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.
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!