Antibiotic resistance
For many years I have spent much of my patient consultations providing education on the use of antibiotics for infections and explaining the difference between those infections which are treatable with this medication and those that are not.
Back in January the World Health Organisation convened for the 79th United Nations General Assembly (UNGA) for the second High-level meeting on antimicrobial resistance (AMR). The WHO describes antimicrobial resistance as one of the top global public health and development threats. It is estimated that AMR is responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths. The misuse are the main drivers for drug-resistant pathogens.
AMR puts many of the gains of modern medicine at risk. It makes infections harder to treat and makes other medical procedures and treatments – such as surgery, caesarean sections and cancer chemotherapy – much riskier.
The National Institute for Clinical Excellence has evidence-based guidance for a wide range of infections, for which treatment is appropriate. This includes antibiotics, anti-fungal and anti-viral medications. They published guidance in 2015 which included definitions of antimicrobial stewardship: an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness. They also define antimicrobial resistance as: loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines.
This guidance includes the need to monitor antimicrobial prescribing patterns, and to audit patient safely incidents relating to their use, such as development of severe allergic reactions, clostridium difficile (which is an infection of the bowel resulting from antibiotic use). They describe these events as potentially avoidable, meaning of course, they would not occur if the treatment had been replaced with watchful waiting and safety netting. The guidance also encourages educating prescribers about local and national prescribing formularies, and evidence-based practice, including the use of robust documentation making explicit the rational for either prescribing or not prescribing an antimicrobial.
As a prescriber it can be daunting when faced with a patient who we think may require one of these treatments, but by offering such, we increase the risk of resistance, or adverse events. This has been the reason why I decided to learn as much as possible about current global attitudes towards antimicrobial prescribing, including the figures and research, so that I would be better equipped for the conversations I have when trying to steer patients away from antibiotic/antifungal/antiviral medication.
The difficulty for clinicians including myself, is the risk that a patient develops more serious health concerns, if they are not offered treatment for presenting symptoms, at the initial consultation. For example, the guidelines for the treatment of an acute sore throat (NICE 2024) follow what’s called the Feverpain score, or the Centor score. These tools provide the clinician with an evidence-based symptom check list which then gives a score, indicating the likelihood that the patient has a bacterial infection. However, even if this is found to be the case, for an otherwise healthy patient, who has no comorbidities, antibiotics will only reduce the infection by approximately 16 hours. Furthermore, the course of this treatment, is two tablets, four times daily, for ten days (unless penicillin sensitive).
In a climate of blame culture and no win no fee claims, as clinicians, we often feel compelled to treat. Even if we decide to adopt a watchful wait, in the hope that patients will improve, lack of appointments, mean they may not get a timely review. As far as improving the antimicrobial prescribing, we need to fix the NHS first! In the last year my experience has drastically changed, from treating only NHS patients, to a role where I am delivering care to private patients.
I can tell you this has been a huge learning curve! No sooner have I developed a rhetoric for my NHS patients, about needing to reduce antibiotic use, to allow the body’s immune system to fight the infection, that suddenly I have new conversations, along the lines of “I am paying for my health, so I want a strong antibiotic”. How do I argue with that? Suddenly money is on the table and conversations move away from health and evidence-based care, to what can be bought.
This forced me to review how I was managing my conversations about self-limiting illnesses for otherwise healthy patients, and what additional information I could find to build up my persuasion (because oftentimes that is what it is) that treatment is not always needed. Over the years that I have worked in primary care, and within the NHS I have seen so many inappropriate antibiotic prescribing, often for young and healthy individuals. One of the fundamental skills in nursing is defensible documentation, and when I review patients who have been on treatment and their symptoms have not improved (no surprise, they were likely given antibiotics for a viral infection) I rarely see any reference to antimicrobial conversations.
When I assess patients, for all manner of conditions (not all applicable for treatment) I will always try to engage the patient in a risks/benefits conversation about antibiotic use. For example, I had a male patient, in my private role, who was suitable for Phenoxymethylpenicillin (Pen V for short). His Feverpain score was > 3 and the evidence therefore, indicated high likelihood of strep throat (a bacterial infection). I encouraged the patient to choose to not treat, providing a rational for this. I explained how the immune system works, and how, given his age, and that he had no chronic or long-term conditions, his body would very likely fight the infection without the need for a ten-day course of treatment which would likely cause unpleasant side effects like nausea, indigestion, diarrhoea.
I was pleasantly surprised and pleased that he chose the watchful waiting approach, deciding against treatment. I must stress; however, the watchful wait is much easier in private health when you know the patient is going to get an appointment anytime they need because it is a 24-hour service. I haven’t been as lucky in other consultations, to use my persuasive skills and avoid prescribing antimicrobials.
I remember a 21-year-old patient, who had reported a two-day history of general cold/flu symptoms. As part of the history taking the clinician asks specific “red flag” questions, which help detect, early on, if there is a likelihood of complications, requiring more urgent intervention. This patient had none. He also had no medical history of note, no respiratory conditions and took no medication. He wanted antiviral medication. Because he was paying privately. I had to explain, politely, that the guidance underpinning every decision we make as clinicians, does not change according to whether we are receiving NHS support or private.
I want to stress that every patient counts, and health and illness means different things to different people. There are many contributing factors, which influence the expectation of a patient, when seeking medical advice. I always avoid judgment or what’s called confirmation bias, which is where we assume a patient’s beliefs, needs, values, based on previous experience. I always provide a patient centred consultation, where their voice leads the conversation, and I facilitate, by directing specific questions, referring to evidence-based guidelines where needed, giving my advice from experience and using a problem-solving approach to reach a diagnosis.
I have found that the more empathetic I am with the patient’s experience, whether it be pain, disability from symptoms, or distress caused by illness, the less they focus on a specific outcome. Often patients just want to be heard and validated. They are often frightened of their symptoms, many experiencing health anxiety, catastrophising what might be self-limiting, and becoming convinced of something more sinister. These patients should never be dismissed. We don’t know what their experiences are, what life stories they have and what beliefs they hold about health and illness.
There are circumstances where I have no choice but to withhold antimicrobial therapy and an example of this is in the private role I have. The Care Quality Commission govern health services and perform regular audits and inspections to ensure the delivery of care is evidence-based, safe and patient centred. I work as a digital remote advanced nurse practitioner and treat patients over either video or phone call. The CQC and the NICE guidance advise that the diagnosis and treatment of respiratory infections is not safe in a remote setting and the patient should always be signposted to an in-person assessment.
I have become very well-rehearsed in explaining this to the many patients who ring with coughs, flu or wheeze. This is after they have ticked a pre appointment checklist, agreeing that we do not treat chest infections. While this can be frustrating both for the clinician, who wants to help, and the patient who wants relief from their symptoms, I have rarely had a disappointed patient. I listen carefully to the symptoms they describe, take their full medical, medication and allergy history, and then perform a remote examination (often this is visual, watching for any respiratory distress, pallor or cyanosis).
When I validate their experience, and provide several possible diagnoses, the news about treatment (or lack of it) becomes less disappointing. The patient has already been given the medical attention, as well as the explanation of their symptoms. I have even developed my own body of research, about the non-medical therapies that can alleviate a cough and improve immune response. This is often very well received and for the most part, patients leave the call thanking me.
Of course, like everything in life, there are exceptions! I had to be very rehearsed in antimicrobial stewardship and be able to recite the guidance when a patient booked in with me with a self-diagnosed chest infection. If you’ve never heard of “heart sink” patients, this is an example. The patient had already come to her own conclusion about what her symptoms were and knew what treatment she wanted.
Sadly, all the work I had done, and continue to do, in communicating effectively, showing empathy, quoting the evidence, made no difference. I listened while she set about a lengthy monologue expressing the disgrace of the NHS, and the outrage she felt, that she paid private health insurance, to be told she couldn’t receive treatment. Furthermore, she wanted me to refer her to her own GP for an emergency appointment. I listened without interrupting. I nodded, validating her frustration (most of it was warranted) and then when she finished, I reminded her that to get the appointment she had to have clicked the button to agree that our service does not treat chest infections.
I can see why she was frustrated, especially when you cannot get an NHS GP appointment easily, and when 111 direct you to A&E for the common cold. All I can do is listen. And remain safe in my decision making. It might surprise you to know that there are now waiting times for private health referrals into secondary care! It beggars’ belief. As much as I love my role as a nurse, I am relieved that a good part of my career is behind me, and I have the option of retiring in five years. I dread to think what state our health service will be by then and understand the frustrations of both patients and health care workers. If you are having difficulty getting an appointment with your NHS GP it is always safest to ring NHS111, regardless of the reputation we hear about them. Ultimately, we are each responsible for our own health, so we must persevere. I am prepared to stay 50 in the queue at eight in the morning, if it means I get an appointment this side of Christmas!
