Guest blogger and Acute Medicine trainee Dr Nicola Fawcett (bio below) writes…I’ve just returned from the European Conference for Clinical Microbiology and Infectious Diseases (ECCMID) in Copenhagen. I got the chance to pop into a few sessions on my first love in Microbiology – Stewardship and behaviour change. Before you all think I’m crazy, I’ll just add that I’m actually a trainee in Acute Medicine – I started out in the overlap area of how you change antibiotic use in acute admissions.
I think acute medics love a bit of behaviour change. Choose your quality target of choice, do your audit and feedback cycle, see your improvement, go home and sleep well at night knowing you’ve made the world a better place. However it’s a bit more difficult when you’re tasked with doing this long-term. Sure you can play the hospital game of ‘hit the arbitrary quality target because then you’ll get nagged at less’, but that relies on a) the willingness to nag continuously, in creative ways b) being someone the medical population will at least listen to, and c) keeping your nag at least in the top 5 of ‘Medicine’s 50 nags of the week’ (VTE risk, dementia risk, oxygen prescription, day-of-discharge-documentation, home-by-lunch, sepsis 6….). You can hope that with time and enough nagging, it gets ingrained into culture. So you duly give your grand rounds. You present the data on Impending Antibiotic Doom, and you say “In conclusion, don’t use antibiotics when you don’t need them, because using more antibiotics at a population level correlates with more resistance”, and repeat your ‘indication and duration’ audits, and maybe for just a second you tell yourself that maybe you’re ‘Making A Difference’.
Unless you also sign up to on-call shifts and return to the stomping ground of A&E at 6pm on a Friday evening, and you’ve got an 85 year old nursing home resident who is mildly confused has a chronic cough, with no collateral history, no other localising symptoms, and no beds in the hospital. What do you do? Well, you go straight back to what you’ve always done, you diagnose a possible chest/urine infection, you give the patient a treatable diagnosis, you give the nursing home the reassurance they’ve done the right thing, and you give yourself a mental ‘safety net’ so that you can send the patient home. And you give the patient antibiotics even though you have no true conviction that there’s an infection. But you’ve seen everyone else do it, and no-one will criticise you for it.
But it makes you think – if you can’t even persuade yourself – how on earth do you persuade others?
I can’t recommend enough the work coming out from Imperial studying the determinants of antibiotic prescribing, and, for those seeking to change antibiotic use, the work of Health Psychology in understanding why we do what we do. Acknowledging that antibiotic prescribing is not a logical calculation, it is a behaviour. And it’s a behaviour fundamentally performed by evolved monkeys whose wants and needs are multitudinous and complex (note: before you write rude letters to Imperial, the monkeys bit is mine). We like doing what we have always done. We have to follow what our leader does and we want their approval (or at least, we dislike their ire). We want to feel our role acknowledged and valued (and do Doctorly things for patients), we like doing things that we’ve seen work before, and we fundamentally want to avoid really bad things happening that we caused, like not treating an infection and the patient coming in with raging urosepsis 18 hours later. You only have to do that once, and no amount of ‘don’t use antibiotics if you’re not sure’ will ever, ever get through.
And I haven’t even addressed the fact that many physicians aren’t completely sold on the idea that antimicrobial resistance will become a major problem. The attitude I commonly encounter is this: “Microbiologists have been talking about resistance for my entire clinical career – why should I think anything has really changed?” (but that’s a topic for another day). Even with ‘believers’, I wonder about the effectiveness of the ‘future resistance’ message. Alison Holmes presented data at ECCMID that very few of us think of resistance when making an antibiotic prescribing decision. I believe it. If you ask me, hand on heart, believer-in-pandrug-resistant-armageddon, whether I consider this when I treat a patient – I’d say – No. Nope. Sorry. Maybe I’ll think about it enough to follow my guidelines and not give Nukepenem to everyone, but if I’m not sure what is going on, I’ll do what I believe is the best, safest thing, not for ‘the population’, but for the patient in front of me.
Current attempts to reduce unnecessary antibiotic use by using the ‘stick’ of increasing population-level resistance fail to address the fundamental issue that at the point of prescription, I believe the Physician makes the decision to prescribe based almost solely on what is best for the patient in front of them, not for the population. Rather than bemoan this apparent lack of ‘bigger picture’ thinking, I hope most patients are reassured by this. The responsibility to the patients to whom you have direct duty of care is something fundamentally ingrained into the role of the Physician, both ethically and legally.
Ethically it is hard to justify a decision for a patient to take on a certain risk (risk of delay in treatment if it is an antibiotic-requiring condition, or risk of viral turning into subsequent bacterial infection) for the benefit of others in the population. Ethically, it is much more viable to ask a patient to take on this risk if there is also a balancing benefit for that same patient. Arguably Physicians in Antimicrobial Stewardship roles have duties of care to the entire local patient population, to protect them from resistance, and one may view their utility in rational antibiotic prescribing rather like the Chief Medical Officer of an institution – able to make bigger decisions for the greatest good. The threat of future resistance to a population is a message that can work for Stewards, but it is not one that addresses the everyday prescriber.
Thus, to fundamentally reduce antibiotic use, clear, well-presented useful data providing evidence on the size of the potential benefit for the patient (namely how small this is) but also useful evidence on the potential detriment of antibiotics, not to the population, but to the individual patient who will receive them.
The C.diff epidemic produced huge changes in antibiotic use for precisely this reason I think. ‘By giving my patient ciprofloxacin I may cause harm’. It’s also why I believe microbiome research has great potential – the harm to beneficial commensals, possible reduction of ‘colonisation resistance’, and a better understanding of the relationship between antibiotic use, colonisation with clonal, resistant strains and future resistant infection to the patient. Of all the multitude of messages I’ve delivered to physicians – senior and junior – I’ve found this is consistently the area of most interest amidst the yawn-fest of resistance data.
One can imagine a future where one applies a scoring system akin to the CHADS2VASC (risk to the patient with AF of ischaemic stroke) versus HASBLED (risk to the patient from anticoagulation), except with antibiotic use. The ‘Likelihood-Severity-SafetyNet’ assessment of benefit of antibiotic, versus the ‘LikelyResistanceCarriage-Resistogenicity’ score of adverse consequences. Perhaps it’s not feasible. But maybe just reinforcing this line of thought into the minds of clinicians – that there’s a balance rather than the currently one-sided argument of ‘give-antibiotics-just-in-case’, may help meaningfully change practice either towards less antibiotics, or towards narrower spectrums where predictions of future resistance currently fail.
I had a senior clinician say to me just the other day “We really don’t want to give this lady co-amoxiclav for a chest infection – she’s just had an ESBL UTI and it’ll wipe everything else out – she’ll just be 100% ESBL”. That sort of thinking, maybe, where lectures and education sessions on AMR are currently falling on closed ears, we can use to change hearts and minds, and behaviour.
Bio
Nicola Fawcett is an Acute Medicine Trainee and currently a MRC Clinical Research Fellow with the Crook/Peto Group at the Nuffield Deptartment of Medicine in Oxford, currently undertaking a D.Phil studying antibiotic resistance in the gut microbiome. Twitter: @drnjfawcett.
Note from author : Credit for the discussions on prescribing behaviour, ethics and strong messages go to the Health Psychologists and other members of my Department; I’m summarising what we’ve all been discussing. Also to the physician population of the John Radcliffe Hospital who tell you when you’re talking tripe during Stewardship sessions, but also engage and discuss what might actually work; honest counter-opinions are worth a million bored ‘whatever’s. In this piece I haven’t addressed the other issues in that many physicians are unconvinced by the evidence that changing prescribing will make any difference to resistance, and convincing physicians of the immediacy of the problem with antibiotic resistance; but these are topics for another day, or another post!
Do you agree? Do you firmly disagree? This blog is presenting a provocative position rather than a comprehensive overview, designed to stimulate discussion – do you think this represents your views or those of your colleagues? Please comment below – I’d love to hear!
Reflections on Infection Prevention and Control 
I completely agree. Just look at how microbiologists and id physicians dole out broad spectrum antibiotics because they know that is ‘safe’. And I think it is important to think honestly ‘what would I really want?’ And by presenting that as a binary choice (good vs bad abx prescribing), and basically setting up a fight with whoever falls on the other side of the divide, we may miss the chance to have a more interesting discussion about risks vs benefits.
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Thanks, that’s a really interesting point, hadn’t considered before. Good v bad prob. just further irritates the already-resistant physician – “Why are you saying what I’m doing is wrong? This is what was on the formulary 2 months ago! Are you really telling me in this space of time Doxycycline has become clinically useless?”
I suppose we have to be very careful when presenting compliance data – and highlight that it represents compliance, but not necessarily good or bad clinical care. Though I suppose it depends on the quality of your ‘non-compliant’ behaviour. if it’s blanket Mero+Metronidazole+Amikacin against ‘infection ?source likely bacterial’ plan 7 days, investigate if not better ) then I suppose compliance is a reasonable surrogate of good care. I think I remember a few ECCMID talks this year with the categorisation of Compliant, Noncompliant-but-sensible, Non-compliant-and-suggest-change…. (although as below, categorisation risks oversimplifying a complex subject…)
I’ve been considering a while how to explain the idea of antibiotics coverage vs collateral damage to physicians. Currently trying the allegory – don’t send in Arnie-armed-with-a-rocket-launcher to take out a few garden moles, or a spider in your kitchen… if you have any ideas please pass them on!
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I concur. Giving a choice between ‘right’ and ‘wrong’ is far too simplistic, especially when behavioural changes are required. “He that complies against his will, is of his own opinion still” has been a mantra of mine for many years.
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That’s a great quote! Hope you don’t mind if I steal it and re-use in upcoming Stewardship sessions (an early defuse of the resistance-against-arbitrary-quality-target-harangue)…
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Feel free!
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I’m a farmer not a medic and while my prescribing of antibiotics is essentially done on advice from my veterinary surgeon, I’m able to keep a range of antibiotics in stock and there is some wiggle room as no one actually questions my decisions. They just occasionally check that I’ve recorded each use and have filled in the number of days it will take for residues of the drug to fall below legal limits and the animal or its products can go into the food chain.
Having had a hospital-acquired infection which needed three courses of antibiotics to cure and made me allergic to penicillin-type antibiotics in the process, I do try not to use antibiotics unless they are really needed, but when it comes to it, it’s often not that simple.
We actually gave a long-acting antibiotic to a limping lamb yesterday even though there was no sign of infection. I was pretty sure it wouldn’t make it better and it hasn’t, but we wanted to help it and we didn’t have anything else to offer.
I sometimes feel that’s also another reason why many doctors over-prescribe, including to me – witness a number of antibiotics they’ve prescribed in the past which I have in a draw, because I decided when I got home that I’d wait and see how things went before I took, or (in the case of two creams), used, them.
They are compassionate people (just as I like to think I’m a compassionate farmer) and they want to help their patients. But they don’t really have much more to offer me than I had to offer the lamb apart from antibiotics. I know they don’t have time to give lifestyle advice or explain the details of some old-fashioned remedies that either worked or at least satisfied a nursing need while nature brought about a cure. But the reality is that even when they know an antibiotic really isn’t needed they’ve not had any training in basic nursing and can’t quite bring themselves to send a patient out of their surgery empty handed. If there were a series of advice sheets they could print out and hand to a patient that might help to fill that gap. Strangely some of the practice nurses are better at this than the doctors themselves and on a couple of occasions I’ve seen them pull a face when they’ve seen or heard what I’ve been prescribed, as if to say they feel it wasn’t really needed.
It strikes me that in both human and veterinary medicine there is a need for more research on both drug-free preventative medicine and non-drug treatments that can be recommended in non-critical situations, and that this should be a priority area for both medical and veterinary colleges.
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Thank you for your interesting and very considered reply. It’s great to hear from diverse areas that use antibiotics, and see the common thread in what we do. Also interesting hearing your joint perspective as patient and administrator of antibiotics.
Your lamb example reminds me very much of using antibiotics with older adults who may have become confused, or suddenly much weaker. Often even after we have access to blood tests, xrays, microbiology… we don’t really know what to do, we don’t have any good answers, but we want to do something.
I really hadn’t considered the ‘compassion’ angle before either. Maybe because we/I are still stuck in the mindset we’re doing a scientific/logical evaluation… The acceptable phrase for talking about compassion without worrying about sounding touchy/feely I suppose would be ‘wanting to do the best for my patient’. Though it’s ironic we want to underplay our compassion role – given when you ask patients what they want from a Doctor, they’d list compassion high. And I absolutely agree about the superiority of nurses on many occasions. We work with some fantastic asthma/ respiratory and diabetes nurses whose consultations with patients are masterclasses at listening, counselling and providing useful advice and joint plans that will be taken on board rather than a set of instructions to be discarded. The expertise of Pharmacists as well, I think is much under-used.
Your description of a booklet and communication and ‘leaving the surgery empty handed’ just pinged something in my mind – you describe one of my favorite recent antibiotic trials – the GRACE INTRO – run by Paul Little, – but, key to this- with significant input from Health Psychologist Lucy Yardley and her team looking at why Doctors, Patients, everyone, use antibiotics when they’re not needed (in this case, coughs).
They made the novel step of actually talking to patients and doctors about their experiences and concerns, and created a booklet that could be given, so the patient could go away with something, and to improve communication of important points in a time-pressured situation. I can’t recommend it enough.
Booklet: http://www.biomedcentral.com/content/supplementary/1748-5908-8-134-S1.pdf
(Of note they also had training sessions to improve communication and immediate CRP blood-tests). The link to a commentary is included below (the link is rather long!) it explains their findings, but in essence any combination of these interventions decreased prescribing. For me it’s a great example of people actually going out and exploring the real reasons people prescribe and targeting them. Clearly the European Commission thought your idea was good enough to fund, and it worked!
Finally (before I waffle on rather than addressing the points you made!) at ECCMID, the conference I was at, they did make some reference to non-antibiotic farming treatment – ‘yakult for chickens’ to reduce colonisation with harmful bacteria: http://www.biomin.net/en/products/poultrystar/. A nascent area! And interestingly in your point “non antibiotic treatment” definitely – rather than saying ‘we’re not treating your infection’ the mindset should be ‘we are treating your infection’ (your ‘doing something’) but it’s antibiotic-free /non-antibiotic treatment. A small semantic difference, but a huge concept change in the minds of both patient and physician.
Thank you again for taking the time to write, and very much hope to hear from you more in the future! Again, it’s great to get opinions outside our rather small bubble of antibiotic-interested medics…
(The GRACE INTRO
http://download-v2.springer.com/static/pdf/583/art%253A10.1007%252Fs11606-015-3181-1.pdf?token2=exp=1431678794~acl=%2Fstatic%2Fpdf%2F583%2Fart%25253A10.1007%25252Fs11606-015-3181-1.pdf*~hmac=f05ac5ea0aee1dbd0acfc4eaa776055625590fedc3c36c2409592db47d3ce5aa)
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We’ve got so many themes running now it’s difficult to know where to start! This is going to be rather long I’m afraid.
On the farm use of antibiotics, I have large numbers of examples I could set out knowing a certain amount about the reasons why antibiotics are often used on farms when they are not needed. On the medical use I only have personal (and close family) examples to refer to, and while there are quite a few of those I’m conscious that my experiences may be unrepresentative or even misleading, since I can only give you my perceptions of what happened.
Probiotics in chickens
My cynical analysis is that provided the agricultural supply sector has something to sell to farmers, either antibiotics to kill gut bacteria or probiotics to encourage them they will be reasonably happy!
I agree, it is a sign of progress, but sadly I’m not too sure ‘nascent’ is quite the right word to describe the situation. Competitive exclusion products have been available to chicken farmers since at least the late 1990s and widely written about in the scientific literature. However, while I don‘t have data to support this, I would be surprised if their use is very widespread or even becomes widespread any time soon. The reason for this is partly economics and partly historical.
On the economic side the poultry industry is so competitive that profits per bird can be as little as 2p, about the cost of feeding a chick for a day. While the use of the 11 antibiotics previously licensed as growth promoters was phased out in the EU between April 1997 and 1 January 2006, lincomycin (cross-resistant with clindamycin is licensed as a growth promoter in the US and chlortetracycline was licensed as a growth promoter in the UK from 1953 until about 1971. But after it was banned for growth promotion its use continued to increase (1600% over the next twenty years, in line with the growth of the poultry sector) because it was also permitted for routine prophylactic use at sub-therapeutic levels, just as low as the growth promoting rates. As such poultry producers are well aware that if they and their vets can justify the use of these, and certain other ABX, to prevent the diseases commonly encountered in intensive poultry systems, then they get those growth promoting benefits, which can make the difference between profit and loss. In addition, if they don’t use antibiotics routinely and an infection occurs requiring therapeutic use of ABX, this will require a legal withdrawal period of perhaps 7 days (to keep residues below the MRLs) and if that means keeping the chicks even one day longer than the 39 days it now typically takes to turn a hatched chick into a dressed bird for the table, then all of that 2p profit can be wiped out. If it has to be kept for two days longer then they can lose as much money as they hoped to make.
This introduces a vicious circle of reasons for the non-essential use of ABX in poultry production – reasons which are broadly similar in pig production and diary farming as well, where you can say we are all in part responsible: we as consumers who are tempted to the retailers that have the best offers on cheap chicken, retailers for having price wars on staples like milk and chicken, and inadvertently pushing producers to use antibiotics and particularly certain antibiotics in order to survive in cut throat markets (in ways that have significant potential to encourage the development of resistant pathogens and resistance genes which can also spread in a large number of ways via harmless commensal bacteria and later transfer horizontally to potentially pathogenic bacteria in the gut or other nutrient-rich environments) politicians for promoting cheap food policies, because they believe this increases their chances of re-election, policymakers and economists for pushing us into trade liberalization deals where we cannot turn away chicken regardless of the antibiotics used if they only give rise to high levels of resistant bacteria instead of illegal levels of residues, some scientists for toeing industry lines because that’s where most of their funding comes from now, big pharma for being driven by the financial side of its fiduciary responsibilities more than the ethical side, regulators for being too close to industry, in part because that’s now the source of 80% of their funding, food producers for trying to make a living, and oh yes doctors for, well, not taking much interest in the medical side of the resistance problem, let alone the agricultural side!
It’s of note that in Denmark they have almost entirely managed to stop all use of antibiotics in poultry production – the exception being only the (toxic) ionophores. If you are interested, the Danish government publishes annual reports detailing the use and resistance patterns associated with both medical and veterinary use of antibiotics. On the veterinary side at least the data is far more precise and detailed than in the UK, making it of much greater value. See the DANMAP reports http://www.danmap.org
However, that said I’m not sure the reduced use of antibiotics will last in their very intensive and unnatural production systems. They made great play of reductions in use in pig production but that has crept back up significantly, though to the Dane’s credit they are doing everything they can think of to get this right, in no small part because the export of Danish bacon and pork are significant to their economy.
It would be wrong to say that no similar efforts are being made in the UK; there has been some small progress in a few areas, but essentially more effort is going into attempts to tone down draft new legislation to minimize its impact on the intensive livestock sector, than into altering production systems so that antibiotics are needed less often.
As mentioned, it’s very hard to get reliable information from the industry, since prescribing decisions are between a veterinarian and his farmer (or company) client (or in the case of big firms, company employer), but I was reliably informed by an industry insider about 4 years ago that 100% of the broiler chickens in the UK that are reared to farm assurance standards – essentially all those that are sold through supermarkets were put on lincospectin (lincomycin plus the aminoglycoside spectinomycin) in their drinking water for the first 7 days of life to prevent E. coli infections, after which they often went onto a tetracycline antibiotic in feed. Given that most if not all of the chicks will have received an antibiotic (previously ceftiofur, possibly now gentamicin) in combination with injected vaccines (prophylactically to prevent infection when the vaccine is administered) this means these chicks can be on their third antibiotic on day one and potentially their 4th antibiotic on day 8. I don’t know the situation today and it’s difficult to know how to get an honest independent assessment of the current situation, but there is direct evidence that these same products are still being routinely used by at least some of the big poultry producers.
On the historical side, poultry and pig producers have traditionally (since 1953 when the erroneously named Penicillin (Prevention of Misuse) Bill was passed by the UK Parliament) relied on the routine preventative use of antibiotics in feed or water and they are used to using them and reluctant to change. Over 30% of the medically important antibiotics used in farming in the UK are given to poultry. And, because we consume something like 850 million chickens a year plus some turkeys and ducks – that’s an awful lot of doses, especially when you consider that most of this is prolonged sub-therapeutic treatment – the conditions most likely to encourage the development of AMR strains. Almost 60% of farm antibiotics are given to pigs, but although there are problems there – pork is now responsible for more cases of salmonella throughout the EU than chicken, for example, it’s less treatment doses which may be of significance in relation to developments of resistance –but I’m unsure about that. A former colleague of mine was recently interviewed about these and other related issues on RT https://www.youtube.com/watch?v=w4rEa6ysjXw
Of course, the justification for probiotics is very strong. In a traditional farmyard poultry system chicks would be colonized by a wide range of bacteria, many from their mother, and develop a good gut microbiome and immune system. We raise our own chicks in a traditional way (not commercially just to produce eggs and poultry for ourselves and a few friends) and we’ve never once needed to give any of them an antibiotic in 40 years. But under the conditions in which they are reared today there is no chance of such natural colonization with beneficial bacteria and they are reared and slaughtered before a traditional chick would even have a fully developed immune system anyway. But due to the cost principally, I suspect that producers only turn to such products when they have an AMR problem, which affects economically, or when they have a bad outbreak of necrotic enteritis. But one also has to wonder why doctors don’t recommend probiotics when they prescribe antibiotics to patients?
The rise of gram-negative infections
While you will know better than me the additional challenge posed in developing new gram-negative ABX c/w gram-positive ABX, because of the double cell wall, efflux pumps and all the rest, it is of note that the antibiotics used as growth promoters until 2006 were almost exclusively gram-positive in action. As such they killed off a lot of good bacteria, such as lactobacilli. But it was hypothesized by the great British microbiologist H Williams Smith (and some others) that this would effectively hand an evolutionary advantage to gram-negative bacteria which would have the benefit of less competition for space and nutrients. In a series of three experiments during the 1970s Smith and Tucker demonstrated that poultry given avoparcin (the agricultural analogue of vancomycin – the most widely used growth promoter in pigs, poultry and cattle until 1997) were more likely to be colonized by salmonella and more likely to be positive for salmonella at slaughter than chickens not given antibiotics. They were trying to get avoparicn (the vancomycin analogue) added to Annnex IV of the EU Feed Additive Directive, wich would have prevented its continuing use. But their work was strongly countered by the drug company making the antibiotic and by other pro-industry scientists who published their own research showing that in their studies there were no such effects. Smith Tucker and Barrow showed in the early 1980s that one of the main reasons for the difference between the industry and the independent studies was the dose of antibiotics used. However, shortly afterwards the UK Government introduced the concept of ‘near market research’, funding dried up and the research facility was closed down, so no action was taken, except by the Swedish Government which banned the use of avoparicn in livestock production in 1984 based on these concerns, rather than concerns about the rise of resistance, as most people assume.
The incidence of salmonella infections greatly reduced after avoparcin was eventually banned in 1997 (due to the research of Dr Janice Bates and colleagues at the Nuffield Hospital in Oxford who identified Van A genes -from memory that’s what I believe they were called- in enterococci in minced pork and a sewage outflow from a pig farm and her willingness to give media interviews about this despite the serious hostility of the industry) though we can’t prove this contributed to it because this coincided with the introduction of salmonella vaccination. There is a huge amount more that could be said on this topic, but the more relevant point perhaps today is that one might expect something very similar to have happened (in fact still to be happening) with E. coli. And while I am aware of only two studies, these showed an up to 100-fold increase in the level of E. coli shedding in pigs given in-feed tetracycline (when the E. coli were tetracycline resistant – which 70% now are) – to all intents and purposes making tetracycline a gram-positive antibiotic as far as the E. coli were concerned. Could this help to account for the 4-fold increase in E. coli bacteremias in the UK since 1990, even before we factor in the rise of AMR? I recognise that the ageing population will also have been a significant contributor as well.
Compassion
I was interested in your response to this more or less throw away comment of mine. Heavens, I’m aware of my incredibly limited experience, which must make my comments of limited value, but I feel there could perhaps be something in making a distinction between hospital doctors and GPs. I suffered an aortic dissection in 2009 aged 59 and was given only a 50:50 chance of survival from an operation to implant a stent using keyhole surgery, in part because it took my local hospital more than 48 hours to work out what the problem was before I was transferred to the Bristol Heart Institute.
I’d say my treatment there lacked almost all obvious signs of compassion – the exception being two exceptionally kind and thoughtful nurses to whom I owe an enduring debt of gratitude -I felt extremely unwell – but it was outstandingly professional and businesslike and I’m well aware that I owe my life to the brilliance and dedication of my surgeon and his team; and although I couldn’t see it at the time, in retrospect I can see that under the pressure they have to work, and bearing in mind the groundbreaking, complex and sometimes unpredictable nature of the methods they have to use, that if they let compassion for the patient as an individual creep into their thought processes, that could only happen that at the expense of their concentration and professionalism.
With GPs on the other hand, I think they are generally compassionate and kindly. They get to know their patients and maybe that compassion (in the form of a prescription) is sometimes all they have to offer, and so they sometimes offer it even when it’s not needed?
I’m aware that revising prescribing guidelines for some infections treated in hospitals has contributed to the dramatic and welcome decline in the incidence of C. diff and perhaps MRSA too, but I read somewhere that GPs actually prescribe 80% of all medical ABX and hospital doctors only 20%. While hospital doctors prescribe some ABX which GPs do not, it nevertheless seems to me that the root cause of the over-prescribing problem is more in the community than in hospitals and that it’s the rise in resistance to amoxicillin, sulphonomides, and even fluoroquinolones in the community, in, for example, E. coli UTIs, which results in bacteremias which then need ABX of last resort administered empirically in hospitals, with all the dilemmas that creates about antibiotic stewardship.
And, although this is straying even further from the compassion issue, I would just add that my own analysis of the evidence strongly suggests to me that a significant proportion of the AMR genes in extra-intestinal E. coli infections (though only a small minority of the infecting pathogenic bacteria) come from the use of antibiotics in food animals, see, for example, this report which I co-authored in 2012 http://www.soilassociation.org/LinkClick.aspx?fileticket=yCT9su5iViQ=&tabid=313
And in particular that includes a significant proportion of the ESBL resistance too, with the farm use of 3rd and 4th generation cephalosporins having risen approximately 500% in recent years during a period when (from figures I saw back in 2012) their use in hospitals had declined by about 30%. It should be noted though that their use in poultry production whilst still legal under the prescribing cascade has probably ended in the UK, for the time being. Though in a very secretive industry where information of this type is not even available to regulators, my fear is that specific use in day-old chicks may have been replaced by the use of gentamicin. That’s what is known to have occurred in some other countries – and it seems to me that this could contribute to resistance problems in human medicine in the future again predominantly via the E. coli food chain or environmental route, if the proportion of UTIs resistant to gentamicin increases from it’s currently, moderately low level in part as a result.
The downside of taking antibiotics
I owe my life to antibiotics so I recognise their value. If I’d been born about 8 years earlier I doubt I would have survived childhood. But I’ve become increasingly aware that there is almost always a downside to their use, so I very much agree with your comments that this should really be part of the consultation between doctor and patient, but in my personal experience it never has been yet.
I was born in 1950 and developed blood poisoning when I was 4 after I scratched my hand on rusty barbed wire on the farm. I had been given a one-off injection of antibiotics the year before by my doctor because I became ill with a high temperature the day before we were all due to go on holiday and our doctor’s partner who came out on that occasion – doctors did a lot more home visting in those days, judging by my recollections – told my mother he could quickly get me better. I can only imagine that he gave me an antibiotic but I do not know which one. But in 1953 there probably wasn’t a huge choice. Although my temperature came down very quickly and we were able to go on holiday my mother claimed that I was never the same child again. She said I was just a shadow of the child I had been and that a long series of more serious health problems started from about then.
In relation to the blood poisoning the following year, a health visitor who came to see my mother and my sister, who had just been born, stopped to say hello to me and noticed a red line running up my arm. I was injected with antibiotics in my buttocks for 5 days in the local hospital. I’ve written about aspects of this myself in a blog http://sustainablefoodtrust.org/articles/action-on-antibiotics/. I’ve tried to find out which antibiotic(s) were used, but no one has been able to find my hospital notes for that period. However, while I had perfect hearing as a young child, I had a 40% loss in all frequencies by the time I was about 20, so I wonder if I was perhaps given penicillin and streptomycin at a high enough dose that the streptomycin affected my hearing? Given the choice I would, of course still have chosen to have the antibiotics!
I don‘t have a note of all the antibiotic treatments I received as a child, some of which I suspect were given when I went into hospital for various conditions and treatments. Nothing particular stood out about them, but I know there were other courses in the years between 5 and 10,. During this time my parents told me that I became a progressively more difficult child and seemed unable to learn anything at school as a result of which I failed my 11+ exam. How much of that was due to my reduced hearing and how much to behavioural change I can’t judge, but I suspect they both contributed. I also changed from being an extremely popular child to being unpopular and my mother found me increasingly difficult too. If you’d seen me at primary school, I’d have been the child standing alone in the playground not really wanting to talk to anyone and with no one wanting to talk to me. I also increasingly found myself getting into fights at school usually triggered by me being picked on by other boys and eventually retaliating.
When I was ten I suddenly developed an allergy to dust. I vividly recall the moment I first started sneezing in a barn on the farm where there was some old straw and hay stacked. I’d been in such conditions before with no problems. That allergy has stayed with me all my life, a major problem for me as a farmer who needs to handle dusty material on a regular basis.
I have a suspicion that one of the antihistamines I was prescribed during the 1970s might have been responsible for some very atypical behaviour on my part which had significant repercussions. But if that’s the case, and my allergy was initially triggered by antibiotics, which drug was really to blame?
Scrolling forward many decades I’ve taken 9 courses of antibiotics in the last 8 years, some as detailed below. And during that period I have put on 6 stones in weight. Part of that is due to reduced mobility due to an accident to my right leg, but you are probably aware of some of the studies in animals which appear to demonstrate that even on exactly the same diet mice given antibiotics in one experiment became obese, while those not given the antibiotics did not.
And finally I will just add that listening to a Radio 4 programme last Tuesday evening about autism in men, I suddenly realized that I must be somewhere on the spectrum – witness the excessive detail I go into, the generally unsocial hours I keep and the fact that given a choice of go to a party or stay at home I’d invariably choose the latter. I find it difficult to see how antibiotics could influence something like that, but it does rather fit with the pattern of my behaviour from three years of age onwards and as you will know there are claims that antibiotics could be one of many factors behind the rise in autism.
More reasons for over-prescribing by doctors
Given what a key part antibiotics play in medical practice I’ve been a bit surprised by what appears to me to be a low level of knowledge about some basic antibiotic knowledge amongst some doctors and a low level of concern about AMR amongst almost all the doctors I have encountered – the starting point for your original blog, I believe.
1. I previously mentioned my hospital-acquired resistant infection and resulting penicillin allergy. The infection developed after an operation on a broken toe. My doctor prescribed Co-amoxiclav 500 mg for 7 days. I took it religiously but it had no effect on the infection. My doctor was on holiday on day 7 when I went back to the surgery and I had to see a different doctor. He had my record in front of him and I told him exactly what had happened. He prescribed flucloxacillin plus amoxicillin. I said to him, what’s the point of giving me amoxicillin without a beta-lactamase inhibitor when it hasn’t even worked with one? He said, ‘they’re not the same antibiotic’, I said they are, and he insisted were not. As I’ve learned you can only argue with your doctor so much without anger or a relationship breakdown and I’m aware that I’m just a farmer with a personal interest in the issue, not a trained professional. He then added, anyway we always have to prescribe amoxicillin with flucloxacillin. So assuming he must know something about a synergistic effect or something, which I didn’t know, I said no more and started the course, but I quickly started to develop a rash, which became so bad on day 4 that I had to stop the course. My GP then prescribed ciprofloxacin, which cleared it up. So that seems to me to be an example of poor training, or inability to realize there are exceptions to every rule, which resulted in an unnecessary prescription and probably removed all the beta-lactams as antibiotics that could be prescribed to me in future.
2. Shortly after that my dentist prescribed erythromycin for a tooth abscess and on day 4 in this case too I started to develop a rash and then swelling of the face and had to go to the casualty department of my local hospital. The abcess cleared up even though I couldn’t finish the course but I can’t help wondering whether the becta-lactam allergic reaction has made me more prone to developing allergic reactions to other antibiotics in some way. I was given teicoplanin and gentamycin prophylactically before a knee replacement operation in 2012 and while it was just a one-off dose I started to develop a rash to that too. I don’t know which was causing the problem but it suggests that I might have problems should I ever need these antibiotics therapeutically.
3. Thankfully a 6 week course of clindamycin for incorrectly suspected cellulitis didn’t cause any allergic reaction or obvious problems, though it didn’t improve the problem – eventually traced to varicose insufficiency, I don’t like to think what it may have done to any good bacteria I might have left in my intestines!
4. Quite recently I had to see a consultant – I won’t mention the hospital or the condition as I have no wish to embarrass anyone. I suspected he would want to shake my hand on entering the room, as they all do, and he did so, so pointedly that even though I’d planned to say let’s not shake hands let’s just bump elbows instead(!) I found that I couldn’t not shake his hand without it seeming rude. However, once that was done I asked him why hospitals didn’t have no hand-shaking policies – if it was a policy surely no one would feel put out and one doesn’t shake hands with one’s GP when you go to see them, so why do it in hospitals where any bugs around are likely to be more serious ones? His reply was that he felt it was extremely important in putting the patient at ease and that in any event he felt the whole thing about antibiotic resistance was exaggerated and not an issue to worry about. I didn’t say that he hardly put me at ease, and that saying AMR infections are not an issue to someone who had a month or considerable pain and a nasty rash following an operation carried out by one of this colleagues didn’t go down terribly well with me! I didn’t even suggest that he might pass some bacteria to me to me, I just suggested that as a farmer who used antibiotics and worked with farm animals I might pass some nasty resistant bacteria to him. He said it wasn’t an issue as he washed his hands between patients. But then he didn’t wash his hands in the consulting room and used the door handle on the way out, the same handle which the nurse who then came in to see me used. Maybe I’m being too sensitive, but even if the risk of such transfer is extremely remote, as I accept I may be, I can’t help feel that a no hand shaking policy would help to raise the general level of awareness about AMR issues with the general public, even if nothing is able to do that with some of the consultants!
Booklets etc.
Many thanks for the link to the booklet on coughs (I couldn’t by the way get the long link to work, even by pasting it into a browser) – that is just the sort of thing I had in mind. I have just sent it to a friend of mine (an essentially fit man in his thirties who has had a troubling cough for several months, which is starting to get him down. He’s actually got an appointment with his GP about it tomorrow.
Clearly there’s considerable scope for similar publications on other chronic conditions. As an example, something caused me to suffer from a relatively mild outbreak of dermatitis on my face about 6 months ago (something I’ve never had before) and despite my growing reluctance to take antibiotics for non-serious conditions, I allowed my GP to convince me that the only thing that would clear it up would be a course of doxycycline, even though he was unable to explain a mechanism to me by which this might come about. It had no effect on my condition, even after a month (though I see it is a recommended treatment). Eventually I managed to get it to resolve on the advice of a pharmacist (I agree with you on their value too!) by stopping using soap to wash my face and using aqueous cream instead. I did manage to complete the course of doxycycline but towards the end of the week (I think it probably was) I came out a bad rash over large areas of my body, including my face. That resolved within a few days but presumably it means I am now allergic to it – unnecessarily knocking one more antibiotic class off the shrinking list I might one day need to save my life!
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I think what we’re talking about here is the difference between normative change (you do what you do because that’s just the way it is) vs rational change (you do what you do because it makes sense… But your heart is not in it) vs coercive change (you’ll be sacked if you don’t do this).
Only normative change is sustainable. So we don’t have to worry about juniors washing their hands so much – it’s been inculcated through training and a normal part of a patient interaction. Hopefully. Anyway, I’ve just written a blog on this with regards to stewardship… Have a look! http://primarycarepathology.blogspot.com/
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THIS IS GREAT
I’m going to send your UTI statements to our Stewardship team right now!
I love this idea of having to create a new narrative, and now want to write far far more than there is space for here. I was saying this just last week to one of my consultant colleagues – ‘boy cried wolf’ effect of constant resistance messages for the last 40 years. And how you shape the world around your core beliefs, once you have them. (You listen only to messages which debunk antibiotic resistance increasing, and discount others as ‘scare mongering’ ). Agree totally with your C diff/Trimethoprim story. We all, I think, do this all the time, the key is whether you have the insight to recognise you’re doing it!
For resistance- I’ve been trying to do exactly as you said – form a new narrative to try and communicate with physicians. (Though I hadn’t got anywhere near your level of explaining why it’s important to do so! )
In my mind it goes something like: Gram Negatives are massively different to common garden strep pneumos and acquire resistance in completely different ways. Bacteria are not all equal. New research has thrown completely new lights on how resistance is acquired, we didn’t know before, but now we understand more- here is a new model – this is how it’s becoming a doomsday scenario so fast. Yes medical prescribing isn’t the only cause, but it is a significant contributor to the pathway, and basic hygiene and infection control play equally crucial roles. It’s up to us to play our part, as other organisations work on all the other steps of the pathway (animals, sewage, plumbing, regulation etc etc ) .
I’ve been thinking very hard about how you convey this paradigm-change of resistance spread in the minds of clinicians. Jon Otter has my proposed blog for next week along this line!
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At risk of adding to the sense of gloom pervading this subject, it seems a bad time to be working in infection prevention and control. Imagine a long-running and rather boozy feast, one that that began before the participants were born. They notice that there’s less food and wine on the table, so they appoint a new catering manager. She sees a famine coming and realizes that if the revellers are to survive she’ll have to persuade them to ration what’s left. “The party’s over, boys and girls” is not perhaps a message for which one will be shot, but it’s not a recipe for popularity, either.
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Can’t add much more to this except YES.
And also I hope you don’t mind if I also shamelessly steal this analogy and try it out in Stewardship sessions? 🙂 Trying to combat the ‘Microbiologists have been saying resistance has been increasing for years and I’ve hardly seen anything’ mindset…
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Your question flatters me. 🙂 You are welcome.
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I can see your point about this being a bad time to be in IPC, however I it also will be the most important time. My concern is that there is no standardised and recognised training for IPC professionals and I still see ENB 329 on job adverts (even though the course stopped about 15 years ago..). I’m also very worried that the current crop of trainees won’t be interested in IPC so HIS have organised a three-year planned programme of free events and have offered free membership to trainees to get some engagement
Martin (emrsa15)
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Yes, sorry for the ‘grumpy old man’ take. I guess my generation, spoilt for choice in the last quarter of the last century, are stuck in the mindset that limited choice is bad news. But for someone starting out in this field, today’s challenges provide tremendous opportunity: especially for radical innovation drawing on developments in many other areas (but not all at once!) – big data, molecular genetics, ecology, social networking, behavioural science, to name but a few. There is just one fly in the ointment: crude, insensitive or absent outcome measures make it difficult to assess the impact of what we do.
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I’ll just add my take on this. I’m a patient in a major hospital in NYC right now who just came off a three-day course of vancomycin. I’m a diabetic, and I got cellulitis of completely mysterious origin on Saturday, was sent to Emergency by my podiatrist on Monday morning, and was admitted to this short-term unit on Monday night. Since there is no lesion, there is no chance of a direct culture, and my three sets of doctors (medicine, podiatry, ID) have had little choice but to drive screws with the largest hammer available while they hope something will grow out on the blood culture.
(Pause while I eat my breakfast.)
Anyhow, although the redness and swelling and heat have not changed much, the level of pain in my leg (my foot itself hasn’t reported pain for many years, though my pulses in it are strong) has gone down from “intolerable pain just from holding my leg vertically” on Monday to “burning paraesthesia rather than my normal tingling paraesthesia” in just three days. Clearly the bugs are in retreat, although podiatry is now making noises about a possible abscess between toes 2 and 3 visible on the MRI. If so of course it will have to come out, though in general if there is one thing I am against rather than another, it is making any further holes in my feet. A clean 5mm x 5 mm x 1 mm lesion administered by a piece of glass hiding on my kitchen floor (I know, I know) taught me a sharp lesson on that recently; it required some highly expensive matrix wound dressing only available because I had some left over from a diabetic ulcer 5-6 years ago when I happened to have very good insurance, so I was lucky in several different ways.
But what I wanted to talk about is that the ABX Apocalypse heavily depends on matters usually called external to the practice of medicine, specifically politics and economics. In particular, we have rigged the drug research system in favor of developing drugs that do not cure (not that I am against palliation at all) rather than drugs that do cure or that prevent disease. We can change that. Though there is of course no guarantees that research will produce results, there is every reason to think that it will not if nobody is doing it! And if they are all chasing the next loratidine (okay, diphenhydramine makes me sleepy too, I’ll live), they can’t be working on the next ten vancomycins, to say nothing of more closely targeted things. So I am ABX-cautious but not ABX-skeptical.
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