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30 January 2019

The doctors fighting our return to an era when people routinely died from common infections

As a profession, we’re supposed to be minimising our antibiotic prescribing to help counter the looming disaster of resistance.

By Phil Whitaker

Our practice recently received a letter from Professor Dame Sally Davies, the chief medical officer for England. She was writing to let us to know that we rank in the top 12 per cent nationally for prescribing an antibiotic called co-amoxiclav. This is not an achievement. As a profession, we’re supposed to be minimising our antibiotic prescribing to help counter the looming disaster of resistance, which is threatening to return us to the era in which people routinely died from common bacterial infections. Drugs like co-amoxiclav are considered the worst of all: they are known as “broad spectrum”, meaning they target a wide range of bugs, but are also more likely to give rise to significant problems through overuse.

We decided to conduct an audit. I was confident of my good credentials; I pride myself on using antibiotics more sparingly than most. And I had my suspicions as to which of my colleagues would be revealed as profligate prescribers. Charlotte, our practice pharmacist, set to analysing three months’ worth of data, then we convened to discuss her findings.

I was slightly late to the meeting and was disconcerted by the faintly amused glances when I entered the room. It turns out I am the worst offender in the building. My immediate reaction was to disbelieve the results. But looking through the case-by-case analysis, I am indeed opting for co-amoxiclav inappropriately in a specific set of patients: children with skin and soft tissue infections such as impetigo and cellulitis.

The bacterium most commonly responsible, Staphylococcus aureus, should ideally be treated with a narrow-spectrum penicillin called flucloxacillin. The problem is that the liquid formulation – which is all kids can swallow – tastes absolutely disgusting. Years of experience of despairing parents ringing to say little Jonny was refusing to take his medicine had taught me not to bother.

And the alternative choice, erythromycin, although more palatable, is notorious for causing vomiting. So I had developed the habit of treating young patients with co-amoxiclav – much nicer tasting, and also less likely to be chucked back up afterwards.

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Our audit showed my colleagues prescribing liquid clarithromycin – a modern, much better tolerated cousin of erythromycin – in these situations. It wasn’t that I’d deliberately decided not to do this, but simply that once ingrained, habits can become unconscious.

Now I’m aware of the issue, I can do something about it. But the audit raised further questions in my mind. If I was so blind to my poor use of co-amoxiclav, was I really as judicious in my overall antibiotic prescribing as I fondly believed myself to be? Charlotte is nothing if not dedicated to the cause of tackling resistance, so she enthusiastically agreed to undertake a similar study looking at our total antibiotic use. This proved more reassuring: out of six of us in the surgery, I am at the lowest prescribing end. And an interesting pattern was revealed. The two most sparing among us are also the youngest; those closest to retirement are prescribing at around double their rate. In the early decades of their careers, there was little concern about antibiotic use. For doctors training today, the culture is very different.

The exercise reinforced the value of examining critically what we do. It’s rare for any of us to be conscious of practising poorly; most doctors consider themselves to be doing a good job. An audit gives a clear-eyed glimpse of the reality.

Charlotte is going to repeat the audit in six months’ time, at which point I am determined to be among the lowest prescribers of co-amoxiclav. Conversations over coffee have seen us swapping our strategies for dealing with tonsillitis, ear infections, bronchitis and sinusitis without recourse to antibiotics. I’m hoping the practice as a whole will prove to have tightened its use of these precious medicines as a result.

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This article appears in the 30 Jan 2019 issue of the New Statesman, Epic fail