Among the many significant problems and tensions concerning antibiotic prescribing, which span the whole healthcare system, some are opposing and can leave prescribers in a challenging position.
Antibiotic resistance is a critical factor to consider for each individual patient and for public health.
There is little question that this should be discussed with patients, to inform their decision-making and help them better understand how it may affect their treatment.
No doubt, most prescribers consider resistance during consultations and many use it as legitimate leverage to dispel patient pressure to prescribe.
Anecdotally, patients seem to be coming around to the concept that antibiotics carry risks, and the patient's agenda is often to seek reassurance, rather than a prescription.
During the consultation
I am certainly mindful of antibiotic resistance during consultations, as are many patients. There are several issues to consider here:
- An understanding of local resistance data can guide medical management. For example, community-acquired UTIs have a significant resistance to trimethoprim and patients should be warned that an alternative treatment may be required if their symptoms do not improve.
- Recent use of a particular antibiotic should alert prescribers to consider an alternative, to minimise the risk of developing resistance.
- Patients should be encouraged to complete the course as prescribed and the risks of not doing so should be discussed.
- The concept of resistance may require samples to be cultured in a laboratory, to determine any sensitivities.
The conversation about whether antibiotics should be prescribed at all must be had with patients. GPs should consider whether patients want a prescription in the first place, or are merely seeking reassurance.
Cost and budgeting
Cost is another factor, not only for the patient in terms of a prescription charge, but also in relation to the practice commissioning budget.
While the price of a prescription is prohibitive for many patients, practices are also under pressure to prescribe within their allocated budget. The NHS arguably should not escape austerity, the caveat being that patient care should not be compromised and neither doctors nor CCGs should be the fall guys for unrealistic budget setting.
Many CCGs will manage practices' prescribing performance. I would hope the metrics used will go beyond cost and translate to a proxy for good prescribing standards.
The use of broad-spectrum antibiotics and inappropriate use of sip feeds are among the many metrics that I consider reasonable. The difficulty is that the tariff for some of the more appropriate drugs can become prohibitive.
My practice team has consistently achieved an underspend against our allocated prescribing budget.
Irrespective of this, we regularly review our data and use this as an educational platform to improve our clinical practice.
One of our challenges is excessive use of co-amoxiclav. We accept it should generally be used first-line in specific situations, such as facial infections, bites and pyelonephritis. We also recognise it is significantly cheaper than appropriate alternatives. Furthermore, it is convenient for schoolchildren, given the three times a day regimen.
Despite these opposing tensions, a systematic approach is more desirable than introducing variation between doctors' prescribing habits and an internal audit has been arranged.
We as a practice take our prescribing seriously. Regular meetings are held and we are discussing the development of a quality agenda, which will include prescribing.
We have recognised that education and timely access to guidelines are required.
On that basis, we are fortunate to have a programme in our area, ScriptSwitch, which alerts prescribers about poor prescribing habits based on clinical quality as well as cost. For example, attempting to prescribe co-amoxiclav will display a high-risk alert for developing Clostridium difficile infection.
Challenging a colleague's prescribing of antibiotics can be as difficult as receiving what is perceived as criticism. Emotions can run high, so while the conversation should be had, the approach should be thought through beforehand.
An alternative is to audit everyone's behaviour, which may show a systematic problem rather than highlighting an individual's behaviour, making any intervention easier.
Any obvious prescribing problems, however, really should be discussed in the spirit of learning and patients' best interests.
- Dr Thakkar is a GP in Wooburn Green, Buckinghamshire