NICE calls on GPs to stop prescribing unnecessary antibiotics

Antibiotics

The National Institute for Health and Care Excellence (NICE) is urging healthcare professionals to "cut back on unnecessary prescribing" of antibiotics to combat a rise in resistance - or face possible disciplinary action.

Antibiotics remain an essential tool in modern medicine and are routinely used to treat otherwise lethal infections including meningitis, pneumonia and sepsis or blood poisoning. Antibiotics also have other valuable applications, such as to prevent post-operative infection and during treatment for cancer when patients are more vulnerable to infection.

However, serious infections such as these are becoming increasingly antibiotic resistant, and this rise has been widely attributed to over prescription of the drug - often for minor illnesses that do not require antibiotics. Overuse gives bacteria more opportunities to survive and spread, and develop resistance.

NICE says this situation is further compounded by a lack of new antibiotics, despite the development of new compounds of existing antibiotics, there have been no new classes of antibiotic discovered since 1987.

In an unprecedented move, NICE has issued guidance for GPs, dentists, nurses and pharmacists to assist them in monitoring the use of antimicrobials with the aim of reducing prescribing by 25%, equivalent to around 10 million prescriptions for antibiotics.

The NHS has been encouraging health professionals to try to minimise prescribing of antibiotics for a number of years, but NICE says 9 out of 10 GPs still say they feel pressured by patients to issue a prescription, and 97% of patients who ask for antibiotics are given them.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE says: "Antibiotics are prescribed in circumstances when they are unlikely to do the patient much good. Knowledge amongst GPs is well established that many patients with early or benign infections do not require and will not benefit from antibiotics. The vast majority of GPs will tell patients that.

"The rise in inappropriate prescribing comes in the face of successive attempts by NICE and by government to reduce it that simply haven't worked. Some of it is about the pressure put on GPs. Despite that pressure, prescribing an antibiotic when you know it’s unlikely to do the patient much good is not good practice.

"It’s not just prescribers who should be questioned about their attitudes and beliefs about antibiotics", added Professor Baker. "It’s often patients themselves who, because they don’t understand that their condition will clear up by itself, or that perhaps antimicrobials aren’t effective in treating it, may put pressure on their doctor to prescribe an antibiotic when it is not indicated and they are unlikely to benefit from it.

Patient pressure

Dr Tim Ballard, Vice Chair of the Royal College of GPs, who described the problem of antibiotic resistance as "a global threat", says the challenge for GPs lies in getting this message through to patients. He says: "The guidance today to prescribe the right antibiotic at the right dose at the right time is a sensible mantra and one that GPs try to abide to wherever possible.

"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, not just 'other people'.

"These can be very difficult and stressful conversations for GPs to have and we know that NICE acknowledges this. We need a societal change in attitudes towards the use of antibiotics and any suggestion that hard pressed GPs - who are already trying to do their jobs in increasingly difficult circumstances - will be reported to the regulator is counter productive and unhelpful."

Dr Ballard expressed concern over complaints or criticism about decisions made over the prescribing of antibiotics, and said that the RCGP would look to the General Medical Council to support any GP or other health professional who may find themselves on the receiving end of such complaints.

He adds: "It is also concerning that there hasn't been a new class of antibiotics produced in over 25 years, so we seriously need investment into research to develop new drugs that are effective at tackling existing and emerging diseases.

"But this won’t happen overnight and in the meantime, we all have a responsibility to curb this trend, and we need to work together to make the public realise that prescribing antibiotics is not always the answer to treating minor, self-limiting illness."

Dr Diane Ashiru-Oredope, Pharmacist Lead, Antimicrobial Resistance Programme at Public Health England (PHE), says: "Antimicrobial stewardship programmes which aim to reduce inappropriate prescribing and optimise antibiotic use are a crucial part of work to combat antimicrobial resistance and antimicrobial stewardship is an important element of the UK Five Year Antimicrobial Resistance Strategy."

NICE says it will publish a second guideline next year that will focus on "changing people's knowledge, attitudes and behaviours in relation to the use of antibiotics".

It also plans to establish a quality standard on antibiotic prescribing as part of a suite of new public health quality standards.

Why is microbial resistance such a big problem?

Antibiotic resistance is a battle fought daily in all hospitals across England and Europe. The spread of highly-resistant strains of bacteria, or superbugs, such as Methicillin-resistant Staphylococcus aureus (MRSA) in hospitals continues to be a major threat to patient safety. In addition, infections such as tuberculosis that was previously effectively eliminated in the UK via a vaccination programme and antibiotics are now re-emerging.

The scenario we are now facing was predicted by Alexander Fleming, the Scotsman who accidentally discovered penicillin in 1928 after leaving petri dishes containing staphylococci cultures stacked in his laboratory while he went on holiday. Despite publishing his findings the following year, his discovery was largely ignored by the medical and scientific community until investment into developing penicillin by British and US governments in the 1940s led to its widespread production and application for injured Allied forces.

A short time after he was awarded the Nobel Prize in 1945 in recognition of his discovery, he said: "The thoughtless person playing with penicillin treatment is morally responsible for the death of a man who succumbs to infection with a penicillin-resistant organism. I hope this evil can be averted."

Prior to the introduction of penicillin on a widespread scale in the 1940s, people often died from what we would now deem to be treatable infections - mastitis, ingrown toe nails, tooth abcesses, ear infections and even minor wounds could lead to sepsis and death. Infant and child mortality was also significantly higher than it is today due to what we would now consider minor infections and women frequently died from infection following childbirth.

The future?

Research is ongoing into the development of a new antibiotic. In January this year, research published in the journal Nature revealed that Teixobactin, described as a 'game-changer' in the fight against the problem of resistance, was found to successfully treat common infections including Clostridium difficile, tuberculosis and Staphylococcus aureus. Teixobactin was discovered by a team at Northeastern University in Boston, Massachusetts, who screened 50,000 types of bacteria found in the soil - the natural home of antimicrobial substances - to identify which bacteria had evolved to overpower their competitors. However, a common obstacle to cultivating these bacteria lies in the fact that only a miniscule proportion of bacteria isolated from the soil will grow in laboratory conditions.

Led by Dr Kim Lewis, the team at Northeastern effectively sandwiched these bacteria between two layers of soil, separated by a semi-permeable membrane which greatly enhanced the chances of antibiotic production. While trials have thus far proven promising in mice, human trials involving teixobactin are expected within 18 months.

In addition, Swiss drug firm Novartis is developing a drug to treat multi-drug resistant tuberculosis, which works by targeting a bacterial enzyme.

What can I do to help?

Don’t ask your health practitioner for antibiotics. Consider alternatives by asking your GP or pharmacist about over-the-counter remedies and if a prescription is issued, take the entire course at regular intervals exactly as prescribed, don't skip doses or save them for future use and never share them with others.

Why can't I be given antibiotics to treat colds, coughs and sore throats?

According to NHS Choices, all colds and the majority of coughs and sore throats are caused by viruses and while occasionally a virus can result in a secondary infection, usually these will get better on their own as antibiotics do not work against infections caused by viruses. Viral infections are also much more common than bacterial infections, so the chances are the cause is viral rather than bacterial.


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