Back in August The National Institute of Health and Excellence (NICE) published new guidance to tackle the increase of inappropriate prescribing, as a staggering 41.6 million antibiotic prescriptions were prescribed from 2013 to 2014.
Further to this, The Health and Social Care Information Centre (HSCIC) released statistics in July 2014 highlighting a soaring increase in the UK over a 10-year period. “The number of prescription items dispensed in the community has increased by 58.5% since 2003."
This has led to speculation as to why over prescribing has become such an issue and how it can be dealt with in practice. It also brings into question the burden it is placing on the NHS, not only in terms of patient care, but the financial consequences.
HSCIC states that: “The overall net ingredient cost (NIC) of prescriptions has increased by 14.8% since 2003. In 2013 the overall NIC of prescriptions stood at £8.63 billion, compared to £7.51 billion in 2003.”
NICE says that the guideline has been produced to “help doctors, nurses and pharmacists promote and monitor the sensible use of antimicrobials”.
A key part of the guidance is that multidisciplinary stewardship teams should be set up in all care settings. Therefore, NICE states that “these teams should be able to review prescribing and resistance data frequently and feed this information back to prescribers”.
Moreover, the feedback the teams provide can help prescribers understand the reasons behind increasing or decreasing antimicrobial prescribing. However, part of the repsonsibility lies with patients.
Speaking of the new guidance Professor Mark Baker, director of the Centre for Clinical Practice at NICE, says: “It’s often patients themselves who, because they don’t understand that their condition will clear up by itself, may put pressure on their doctor to prescribe an antibiotic when it is not indicated and they are unlikely to benefit from it.”
Baker adds that an “open and transparent culture” needs to be encouraged around antibiotic use to prevent unnecessary prescribing.
Dr Nick Francis, a GP practicing in South Wales and a clinical reader in general practice in the School of Medicine at Cardiff University, agrees that over-prescribing is linked to patient views. He says: “I think the key is that culturally we have developed an inflated sense of the value of antibiotics.”
Gillian Brown, Queen’s nurse and community matron at Northumbria Healthcare NHS Foundation Trust, also feels a lot of patients expect their GP to prescribe them something for illnesses that don’t necessarily need antibiotics such as a cough or cold. “I do think it is a historical, cultural issue and undoing years of this type of practice is a slow process,” she says.
Adding that “if a patient has always had antibiotics from their GP they will continue to expect them. GPs may feel under great pressure to prescribe and sometimes it’s easier to say yes.”
Dr Tim Ballard, chair of the Royal College of GPs, also recognises the role of patients in overprescribing.
“We can come under enormous pressure from patients to prescribe antibiotics, even when we know they are not the best course of action. People must realise that this is dangerous for each and every one of us,” he explains.
The Medical Research Council (MRC) also emphasises this pressure. The council says: “In England, nine out of 10 GPs say they feel pressured to prescribe antibiotics. It’s clear that as a society we all need to change our perceptions and our behaviour around antibiotics.”
This is particlarly interesting as the HSCIC report also states that "over 1.03 billion items were prescribed in 2013 compared to 649.7 million in 2003".
Antibiotics are life changing and their benefits are not to be misunderstood. However, when they are prescribed incorrectly an even bigger problem arises.
Dr Tim Ballard says: “The growing resistance to [antibiotics] is a global threat and our challenge remains getting this message through to our patients.”
The NHS has highlighted the possible future problems, stating on NHS choices that it could have a “far-reaching healthcare impact. For example, emerging antibiotic resistance increases the chance that surgical sites could be infected by bacteria resistant to antibiotics”. The Centers for Disease Control and Prevention also says: “Antibiotic resistance has been called one of the world’s most pressing public health problems.”
The World Health Organization (WHO), NHS, Department of Health (DOH) and Public Health England (PHE) have also been involved in campaigns to improve the awareness of antibiotic resistance, for example World Antibiotic Awareness Week, but this still remains an issue.
The WHO “estimated 25,000 patients die because of a serious resistant bacterial infection acquired in hospitals” in the European Union alone.
WHO also explains that with resistance increasing the effective number of antibiotics is decreasing and “this means that one day no antibiotics may be left to fight life-threatening diseases”.
NICE, when releasing its new guidance, shed light upon this: “The overuse of antibiotics leads to bugs becoming resistant to them – meaning that we may no longer be able to fight infections and diseases that are currently treatable.”
Dr Nick Francis believes there is “a lack of appreciation of the risks, the side effects and development of antibiotic resistance as a problem for the individual, their close contacts and the community”.
The research council says that it is a “huge global issue”. Adding that “antibiotic overuse and misuse – in agriculture and human medicine – has led to a growing number of bacteria in humans, animals and the environment that are resistant to them”.
If overprescribing can affect the strength antibiotics have in terms of treating diseases, what are the repercussions of prescribing incorrectly to the prescriber themselves?
Niall Dickson, chief executive of the GMC, explains that the implications can be severe. “Doctors can, and do, face sanctions for misprescribing, although the law dictates that each case has to be considered on its merits to determine whether the doctor’s actions pose a risk to patients or confidence in doctors,” he says.
So what can be done to help healthcare professionals when they are prescribing antibiotics? Dr Joe McGilligan, GP and former chair of NHS East Surrey clinical commissioning group, sees a resolution. When nurses and doctors are placed under pressure by patients to prescribe unnecessary antibiotics, he says the “ideal solution” would be to use a C-reactive protein (CRP) test.
The CRP test is a blood test that NHS Choices say is “used to help diagnose conditions that cause inflammation. CRP is produced by the liver and if there is a higher concentration of CRP than usual, there is inflammation in your body”.
McGilligan feels this “would help in the diagnosis and need for antibiotics”.
However, he recognises the problems with this, which is the cost of the test, but he feels: “In the long run it would save resources and prevent unnecessary prescribing and the resultant increase in antibiotic resistance.”
Francis also agrees that CRP would help with over prescribing. He also thinks there are many other techniques that can help tackle this issue, such as good consultation skills, prediction rules (like FeverPAIN scores for sore throat), leaflets/booklets, tools for clinicians (education or feedback on prescribing) and education for members of the public.
The guidance aims to reduce prescribing, and NICE says that if it's successfully implemented it "could help to reduce inappropriate antibiotic prescribing by 22% – accounting for 10 million prescriptions”.
NICE also plans to release a quality standard and a second guideline to add to the information prescribers have.
Campaigns are continuing to raise awareness, for example, Antibiotic Guardians, a campaign led by PHE, which continues to urge “members of the public and healthcare professionals to take action in helping to slow antibiotic resistance and ensure our antibiotics work now and in the future.”
They aim to have around 100,000 guardians signed up by March 2016.
Additionally, the RCGP has developed an antibiotics toolkit with PHE named TARGET. The toolkit has a range of resources that can be used to “support GPs in the appropriate prescribing of antibiotics” says the RCGP.
Moreover, the DH has produced a UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018, which sets out measures to “slow the development and spread of antimicrobial resistance”.
Therefore, awareness will continue to be raised, not only on how antibiotics should be prescribed sensibly but also the implications caused by over prescribing.
Revalidation for doctors could also help. Dickson says: “We would certainly hope that the annual appraisal, which forms part of the revalidation cycle, provides a valuable opportunity for a doctor to reflect on all aspects of their practice including their prescribing.”
With revalidation set to begin from April 2016 for nurses and midwifes, hopefully this will also help them reflect when prescribing.
Dr Ghada Zoubiane, programme manager for general infections at the MRC is confident that nurses play an important role in helping to promote correct antibiotic use.
She says: “Nurses can play an important role in changing perceptions and behaviour around antibiotic use, by raising awareness with patients directly and as spokespeople within their wider communities.”
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