day or two of ear pain. Anecdotally, from looking at hospital letters, it does seem that patients who attend the emergency department with a chesty cough, ear pain or a sore throat are quite likely to leave with a broad spectrum antibiotic such as co-amoxiclav.

So, how can we work together on this? Pharmacists are highly trained healthcare professionals. It’s important that you can have the courage of your convictions in antimicrobial stewardship and be backed up by your GP colleagues. There are various urban myths that we should challenge.

For example, most patients with a slightly red insect bite don’t have cellulitis, they have an inflammatory reaction and need some over-the-counter (OTC) antihistamine, a topical steroid or an antipruritic. Both pharmacists and GPs should be happy to tell patients this and to reassure them that they don’t need an antibiotic, while offering safety-netting advice if things worsen.

White spots on the tonsils is another classic example of a misunderstood symptom. The public seems to think these represent a definite indication for antibiotics, whereas in reality most people will not need them. Even a patient with a full Centor criteria score – a fever, tonsils with a grey coating, enlarged lymph nodes and no cough – is associated with only around a 50% chance that the cause is bacterial. In this scenario, the National Institute of Health and Care Excellence advises only that we should “consider” antibiotics.

The other common classic is having patients say: “It’s gone to my chest doctor, I need an antibiotic.” In reality, most coughs will resolve on their own within seven to 10 days, whether or not they sound wheezy or their phlegm is green.

Antibiotic stewardship is the business of all healthcare professionals and we all need to stand firm. GPs must take the time to explain the reasons behind not prescribing antibiotics, rather than the quicker solution of reaching for the prescription pad. As pharmacists, your knowledge is invaluable in persuading patients that they can manage their self-limiting illness with OTC treatments, and don’t need to try and get antibiotics.

If we all work together on this then maybe there will still be usable antibiotics by the end of my career, rather than my last years in medicine being spent in an antibiotic-free zone where patients die from currently treatable infections.

Toni Hazell is a GP based in a practice in London

24 Comments

R A, Community pharmacist

Hi Toni,

I fully agree with your sentiments but I think for this to be effective all members of healthcare profession has to adopt this stance.

As an example I have lost count of number of people attempting to buy Chloramphenicol when there was no clinical indication naturally I refused. The only problem is that they went to another pharmacy which were happy to sell. Until everyone takes a consistent approach a minority challenging the public will make little difference. Not that it does stop me.

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I think another thing that needs to happen is for GPs to understand what we can and can't sell OTC. So many patients are being told you can buy codeine I've lost count and the regulations surrounding OTC sale of chloramphenicol  seem to be a total enigma to GPs, which is often a cause of conflict between us and the patient, caused by a GP. Also, although vets won't be reading this, I so wish they would understand we cannot sell human meds for animals.

David Lamb , Dispenser Manager/ Dispensing Assistant

So why do GPs hand out antibiotics like sweets?

Toni Hazell, GP

we don't. At least good GPs don't. I very rarely prescribe for simple upper respiratory stuff and I often go weeks without prescribing any antibiotics. A&E however......

Tarvinder Juss, Locum pharmacist

A lovely article which will influence my practice. What Toni is saying here (correctly) is that sufficiently enough of the cases we come across in the pharmacy are self-limiting for us to say to patients that there is no need to go to the GP to consider antibiotics. I fully understand how in this situation, where the pharmacist has been the first professional to be consulted, s/he could play a pivotal role in AB stewardship and I therefore undestand what Toni is advising. My biggest worry is that, for example, a pt. with otitis media is prevented by me for progressing their request for ABs to a GP, then suffers damage to the osscicles. Wouldn't I be liable for personal injury claims? Am I able to fully mitigate this scenario by safety netting? I think the article has not left much scope for safety netting. If you read this Toni I would appreciate your advice.

Toni Hazell, GP

Hi Tarvinder. I'm not 100% clear what your training allows you to do, but I think it's the basics - so we know with that example that well over 50% of otitis media will clear up within 48-72 hours without antibiotics, so it would be great if pharmacists say this, encourage parents of kids with ear ache to use regular analgesia (as many parents don't do this as they worry it 'masks the pain') and maybe to say contact the GP if not improving over 48-72 hours and it's then our responsibility. 

Tarvinder Juss, Locum pharmacist

Okay, so the best course of action for me might be to buy an otoscope and make this assessment myself  (compacted wax versus otitis media, guarding for the fact that compacted wax may make it difficult to visualise otitis media), and to clearly advise the patient that if symptoms worsen, then they must see their GP. The GP may then wish to consider whether ABs are appropriate. The purchase of an otoscope might soon become compulsory given that the CPCS has now progressed to the stage where GPs will now refer patients to pharmacists.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Sorry, but in a case such as this I would refer straight back to the GP. I have had no training whatsoever in the use of an otoscope nor do I want any. We are not and never have been, hands-on diagnosers and we should not see ourselves as such - that is literally WAY above our pay grade.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I think your safety netting is if there is any doubt in your mind whatsoever, you pass the patient on to their GP who has the first duty of care to that patient.

Tarvinder Juss, Locum pharmacist

No, if the patient comes to the pharmacist first, then the pharmacist has the first duty of care. Things are moving in that direction.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Referral to a GP if  the condition is outside of your scope of competence (as anything requiring an antibiotic is) means that you have discharged your duty of care. In all things, the main duty is with the patient's GP. We only see patients on a random, ad-hoc basis - they are free to visit any pharmacy they want.

Benie I, Locum pharmacist

Yes everything moving except payment for doing this work.

N O, Pharmaceutical Adviser

I am always confused when people point fingers at Pharmacists whenever the antibiotic issue crops up. It is even part of the QPS to have antibiotic stewardship. What do they expect from Pharmacists? To refuse supply for a legitimate Rx for an antibiotic? Do you think Pharmacists refer patients to surgeries for antibiotics? Even so, when did the GPs start doling out stuff, just because a Pharmacist asked for it? Just a pass on the buck game.

C A, Community pharmacist

Perhaps its worth checking with the patient if they actually saw a clinician, or if it was empirical treatment over the phone. Then having a word with the practice medicines manager.

I had the fortune to attend a virtual meeting on a PLT day that I was off, and antimicrobial stewardship was brought up - with the CCG saying that prescriptions for antibiotics should only be given without a face to face consultation in the most dire of circumstances. Of course the GPs that were there all pleaded that they never prescribe antibiotics without seeing a patient.

I'm sure plenty of pharmacists have their own anecdotal stories of how true this is...

The PMMs did seem to thing it would be good to keep an eye on for antimicrobial stewardship. 

The problem in doing this in pharmacy is time and resources.

Hope Mask, Locum pharmacist

If you prescribe antibiotics when infectious microbes are implicated you are actually doing the right thing for the patient. Infectious microbes are not normal residents of the human body. They are foreign invader which must be deleted one way or the other. If there are clear signs a patient has such infections you should not hesitate to prescribe antibiotics that will save lives. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Debatable because that's why we have an immune system and it is the knee-jerk prescribing of antibiotics which is leading to resistance. Just whacking a broad-spectrum antibiotic into everyone with a suspected infection 'just in case' will rapidly render that antibiotic useless.

C A, Community pharmacist

It needs to be thought through - risk/benefits

I've had patients with C difficile due to frequent antibiotic scripts and it's not nice.

Also in terms of risks- weight should be given to - "if I give this patient an antibiotic and it's not needed, the next time I give a patient one it might not work" 

Kevin Western, Community pharmacist

I rarely tell anyone they need antibiotics nowadays, simply that whatever it is needs assessing, but  what would be really useful would be feedback on whether the people I send for such are correctly chosen... 

there is still a huge barrier in accessing surgery appointments here and most patients believe they wont see anyone if they try. 

its time for surgeries to open up properly and get back to some sort of normality, and the current model, fashionably high tech though it is, isnt doing it for the people who matter, - the patients....assuming thats who surgeries think are the ones who matter...

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I think that's the right approach if you think there's an infection lurking. Don't build people up to expect something - I just say 'It looks like it might be an infection, go see your GP' then it's their call. 99 times out of a hundred, they return with an AB Rx

C A, Community pharmacist

Though have they returned with an antibiotic because you've primed them into thinking it's an infection and they therefore go into the surgery asking for an antibiotic?

cardiff pharmacist, Superintendent Pharmacist

mmm...since when have I been doing the prescribing of these antibiotics...GP's prescribe (on the whole) we dispense. So..direct this to GP's who actually write the Rx's!

Toni Hazell, GP

yes but often the pharmacist has suggested it. For example I regularly get patients ringing me because the pharmacist has said that they'll need antibiotics for their slightly inflamed (not infected) insect bite - I'm quite capable of saying no, that's not right, you don't need antibiotics, but it isn't an ideal situation where two professionals are contradicting each other. I'd say the role of the pharmacist is to know when antibiotics are not needed and to be happy to tell patients that. Of course I'm not suggesting that you refuse to dispense antibiotic scripts. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I'm surprised at this one. It's normally pretty obvious when a bite is infected, purely from routine questioning - the WWHAM questions can cover it nicely.  However, in their defence, the first line treatment for a bite is hydrocortisone cream (please no-one tell me it's Anthisan - that stuff is useless) but if there is any suspicion of an infection, hydrocort is contra-indicated. It could just be a case of a pharmacist being cautious because of the risk of error.

I have to disagree with you over the last bit though - it isn't our place to say when antibiotics are or are not needed - most of us nowadays would err on the side of caution as I suspect is the case with Bitegate, because the risk of sepsis is rammed down our throats with such force that ANY chance of missing an infection which could escalate rapidly must be eliminated at all costs.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

We might as well bang our heads up the wall or widdle in the wind. Patients believe Dr Google or Dr Twitter over us any day of the week.

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