Antibiotics – to prescribe or not prescribe?

“If I give you antibiotics for your viral illness, you’ll be better in a week. If I don’t give the antibiotics, you’ll be better in seven days!”

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This week, the National Institute of Clinical Excellence (NICE) issued guidance to healthcare professionals on antibiotic prescribing and antibiotic stewardship programmes. They contend that around 25% of the 40 million annual UK antibiotic prescriptions are unnecessary.

Mark Baker, NICE’s director of clinical practice, gave some stark warnings. He noted that increasing antibiotic resistance threatened healthcare and the “whole basis of medicine”. He went on to describe the entrenched expectation that patients would receive antibiotics ‘on demand’. “There are people who are addicted to the idea of having antibiotics. If there is a soft-touch doctor, they go to them” he suggested.

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So what’s the truth of the matter? Do doctors really prescribe antibiotics when they don’t believe that they are necessary? Sadly, I’m sure that they do. But there are mitigating circumstances for most.

There is no doubt that some patients have elevated expectations that they will receive antibiotics for common complaints such as sore throats and upper respiratory tract infections. Hopefully, most doctors will identify that antibiotics would not be appropriate and attempt to convey that message to the patient. And herein lies the difficulty faced by the doctor!

The time taken to explain why antibiotics are not required may markedly exceed the ten minute consultation time (compared with the few seconds it takes to print a prescription). In an ideal situation, the patient would be reviewed one or two days later to ensure that there had been no deterioration in condition. We’re able to manage that within Concierge Medical Practice (by limiting client numbers) but the pressure on NHS GP appointments makes this extremely difficult elsewhere. Furthermore, patients are now able to write reviews of their doctors, which are visible online. These do not distinguish between reasons why doctors may be unpopular. Do some doctors prescribe unnecessary antibiotics in such scenarios? Undoubtedly! (And, even if they didn’t, the patient may still find an A&E or Out of Hours doctor willing to do so!)

So what’s the answer? Well, individual doctors, practices and organisations must monitor their antibiotic usage and respond if that usage is unusually high or divergent from local guidelines. ‘Delayed’ antibiotic prescriptions may be utilised. These are only to be collected if symptoms do not improve in an agreed period of time. The shortest effective dose should be prescribed (three days is sufficient for some conditions) and repeat prescriptions of antibiotics should be discouraged.

It is not hyperbole to suggest that overuse of antibiotics and increasing antimicrobial resistance threaten “the whole basis of medicine” (click here to see why). Patients and doctors alike must unite to tackle the issue

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