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