Concerns around the overuse of antibiotics and antimicrobial resistance (AMR) have been prevalent in the past few years in the national media, leaflets, walls and windows of community pharmacies and practice waiting rooms, and on the clipboards of those at the Clinical Commissioning Groups. There have been excellent educational packages produced for clinicians, such as the Royal College of General Practitioners (RCGP) TARGET resources, educational packages for schools such as the e-Bug, a Public Health England (PHE) approved public awareness film called CATCH (2019), and patients and clinicians can now pledge to be an Antibiotic Guardian (www.antibioticguardian.com). As a guardian, you can choose one pledge that you will incorporate into practice, for example consulting guidelines when presented with patients with respiratory infections and making sure all prescribers in your practice have access to your local antibiotic guidance.
There has only been a 6% reduction in total prescribing from 2014–2017 (PHE, 2018). However, as the Antibiotic Guardian Campaign stresses, it is everyone's responsibility to reduce antibiotic prescribing, not just the prescriber's. After all, losing the effectiveness of one the most lifesaving groups of medications will be a problem for everyone.
Antimicrobial resistance
AMR arises when the organisms that cause infection evolve methods to survive attempts to kill or suppress them. This can happen naturally, but it is accelerated by the inappropriate use of antimicrobial drugs whether in medicine, animal health or the food industry. Antimicrobials also find their way into the environment, via rivers and streams, which also increases the development of resistance. The UK's action plan for 2019–2024, in parallel with the World Health Organization's (WHO's) action plan, has adopted a One Health programme across all these sectors, for example there have been some significant reductions in the animal sector (WHO, 2015; HM Government, 2019). The main focus that will particularly affect clinicians in primary care is to reduce UK antimicrobial use by 15% in 2020. This article will explore how this can be achieved.
What has been done so far?
The TARGET website has worked in conjunction with PHE and the Antimicrobial Stewardship in Primary Care (ASIPC) group to produce a wealth of information, including condition guidelines, continuing professional development accredited modules, advice on practice-based approaches to reducing prescribing, audit tools and patient information leaflets. TARGET is free for anyone to access (RCGP, 2019).
With initiatives from TARGET and PHE (2018), primary care prescribing has fallen 13% from 2014–2017 in England, without increasing serious complications (Balinskate et al, 2018). However, secondary care prescribing has gone up by 7.7% in the same time, therefore the total health antimicrobial prescribing reduction is 6%. Secondary care has its own specific challenges and separate initiatives, yet 81% of antimicrobial prescribing is in primary care (86.3% of which from practices, including dental and some community pharmacies). PHE estimate that at least 20% of primary care prescribing is unnecessary (Johnson et al, 2018). It is a challenging target on top of previous reductions, and will require a change of behaviour from both health professionals and the public.
The theory of planned behaviour
The TARGET resources are based on three principles of behaviour change:
- Personal attitudes – are you convinced that AMR is an important problem?
- Subjective norm – are you under social pressure to change your behaviour?
- Perceived behavioural control – do you have the knowledge, skills and tools to reduce antimicrobial prescribing? If so, has your practice already taken steps to reduce prescribing and cannot reduce it any further?
The STAR study (Butler et al, 2012) attempted to address these behavioural areas with a multifaceted educational trial, with a focus on whole practice team seminars. They achieved an overall reduction of 4.2%, with no adverse outcomes. The REDUCE trial (Guillford et al, 2019a) took a similar approach but with an electronically delivered package: a short initial educational webinar and patient information leaflets, and monthly prescribing figures fed back to the practices (with comparators to the national average). They showed a modest improvement in prescribing overall – 1 in 62 prescriptions saved per patient per year – but only in the practices who began as high prescribers.
Hallsworth et al (2016) took a peer pressure approach to high prescribers in general practice: 20% of the highest antibiotic prescribers were sent feedback informing them that 80% of practices had lower prescribing than they did. This resulted in an overall reduction of 3.3%, with no increase in adverse outcomes.
These three trials have shown modest single figure improvements. There can be huge variability in prescribing rates across boards and practices based on the defined daily doses (DDDs) (amount of antibiotics per day per 1000 population). The best practices prescribe around 11 DDDs, and the worst around 30 – the 2017 average is 17.9. The Guillford et al (2019a) and Hallsworth et al (2016) trials suggest that greater improvements may be achieved if resources were focused on the higher prescribing practices.
However, even the very best practices in the UK do not achieves as many improvements as the Netherlands. Their average is better than our lowest prescribing practice, at 10.7 per 1000 DDDs (European Centre for Disease Control, 2017). In a letter to the British Medical Journal (BMJ), Gulliford et al (2019b) asked ‘what is normal prescribing?’, and blamed a UK culture of high prescribing compared to countries such as Sweden and the Netherlands.
Reducing patient demand
PHE have done a considerable amount of work to try to change the ‘pill for every ill’ culture, with awareness campaigns previously mentioned. The Realistic Medicine Agenda and What Matters to You? campaigns in Scotland are attempting to encourage more shared discussions between clinicians and patients to weigh up the risks and benefits of any treatment, including with antibiotics.
Educating patients to believe that they can get better with self-management strategies will help. For example, Bunten and Hawking (2015) demonstrated that increased patient information can improve appropriate antibiotic prescribing. TARGET has excellent leaflets, especially on sore throats, coughs, dermatology issues and urinary tract infections (RCGP, 2019). These all use similar source material from the Nation Institute for Health and Care Excellence (NICE) clinical knowledge summaries.
If a patient is feeling unwell, they may interpret the withholding of antibiotics as not being in their interests, despite it being the better option for their health and public health. It should be discussed how unnecessary antibiotics can negatively affect the patient, and not just from the obvious side effects of nausea, diarrhoea, thrush and occasional allergic reactions. Evidence is emerging that disturbing the gut bacteria that form our microbiome not only causes expected side effects such as diarrhoea, thrush (and occasional allergic reactions), but can affect mood, sleep, and weight (Francino, 2015). AMR may be seen as a public health problem, but increased resistance can be detected in bacteria in an individual patient for up to a year after a course of antibiotics (Costelloe et al, 2010).
Changing the culture
Patient beliefs will not change unless health professionals change theirs. The author has discussed these belief systems with fellow clinicians, but few admit to unnecessary prescribing. Many will point to their average prescribing figures, perhaps with modest reductions from previous years. Understanding that change is needed is the first step towards reforming personal attitudes. The second step, the subjective norm, depends on who we compare ourselves with: maybe we are prone to congratulating ourselves that our prescribing is better than a nearby practice, when we should be comparing ourselves to accomplishments in the Netherlands. If the Dutch, who already prescribe half as much as the UK average, are discussing targets for a further 20% reduction, then it must be possible to reduce ours by a further 15%.
Top ten tips
Reducing microbial prescribing has to be approached from several angles, so here are some to consider. They fall under categories of whether to prescribe, what to prescribe, and how long to prescribe for:
- Do not use antibiotics as placebos. Studies have reported antibiotics in clinical practice across the world from 17–99% (Fässler et al, 2010; Kermen et al, 2010)
- Take a good history and examination. There are better ways to please your patient, as van Duijn et al (2007) found, patients were satisfied with a good examination and reassurance. Use tools in TARGET such as FeverPAIN to assess the need for antibiotic treatment for a sore throat
- Consider other diagnoses. For example, that cough may be asthma or medication induced (eg from angiotensin-converting-enzyme inhibitors); it is probably not cellulitis if both legs are swollen, or within a couple of days of an insect bite or sting
- Consider better treatments. For example, using topical retinoids rather than long courses of antibiotics in acne. Elevate the swollen limb, even if it is cellulitis
- Point-of-care testing. There has been a lot of interest in the use of c-reactive protein (CRP) point-of-care testing machines in diagnosis cough and lower respiratory infection. There is a good summary review showing a 30% reductions in some studies from Cooke et al (2015). NICE (2014) has guidance for its use in diagnosing pneumonia: CRP <20, self-limiting respiratory tract infection; if 20–99 consider antibiotics, and if >100, prescribe. The machines cost approximately £1000, and the test strips about £4 each. Depending on the make, they take around 3 minutes to produce a result. It is not there to replace clinical judgement, but it can be used as another diagnostic tool to increase clinical confidence
- Patient information. Empower the patients with knowledge in the consultation, backed up by patient information leaflets. The TARGET and NICE summaries give self-help suggestions and a table of likely lengths of self-limiting illnesses. Sign up as an Antibiotic Guardian
- Safety-netting. The patient needs to be confident as to how and when they can access help if any deterioration.
- Deferred prescribing. Spurling et al (2007) found that a delayed prescription can reduce overall antibiotic usage with no detriment to safety. There is more about this on the TARGET website
- The right antibiotic. Check local guidelines on microbiological sensitivities where available and always use narrow spectrum rather than broad spectrum. This message seems to have been well received with a three fold reduction of the ‘4C’ antibiotics (ciprofloxacin, and other quinolones, cephalosporins, co-amoxiclav and clindamycin) in the past 5 years. The right antibiotic will reduce the amount of ineffectual antibiotics prescribed, allowing the patient to recover faster
- Prescribe the right length of treatment. The message that 3-day prescribing for most simple urinary tract infections has been largely received, but the message that 5 days is sufficient for most respiratory illness has not been so well acted upon.
‘The overuse of antibiotics is a serious threat to the future of modern medicine and to our patients' health. At least 50% of antimicrobial prescribing in primary care is probably unnecessary, therefore we should be able to achieve the 15% total antimicrobial reduction target for 2020’
Prescribe shorter courses
The STAR and REDUCE trials used a multifaceted approach to reduce inappropriate microbial prescribing, which remains very important, but were quite resource intensive to apply nationwide (Butler et al, 2012; Gulliford et al, 2019a).
To achieve the 15% reduction on antimicrobial prescribing, prescribe shorter courses as per the NICE clinical summary guidelines. Pouwels et al (2019: I440) found ‘for most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.’ Up to 80% of these were for longer than the recommended guidelines. The NICE guidelines for acute cough (2019), sore throat (2018), chronic obstructive pulmonary disease (2018) and even pneumonia (2014) suggest 5 days is enough.
Commentary by Hay (2019) said that if these guidelines on treatment length were adhered to, there would be 65 million fewer antibiotic days each year for the UK, which would meet the target. Hay's final point was a good one: that patients should be advised that symptoms may extend beyond the end of the course, in some cases up to 4 weeks. Hay discussed the reasons why clinicians do not always follow guidelines on a BMJ talk podcast (BMJ, 2019), which includes: guideline overload; conflicting information (with the Sepsis Kills poster sitting next to the ‘don't take antibiotics for colds and flu’ message on the Keep Antibiotics Working poster); and the power of habit. Added to this, a pack of amoxicillin from the pharmacy is usually for 7 days, and prescribing systems often default to the 7-day pack. Patients and experienced clinicians have been indoctrinated with the message to complete the course of antibiotics to avoid resistance, and perhaps we need to hear the ‘shorter course is better’ message more than once.
If you need to use antibiotics at all, a 5-day course is enough for cough, exacerbation COPD, siusitis, otitis media and most community acquired pneumonia (NICE, 2014). Five days is usually enough for sore throat – it used to be 10 days to ensure clearance of streptococcal, but this is thought to be a theoretical risk now. Skin infections may need 1 week and then a review. Three days is enough for simple urinary tract infections in women.
Conclusion
The overuse of antibiotics is a serious threat to the future of modern medicine and to our patients' health. At least 50% of antimicrobial prescribing in primary care is probably unnecessary, therefore we should be able to achieve the 15% total antimicrobial reduction target for 2020. Practice nurses can sign up to be an Antibiotic Guardian, and increase their confidence, and our patients' confidence in us, with the educational resources such as those found on the TARGET website. We need to work as a practice team. Only prescribe when necessary, and if we do prescribe, prescribe the right antibiotic for right length of time according to guidelines.
KEY POINTS
- Acknowledge that antimicrobial resistance is a potential public health and humanitarian disaster
- Unnecessary antibiotic prescribing causes harm to your patient today, and to the patients of tomorrow
- Primary care has made some reductions in prescribing in the past 5 years, but the UK still prescribes nearly double that of the Scandinavian countries. The new target is to reduce antibiotic prescribing by a further 15% by 2020
- Commit as a practice to reduce unnecessary prescribing by education of the whole team and the patients (see TARGET for additional resources)
- Shorter antibiotic courses are now recommended by the National Institute for Health and Care Excellence. Five days will suffice for most common infections in primary care