Could reducing over-prescribing cause harm?

The lead headline in many media outlets yesterday was how GPs and the 111 system had failed in the sad case of a 1-year old, William, who died of an undiagnosed infection. I was interested to be contacted by a journalist from one paper, who asked me if I had any views on one particular issue raised by the investigation: whether the campaign against over-prescribing might be leading to the unintended consequence of some patients not receiving drugs when they need them.

The report recognised that there is “national pressure on doctors not to prescribe antibiotics, which might well lead them to not do so when in fact it might be clinically indicated”. This led the panel to recommend that the issue of pressure on GPs to reduce antibiotic use be taken up by national bodies, and be investigated by the Child Death Overview Panel to identify how many cases this might involve. It was not entirely clear to me on reading the report whether the issue of antibiotics was one explicitly raised by the clinicians involved in the case, or if it was something that came solely from the panel.

There is huge concern about the public health implications of increasing antibiotic resistance, aggravated by a lack of new antibiotics in development (see the recent declaration at the World Economic Forum earlier this week). It is also recognised that antibiotics are frequently used unnecessarily. So curbing such inappropriate use is crucial from a public health perspective. It may also be in the best interests of individual patients too, as antibiotics can cause direct harm (for example, diarrhoea and vomiting, or allergic reactions).

I’m personally not aware of any scientific evidence that the pressure on GPs to reduce antibiotic use is leading to harm. Indeed, in the example of acute bronchitis, there is evidence that an intervention which reduces antibiotic use does not lead to adverse consequences for patients.

The key thing to remember is that we need to distinguish appropriate use of antibiotics from inappropriate use; it is reducing the latter that is required. No-one is advocating reducing the use of antibiotics in people for whom they are clearly indicated, which would include individuals with sepsis such as in this particular case. I suspect all GPs, if faced with a clear diagnosis of sepsis or other serious infection, would quite rightly not hesitate to prescribe antibiotics. Where the clinical benefits of antibiotics are far less certain, then GPs are more likely to follow the advice to reduce use of these medicines, and that seems to me appropriate from both an individual patient and a public health perspective.

The case of William is very sad. It highlights the importance of recognising signs of sepsis, and investigating and treating appropriately. However, the retrospectoscope is a powerful diagnostic tool. There may well have been some subtle clues suggesting underlying sepsis, but without having access to all the evidence, I suspect the majority of doctors – myself included – would have managed this case exactly the same way. And that doesn’t necessarily reflect “pressure not to prescribe antibiotics” – it reflects the fact that this is a relatively atypical and indeed even benign presentation of a critical illness.

What I hope comes out of this incident is that GPs awareness of sepsis and pneumonia in children improves. What I hope does not come out of it is an undermining of the current drive to reduce inappropriate antibiotic use. Prescribing antibiotics “just in case” in inappropriate circumstances is not what is required, and could potentially cause far more harm in the longer term.

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