Okay, now I’ve been pretty critical of the NICE guideline “Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use” I probably should put my money where my mouth is and see if I can do any better… I believe that any guideline should try to follow SMART principles (Specific, Measurable, Realistic, Achievable and Timed) and they should also where possible be evidence–based or at least expert opinion guided and free from bias or conflicts of interest.
On the 18th August amidst great excitement Microbiologists across the land awaited the publication of the new National Institute for Health and Care Excellence (NICE) guideline “Antimicrobial Stewardship: systems and processes for effective antimicrobial medicine use”. So do we finally have the road map to stave off the post antibiotic era? Hmm...I didn’t exactly warm to the document.
I was listening to the radio in the car on my way to work and heard a story on the news which made me grind my teeth in frustration. The sound bite was encouraging students heading off to university to get vaccinated against meningitis, (all fine so far) then it went on to say how a rash that doesn’t disappear when pressed with a drinking glass is a feature of meningitis (ARGH!!). Not only is this information factually incorrect, I think it is also potentially dangerous.
A 50 year old man presented with acute onset confusion and a severe headache. He was taking Mycophenolate mofetil and prednisolone as anti-rejection drugs for the kidney transplant he had had in the past. He had not travelled recently, had no pets and had not been in contact with anyone else unwell. The doctors diagnosed a possible meningitis or encephalitis and started IV Cefotaxime and IV Aciclovir. The patient was then transferred to the Critical Care Unit who called me in the middle of the night for further advice. Bleary eyed I was wondering why I was being called at 3am as there are hospital guidelines to cover meningitis? And who was going to tell my cat it wasn’t time to be fed yet!?
The team had covered for the usual causes but they had forgotten the unusual suspects related to immunosuppression, such as Listeria monocytogenes and tuberculosis. The bit of their story that made me prick up my ears was the history of rash with penicillins the previous year. Unless you think of listeriosis you won’t realise that the penicillin allergy is a problem. It was easy to rule out tuberculosis as the patient had a BCG scar showing he had been vaccinated, and had had a T spot blood test before his kidney transplant which indicated he had not had tuberculosis in the past. This left listeriosis.