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We need to educate patients on antibiotics – Dr Martyn Diaper and Philip Howard

In the last of our blogs marking World Antibiotic Awareness Week, Dr Martyn Diaper, a practicing GP and NHS England Head of Patient Safety (Primary Care), and Philip Howard, Consultant Pharmacist in Antimicrobials at the Leeds Teaching Hospitals NHS Trust, and NHS England Antimicrobial Resistance and Healthcare Associated Infection project lead, explain how the prevention of antimicrobial resistance requires help from patients:

Dr Martyn Diaper: The actions I have taken in practice have been amplifying many of the things I have been doing for years but I find in many cases I am now pushing at an open door with patients where I may have met resistance in the past.

Patients are more open to hearing about and understanding of the difference between viral and bacterial infections and why antibiotics don’t help coughs and colds.

They are keen and willing to listen to the risks of antibiotics – side effects of the course as well and possible risk of resistant infections in the future – and are more willing to discuss the evidence around infections which may not benefit from antibiotics. I find patients are also keen to look at other ways to get better through analgesia, rest, etc.

The key to prescribing less antibiotics is making yourself available to the patients for review, showing them compassion and concentrating on symptomatic relief. Really understanding how people are using their symptomatic treatments – exactly what painkillers are they taking and how often – exploring what they expect the course of the illness to be, and challenging their expectations of the natural history. Take time to explain that this really might take a week or two and antibiotics won’t speed that up.

Patients want the GP to give them something to help them. For too long we have relied on an antibiotic prescription but in reality, availability, humanity, compassion and understanding makes for a better recovery with less risk for patients.

Philip Howard: Antimicrobial stewardship is about improving patient outcomes while avoiding harm from antibiotic side-effects and minimising antimicrobial resistance.

I think we are on a journey with antimicrobials stewardship (AMS) with hospitals being further ahead of the community. The next phase of AMS in hospitals needs to get better local ownership by individual hospital departments so improvements in antimicrobial consumption and resistance can be measured and managed by the specialty.

An example of this from the Leeds Teaching Hospitals NHS Trust (LTHT) shows that local engagement can give greater insight. At LTHT we already have a broad multidisciplinary and cross-sector involvement in our antimicrobial stewardship group (AMSG).

Our approach this year has been to invite each of our directorates to our AMSG to present how they are engaging with their full team of doctors, nurses and other staff. The clinical director, head of nursing, link microbiologist and lead pharmacist are all invited to present their antimicrobial stewardship activity and performance.

The discussions around local triumphs and barriers help us focus the Trust’s AMS activity and overcome “issues” between directorates. For example, the acute medical wards would prefer to delay starting antibiotics where the patient doesn’t have severe sepsis, rather than starting them in the emergency department.

A recent study from the USA showed that diagnostic error is a major factor leading to inappropriate antimicrobial use in over 70% of cases. Consultants will make more accurate diagnoses than trainee doctors, and this may lead to less antibiotics being started, for example, heart failure can be mistaken for pneumonia.

Another strategy to reduce antimicrobial resistance by decreasing the use of broad spectrum antibiotics is to remove inappropriate allergy labels from patients’ records. There is growing evidence that having a penicillin allergy label – real or otherwise – is linked to higher rates of antibiotic resistant bacteria such as MRSA and C.difficile. Patients with penicillin allergy get prescribed more powerful (broad spectrum) antibiotics, so removing this label as part of a thorough drug history in the medicines reconciliation process on admission can help increase the use of first-line antibiotics.

In the community, prevention is a key element of antimicrobial stewardship. The expansion of flu vaccination to at-risk groups in community pharmacy should increase overall uptake of the flu jab, and hopefully decrease antibiotics for respiratory infections.

In GP practices, the use of point-of-care CRP – used to detect inflammation in the body – as recommended in the NICE pneumonia guideline offers real opportunities to impact on prescribing. This is used by most European countries with lower antimicrobial consumption rates.

Finally, antimicrobial stewardship in community pharmacy is only just starting to become main-stream. A pilot study in Yorkshire showed that 93% of the public would be happy to have the reason for their antibiotics to be on the prescription.

The study being presented at the Federation of Infection Societies this weekend showed most community pharmacists did not ask the patient what the antibiotics were being used to treat, and so subsequently the community pharmacist couldn’t check against local guidelines. This is done routinely in hospital out-patients, so could be implemented in the community.

Importantly, community pharmacists need to ensure that all patients receive information about potential adverse effects that could stop patients from taking their antibiotics as prescribed and completing the course. Telling patients to return any leftover antibiotics for destruction will decrease the chance of using them for another infections and increasing resistance.

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martyn-diaperDr Martyn Diaper is the Head of Patient Safety (Primary Care) and the chairman of the Primary Care Patient Safety Expert Group at NHS England.

Born and raised in Southampton, Martyn trained at St Thomas’s Hospital and worked in the UK and Australia before settling with his wife in Winchester, where he was a GP for nearly 20 years. During that time he gained an MBA with the Open University and worked with the NHS Institute for innovation and improvement as clinical lead for patient safety.

In 2011 he trained as a Patient Safety Officer in Boston MA at the Institute of Healthcare Improvement. Martyn worked as Clinical Director for South East Hampshire ISD at Southern Health from 2013 to 2014, and later became Southern Health medical director until July 2015.

He has also worked for NHS Improving Quality as clinical lead for patient safety and commissioner development in its delivery team.

philip-howardPhilip Howard is Consultant Pharmacist in Antimicrobials at the Leeds Teaching Hospitals NHS Trust, an Honorary Senior Lecturer at Leeds University, and is currently seconded part time to NHS England as an Antimicrobial Resistance and Healthcare Associated Infection project lead.

Philip has been active in the field of Antimicrobial Stewardship (AMS) for many years. He has been involved in the development of national AMS guidance for primary care and hospitals, the national Antimicrobial Prescribing and Stewardship Competences.

He is a member of the UKCPA Pharmacy Infection Network, BSAC Council, ESCMID AMS committee and has represented FIP on the WHO AMR Strategy.  He is also a spokesman for the RPS on antimicrobials.

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