Nest week, on the 18th November, it's European Antibiotic Awareness Day. As part of our activities for this event, we've been supporting the Listen To Your Gut campaign (www.listentoyourgut.org.uk). This is aimed primarily at parents, helping them understand the role bacteria have in keeping us healthy, and understanding why we want to try to look after our 'healthy bugs' by only giving antibiotics when they're really necessary. The 'Treating Your Infection' self-help guide that goes along with this teaches people what to expect from self-limiting infection, and symptoms to look out for that suggest they need to see a doctor. Yesterday I launched this programme to GPs in North Devon at their prescribing day, and today I went to a practice to talk in more detail about antibiotic stewardship. This is by far the most enjoyable bit of my my job, and here are some thoughts as to why that's the case.
1. Data. It's so easy to get data on things in primary care, in ways that are completely impossible often in secondary care. Prescriber, time of prescription, nature of consultation (face to face vs telephone), basic patient demographics, co-morbidities. The one thing that's a bit hard is indication for antibiotics, but that's often not that important if you approach the data in the right way - this is just a starting point for conversation. So we see some interesting things coming out that are the starting points for challenging (and often supporting) practice. So for instance,
- 20% of young people (aged 20-39) get an antibiotic each year. This is mainly amoxicillin. And it's mainly for coughs and colds.
- 10% of antibiotic prescriptions occur within 2 weeks of a previous prescription. Why is this? Is it treatment failure? Intolerance to first choice? Never infection in the first place? If someone is not better in 3 days in primary care, how often is there an indication for a second course? I don't know the answer to this - but I'd quite like to think about it a bit more. Do any microbiologists understand this group of patients?
- If you get given fluclox, then the follow on antibiotics are doxycycline, co-amoxiclav and clarithromycin. What could these antibiotics be doing that fluclox wasn't doing? Is it a dosing issue? Is it non-infective? Is it pilonidal sinuses involving gram negatives? And how actually do you manage these nowadays in primary care, especially now that access to surgical specialities is apparently more difficult?
Nursing prescribers are the biggest prescribers by far. They see all the minor ailments. Are we giving them the support they need?
2. Trusted relationships and continuity of care. GPs really know their patients and their lives. They work in close knit teams and have a shared purpose. And, having worked closely with them for a number of years, it feels that I have developed a culture of trust with them. We can talk about anything without fear of judgement. They can talk with me about specific issues in context, not abstract 'guideline' derived approaches which often fail to address the difficult situations which do not 'fit' our medical archetypes. It's no good saying "Don't ever give prophylaxis for urinary tract infections" if you haven't sat with them and talked in a specific way about just what you would do, and show that you understand the problem from the perspective of the patient. I gained 'validity' here by doing joint clinics with GPs talking to patients with recurrent infection.
We had a great discussion today about different techniques GPs use to talk to patients. Again, this sort of peer led discussion is a key part of any 'norming' part of a behaviour change methodology, and can only be done within a culture of trust. We talked about how it's really helpful to draw a graph of 'symptoms' vs 'time' and show patients where they are on the line. We then thought about how the 'Listen To Your Gut' message could fit in after this. Then talk about red flag symptoms and whether the patient has any. And then really allow the decision to prescribe antibiotics to sit with the informed patient. It's no longer a battle, but a conversation.
3. The detail is important. So developing this concept of validity, you have to be able to talk in detail about things in a way that connects with those asking the question. If you can't have a trusted opinion on how to manage a patient who's had a cough for 3 weeks (even if it's "I don't know - there is no evidence; my feeling is that this is appropriate") then there is not a huge point in having a meeting.
4. It's a two way thing. These meetings in primary care are not about me ("the expert") giving information. It's partly about this ("frankly I only really worry when they're rigoring and dropping their blood pressure...you can probably watch and wait in most other situation"; "co-amoxiclav adds no significant additional cover to fluclox for skin infection and has worse pharmacokinetics and more side effects" "I know we use multiple antibiotics to treat TB to stop emergence of resistance. But it doesn't seem to work that way in most infection, and you just increase side effects.")
But for me, it's more about giving me a sense of the demand as it present to primary care, and thinking about how we help. Just what do you do in a confused old person? In hospital they get chest X-rays, blood tests by the gallon and we then sort of have a plan. This is just so much harder in primary care. How can we support people to do this better. Urgent bloods? In someone with otitis media not responding to amoxicillin, is it reasonable to give co-amox? I have to confess I don't have a strong opinion on this - I can explain the bacteriology of why this might be appropriate because of resistant Haemophilus - but actually, do I know what the natural history of this disease is, and what investigations are appropriate, if any? If we don't hear these stories as they present, how can we have an opinion?
Three next steps for primary care infection optimisation
1. Is stewardship a bit too negative? Our common purpose is to optimise the care of the patient in front of us with possible infection. I would suggest that we should talk more in this positive manner. Again, I would note how the Listen To Your Gut message fits well with this approach.
2. We need to develop antimicrobial stewardship teams that work across health communities. It is important I know about how infection is managed in both primary and secondary care. We need to develop teams that can work in this way.
3. We need to work with all stakeholders - and we clearly need much more focus on non-medical prescribers; but also HCAs and nursing homes. They may not be able to prescribe, but they can strongly influence prescriber behaviour by the way they relate the patient story or request investigations.
