The National Institute for Health and Care Excellence (NICE) has declared its intention to produce new guidelines and quality standards to tackle antibiotic resistance.
In my opinion, as a Clinical Microbiologist working on the front line in a UK hospital, I think this is a great idea, but I'm worried that there are a number of big obstacles: lack of clinical microbiology knowledge, previous attempts to reduce antibiotic usage have not stopped increased prescribing, insufficient diagnostics to support clinical decision making, doctors tendency to treat individuals whereas guidelines consider disease in populations, there are no new antibiotics on the horizon and of course, cost of everything versus budget.
- Safe and effective antimicrobial stewardship in relation to the use of antimicrobials in health and social care
- A public health guideline focused on changing people’s knowledge, attitudes and behaviours in relation to the use of antimicrobials
- Quality standards (statements which can be measured) on antibiotic prescribing as part of a suite of new public health quality standards
In my opinion, as a Clinical Microbiologist working on the front line in a UK hospital, I think this is a great idea, but I'm worried that there are a number of big obstacles: lack of clinical microbiology knowledge, previous attempts to reduce antibiotic usage have not stopped increased prescribing, insufficient diagnostics to support clinical decision making, doctors tendency to treat individuals whereas guidelines consider disease in populations, there are no new antibiotics on the horizon and of course, cost of everything versus budget.
Lack of clinical microbiology knowledge
It is my experience of a number of medical school curriculums that teaching about antibiotics and infectious diseases, not to mention microbiology, has inadequately prepared the current generation of doctors to manage infections effectively. I appreciate this is a bold statement but I do have some experience in both helping these doctors manage their patients as well as trying to provide teaching to doctors and medical students to help improve their knowledge. Despite 30% of hospital patients having an infection, very little time at medical school is devoted to learning how to manage these patients. This is a shame and does those medical students a disservice, as I know they can learn and understand it if they are taught it.
The solution to the creeping lack of knowledge about infections back in the early 2000s was to put resources in to pharmacy departments to develop antibiotic stewardship. Antimicrobial stewardship promotes the use of the right antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance. Unfortunately, antimicrobial stewardship has not reduced the amount of antibiotics we use.
It is my experience of a number of medical school curriculums that teaching about antibiotics and infectious diseases, not to mention microbiology, has inadequately prepared the current generation of doctors to manage infections effectively. I appreciate this is a bold statement but I do have some experience in both helping these doctors manage their patients as well as trying to provide teaching to doctors and medical students to help improve their knowledge. Despite 30% of hospital patients having an infection, very little time at medical school is devoted to learning how to manage these patients. This is a shame and does those medical students a disservice, as I know they can learn and understand it if they are taught it.
The solution to the creeping lack of knowledge about infections back in the early 2000s was to put resources in to pharmacy departments to develop antibiotic stewardship. Antimicrobial stewardship promotes the use of the right antibiotic, at the right dose, route and duration, for the right infection at the right time in order to improve patient care whilst reducing antibiotic resistance. Unfortunately, antimicrobial stewardship has not reduced the amount of antibiotics we use.
From 2010 to 2013, the total use of antibiotics increased by 6%: within general practice use increased by 4%, while prescribing to hospital inpatients increased by 12%. This has largely been due to a rise in the use of beta-lactamase inhibitor combinations, such as Co-amoxiclav and Piptazobactam, as well as the carbapenems. During this same time period the over reliance on this small number of newly-used antibiotics has lead to the development of resistance to them (AmpC, Extended-spectrum beta-lactamases and carbapenemases).
Perhaps the situation would have been a lot worse without the antimicrobial stewardship program but I think we need to consider that the emphasis was wrong. Antimicrobial stewardship has inadvertently made front line clinicians reluctant to make antibiotic related decisions, instead referring to the microbiologists or pharmacists, to ensure they don’t fall foul of the “antibiotic police”. Perhaps resources should have put into providing better clinically focused education and teaching about the key elements of microbiology and infections. But I would think this as that’s what my pocket guide, Microbiology Nuts & Bolts, is about!
Insufficient diagnostics to support clinical decision making
The NICE guidelines suggesting a delayed approach to prescribing can be extremely helpful. The guideline NICE refers to is for respiratory infections such as acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis and acute cough/acute bronchitis.
National guidelines consider wider populations, but as doctors we treat individual patients not the wider population. We are very good at seeing the “exception to the rule” where guidelines are concerned and doing what we feel is best for the individual, e.g. if a guideline tells us 97% of patients don’t need an antibiotic we tend to see our patient as one of the 3% who do. This is made worse by the increasingly unrealistic expectations placed on the healthcare profession to make everyone better and the threat of complaints or litigation should we fail to treat the 3% may make us over treat the 97%. Just saying don’t treat with antibiotics will not change our tendency to treat patients as individuals.
Perhaps there is a need for a different strategy to support doctors in justifying and feeling comfortable with delaying antibiotic treatment. One such approach would be to take samples at the first consultation in order to help diagnose those individuals who do need antibiotics. For example, if there is concern that a small number of patients might get complications after Group A beta-haemolytic streptococcal tonsillitis, taking a simple throat swab for culture will help identify those with the bacteria who need 10 days of Amoxicillin to prevent those complications whilst the rest can be reassured that they will get better in due course.
However, before you all rush out and start sending in samples of every kind to the laboratory please bear in mind that pathology services are struggling to meet cost savings like everyone else, and perhaps they are in an even worse situation. Most laboratories have had to implement the recommendations of the Carter Report which said that consolidating services could save up to about 20% of pathology budgets in order to reinvest the savings to modernise and improve diagnostics. Unfortunately, this was read as making 20% savings, and the reinvestment bit was overlooked. As a result most laboratories do not have access to and cannot afford to do the tests that would help support better prescribing of antibiotics.
So how does the lack of investment in laboratory services affect a common diagnosis such as community acquired pneumonia (CAP)? The NICE Respiratory Guidelines categorically recommended antibiotics for pneumonia however 25% of CAP is viral and therefore requires no antibiotics at all. To diagnose those cases of CAP due to viruses requires a molecular test costing in the order of £50-100 whereas the antibiotics needed to empirically treat patients are approximately £1.30. Therefore to test 100 patients will cost at least £5000 and the savings in terms of antibiotics will only be about £26. The numbers just don’t add up.
What is more valuable, investing in diagnostics to preserve current antibiotics or cost savings at the expense of antibiotic resistance due to over prescribing?
No new antibiotics on the horizon
There is a small error in the blog on the NICE website. They say that it is 30 years since a new class of antibiotics was introduced but this is incorrect. Linezolid, an oxazolidinone, was developed in the 1990s and became available in the early 2000s. But it is the only one! Since I went to medical school in 1992 the number of antimicrobials in the BNF has reduced from 87 named agents to 72. The oxazolidinones are the only completely novel agents and there are a few new modifications of older antibiotics such as Tigecycline (a modification of Minocycline), Daptomycin (similar to Teicoplanin) and Ertapenem and Meropenem (similar to Imipenem). So taking this in to account, the BNF has “lost” 20 antibiotics in just over 20 years... a depressing statistic. So the NICE blog can be forgiven for not being completely factually accurate, the situation is just as bleak whether it’s one new class in 30 years or none.
So why have the number of antibiotics in the BNF gone down? Why has there been only one new class of antibiotic in thirty years and why are none being developed? The answer is again, money. Developing new antibiotics and bringing them to market is not cost effective for drug companies; according to Forbes it costs $4-11 billion and takes more than 10 years. If you had the choice of producing a new heart medication which a patient would take every day for the next 30 years, or an antibiotic which would only be used for up to 7 days at a time which would you produce? Even the impending post-antibiotic era will not encourage drug companies unless there is sufficient financial incentive for them to invest in antibiotics.
So NICE has made its intentions clear and they are to be applauded but I’m uncertain how easy this is going to be in practice. Do you think delayed or no antibiotic strategies can be achieved? Will they work? Please vote and feel free to comment.
Perhaps the situation would have been a lot worse without the antimicrobial stewardship program but I think we need to consider that the emphasis was wrong. Antimicrobial stewardship has inadvertently made front line clinicians reluctant to make antibiotic related decisions, instead referring to the microbiologists or pharmacists, to ensure they don’t fall foul of the “antibiotic police”. Perhaps resources should have put into providing better clinically focused education and teaching about the key elements of microbiology and infections. But I would think this as that’s what my pocket guide, Microbiology Nuts & Bolts, is about!
Insufficient diagnostics to support clinical decision making
The NICE guidelines suggesting a delayed approach to prescribing can be extremely helpful. The guideline NICE refers to is for respiratory infections such as acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis and acute cough/acute bronchitis.
National guidelines consider wider populations, but as doctors we treat individual patients not the wider population. We are very good at seeing the “exception to the rule” where guidelines are concerned and doing what we feel is best for the individual, e.g. if a guideline tells us 97% of patients don’t need an antibiotic we tend to see our patient as one of the 3% who do. This is made worse by the increasingly unrealistic expectations placed on the healthcare profession to make everyone better and the threat of complaints or litigation should we fail to treat the 3% may make us over treat the 97%. Just saying don’t treat with antibiotics will not change our tendency to treat patients as individuals.
Perhaps there is a need for a different strategy to support doctors in justifying and feeling comfortable with delaying antibiotic treatment. One such approach would be to take samples at the first consultation in order to help diagnose those individuals who do need antibiotics. For example, if there is concern that a small number of patients might get complications after Group A beta-haemolytic streptococcal tonsillitis, taking a simple throat swab for culture will help identify those with the bacteria who need 10 days of Amoxicillin to prevent those complications whilst the rest can be reassured that they will get better in due course.
However, before you all rush out and start sending in samples of every kind to the laboratory please bear in mind that pathology services are struggling to meet cost savings like everyone else, and perhaps they are in an even worse situation. Most laboratories have had to implement the recommendations of the Carter Report which said that consolidating services could save up to about 20% of pathology budgets in order to reinvest the savings to modernise and improve diagnostics. Unfortunately, this was read as making 20% savings, and the reinvestment bit was overlooked. As a result most laboratories do not have access to and cannot afford to do the tests that would help support better prescribing of antibiotics.
So how does the lack of investment in laboratory services affect a common diagnosis such as community acquired pneumonia (CAP)? The NICE Respiratory Guidelines categorically recommended antibiotics for pneumonia however 25% of CAP is viral and therefore requires no antibiotics at all. To diagnose those cases of CAP due to viruses requires a molecular test costing in the order of £50-100 whereas the antibiotics needed to empirically treat patients are approximately £1.30. Therefore to test 100 patients will cost at least £5000 and the savings in terms of antibiotics will only be about £26. The numbers just don’t add up.
What is more valuable, investing in diagnostics to preserve current antibiotics or cost savings at the expense of antibiotic resistance due to over prescribing?
No new antibiotics on the horizon
There is a small error in the blog on the NICE website. They say that it is 30 years since a new class of antibiotics was introduced but this is incorrect. Linezolid, an oxazolidinone, was developed in the 1990s and became available in the early 2000s. But it is the only one! Since I went to medical school in 1992 the number of antimicrobials in the BNF has reduced from 87 named agents to 72. The oxazolidinones are the only completely novel agents and there are a few new modifications of older antibiotics such as Tigecycline (a modification of Minocycline), Daptomycin (similar to Teicoplanin) and Ertapenem and Meropenem (similar to Imipenem). So taking this in to account, the BNF has “lost” 20 antibiotics in just over 20 years... a depressing statistic. So the NICE blog can be forgiven for not being completely factually accurate, the situation is just as bleak whether it’s one new class in 30 years or none.
So why have the number of antibiotics in the BNF gone down? Why has there been only one new class of antibiotic in thirty years and why are none being developed? The answer is again, money. Developing new antibiotics and bringing them to market is not cost effective for drug companies; according to Forbes it costs $4-11 billion and takes more than 10 years. If you had the choice of producing a new heart medication which a patient would take every day for the next 30 years, or an antibiotic which would only be used for up to 7 days at a time which would you produce? Even the impending post-antibiotic era will not encourage drug companies unless there is sufficient financial incentive for them to invest in antibiotics.
So NICE has made its intentions clear and they are to be applauded but I’m uncertain how easy this is going to be in practice. Do you think delayed or no antibiotic strategies can be achieved? Will they work? Please vote and feel free to comment.
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