Bullying antibiotics out of your GP

The man stares rudely at me as if I don’t know my job. ‘But my ears and my throat are painful so I need antibiotics.’

Patiently, I explain that his ear drums both look normal. His throat and glands are fine too, that his multiple symptoms fit with a viral infection, so antibiotics wouldn’t help. In any case he’s already had 5 days of antibiotics (given to him by some dodgy walk-over walk-in GP service).

‘But I’m going on holiday tomorrow so I need them for the flight.’

Again, I explain that antibiotics won’t make a difference and try to move the conversation onto the possible risk of flying and how to manage a sore throat and ear pain during takeoff and landing.

‘But they’re painful. So, I need an antibiotic to treat the pain.’

He now has the manner of customer at Sainsbury’s who had found the organic tomatoes were not to his liking. I am the floor manager.

My heart is starting to pound with aggravation. I try to relax because I am just not going to give this patient antibiotics. This time instead of another placatory remark I (unfortunately) say, ‘Your ear and throat pain is not a trump card.’

‘What’s Trump got to do with it? He frowns and raises his voice. ‘Look I’ve got stuff to do so can we sort this out?’

It’s all consumer rights these days. A colleague was threatened with the GMC for not taking his shoes off

The Salisbury Review — Summer 2019 when entering a patient’s house. They had new carpets you see.

‘Your ears and throat need time to get better and heal up. Your own body will do this but it will take time to do it.’

And then eventually, as he starts shouting, I say simply, ‘No.’

I have been a GP for 15 years and have had the ‘Antibiotics are not the right treatment for you because this is a viral infection’ conversation 3-4 times a day throughout this time. This cuts no ice with my patient, he demands to see the practice manager and the partners because they, ‘Can give him what he wants’; like the song, ‘So tell me what you want, what you really, really want’.

I stand up. The consultation is terminated as far as I am concerned. I open the door as a suggestion that he should leave. He storms off.

Now I know exactly what you are thinking, how could I be so sure I was right? And the answer is, ‘I just am.’ I can’t sit down and explain the whole of medicine to you or to him or to pass on all the patient examinations I have done in a quick download. But in case I am wrong, I (and all other GPs) give ‘just in case’ advice, for example, ‘If I am wrong and your ears get worse, see a doctor in Barbados.’

I know your next question too; ‘Why didn’t you just give him a ‘delayed prescription’ of antibiotics’? (Some tablets to have in his wallet just in case).

Because that option is a fudge. It’s for a doctor who lacks commitment to his own diagnosis. Sometimes I do use that option but the other way around; ‘I think you need them but let’s wait 24 hours to see if it settles with this alternative strategy first.’

And I know your last question too – did he get them? Yes, of course he did, because no practice wants to have to handle a formal complaint when they can nip it in the bud by giving a patient what they want.

How do I feel about all of this? I would like to give the adult answer; that I am resigned to the situation, but really that’s not true. I am burning with annoyance and indignation. I feel slighted, my medical experience not taken seriously, critical that the practice is unable to hold its ground against demands like this and baffled that doctors are not giving the same message about antibiotics and avoiding prescriptions. Our first duty is not to make things worse by sticking our oars in. We make an oath to do no harm. So how much harm are we doing?

Just step back from this fly-on-the-wall view of a patient consultation for a moment. There are 5 other GPs at my practice simultaneously having the same conversation. Step back further and see all the practices in the city and then all the doctors in the UK (250 000

of them) and think how much antibiotics are being dished out inappropriately right now.

It’s not a cost issue which, by the way, my patient accused me of in passing. A course of antibiotics costs the government less than £2. The issue here is antibiotic resistance. The more we use them, the more resistant bacteria survive and grow.

The most worrying sort are ‘carbapenem resistant bacteria’. These are bacteria that are resistant to multiple antibiotics including the last resort antibiotic; carbapenem.

I trained in a happy golden age of antibiotics and medicine. As a medical student I met GPs who were practicing when penicillin was first available. One intramuscular shot was all it took back then to cure a patient with an infection. The advent of antibiotics has meant all sorts of surgery, chemotherapy, leukaemia treatments and bone marrow transplants have been possible.

But now antibiotic resistance means that children and adults, especially in intensive care units, simply die of resistant infections. This situation is particularly severe in Greece where up to 67 per cent of Klebsiella bacteria are carbapenem resistant (compared to 1.3 per cent in the UK, although it used to be zero). In fact, rates of resistance of all bacteria in Greece are the highest in Europe. Greece gives us a useful preview of how things will be here in a few years’ time. All of their hospital admissions are complicated, their patients have multiple resistances and the risk of dying from a usually treatable infection is greatly increased.

Why are some countries more affected? Because they use more antibiotics, either because they are available simply to buy without seeing a doctor first or because the doctors over-prescribe. France is famously culpable; its doctors prescribing (and patients demanding) three times more antibiotics than the European average. The tagline that they try to use is, ‘Antibiotiques c’est pas automatique’ which seems to imply that until very recently they were. In countries which have antibiotics available over the counter such as Greece, of course they are over used, and antibiotic resistance is rife. Globally, the sale of antibiotics over-the-counter is widespread, but it is rare that countries track resistance to the drugs,

We can pat ourselves on the back in the UK because our antibiotic prescribing rates are near the bottom of the table (along with Sweden, the Netherlands and Denmark) at about 600 prescriptions per 1000 patients per year (836 in USA). But even so doctors in the same practice have prescribing rates that vary widely. In some NHS practices one doctor may see exactly the same sort of patients and yet prescribe 3 times more antibiotics than his or her colleague.

Web: www.salisburyreview.com But even assuming our antibiotic prescribing rates were perfect, GP prescribing rates uniformly low and patients never argued, does that mean we would be safe from infections? Would antibiotics continue to work for us?

The short answer is no. Antibiotic resistant bacteria are spreading. Carbapenem resistant bacteria were first noticed in the world in 1993, (the first USA case in 2001 and the first in the UK in 2003). The spread can be tracked like a black ink stain moving from Greece and Italy through Europe. In the UK the map is marked with spreading black spots representing the fact that it is found in medical centres but not yet generally throughout the community.

I have treated patients who have imported resistant toxin-producing bacteria from India and elsewhere and then seen the same illness again in other local patients. If we travel to countries with a high prevalence of resistant bacteria and end up in the hospital system, the chances are high that we will be colonized by resistant bacteria to bring back to the UK.

Avoiding antibiotics makes sense since we mainly don’t need them. We understand using antibiotics encourages the resistant bacteria to thrive. Avoiding antibiotics is the only thing we can do to avoid resistant bacteria.

Antibiotic resistance is not a new phenomenon. It was recognised the moment antibiotics were invented when Alexander Fleming, the discoverer of penicillin, warned of it in his Nobel Prize acceptance speech in 1945. But for our generation, a world without effective antibiotics is a new phenomenon indeed.

In the future we may see our children and grandchildren die of infections in a way that we have never seen. My great-aunt died, following childbirth, of puerperal infection in 1942 leaving her baby to be given away to another family. If we all continue to argue that we need antibiotics for viral infections, perhaps stories like this will once again become common in our lifetimes.

In the meantime, should I learn from my encounter with my ear-throat patient to compromise with future patients on antibiotic prescriptions and avoid aggressive confrontations like this one? Or should I hold the line, try to keep the UK prescription rate down and maybe delay, for a while, the development of complete antibiotic resistance?

Of course I will hold the line. Hippocrates said: ‘First do no harm.’ Complete antibiotic resistance would be Armageddon.

Berenice Langdon is a GP

This article first appeared in the Summer Edition of the magazine.

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9 Comments on Bullying antibiotics out of your GP

  1. Interesting perspective. There are cases though, based on my own personal experiences, where I the patient should feel capable of determining when immediate start to a dosing regimen of antibiotics would be prudent. I have done this twice in the past six months and spared myself potentially serious complications. This February while in Paris, FR I took a seven day course of amoxicillin for a condition that was worsening daily and had just started to affect my head by creating intracranial pressure so great I could not lay it down even on a pillow without great discomfort. That symptom disappeared a few hours after starting the regimen. Now, while on extended stay on a Greek island, I started to experience the same progression of symptoms I had twice before in the last six months: cellulitis! As soon as the pain and swelling affected area of my toe started to radiate heat I knew what to do: 10 to 20 day regimen of both 2/day Bactrimel (800 mg Sulfamethoxazole + 160 mg Trimethoprim) and 3/day Amoxicillin (500 mg). In this case I substituted Amoxicillin in place of 4/day Cephalexin (500 mg) which is not available in Greece. The symptoms started to abate immediately though as before took about 20 days of treatment to be almost completely gone.

    I think it would be most helpful to inform the public how antibiotic resistance occurs. Not necessary to delve into the molecular biology realm of plasmids and resistance transference between bacteria, but instead just the basics about continuing the antibiotic regimen for a minimum period of at least seven days even if feeling better much sooner, and using only antibiotics that haven’t caused side effects and that have worked against the exact same set of symptoms.

    In Greece Bactrimel is dispensed in quantities of ten tablets, sufficient for a five day dose. Perhaps this is why Greece has such a problem with resistance?

    BTW I am aware of the difference between gram negative (wall + membrane) and gram positive (membrane only) bacteria, and how certain antibiotics work. Ciprofloxen, also not available in Greece, interferes with Topoisomerase IV (or, if remembering wrong, then DNA Gyrase) and prevent separation of the DNA catonates that would be necessary for bacteria to complete their reproductive cycle. I am also aware of a potential for serious complications from even normal and regulated antibiotic use: C. difficile. I do not have any C. difficile in my stool culture.

    Bottom line: please don’t paint all patients who self-medicate with the same broad brush. I would like to keep my limbs whole and I ntact, and not be given sympathy instead from a physician whose meeting with me inadvertently delayed treatment for a few critical days.

    We ‘patients’ are not all the same; just as all ‘medical doctors’ are not the same. Sorry John Locke for the apparent contradiction to your otherwise excellent conclusions which assisted I believe in the profound statement “….we take these truths to be self-evident..that all ‘men’ are created equal…”

  2. Antibiotic resistance is a meaningless argument without some real data about the issue – by which I don’t mean cherry-picked scare stories. It is a dynamic process, and the balances need to be understood and communicated. Patients should not simply be told that they can’t have something that, after all, they are paying for. There is, of course, no point in prescribing something which will be completely ineffective, but the physician’s armoury contains a wide variety of palliatives – which is what was needed here.

    Resistance will evolve in a wide variety of circumstances. If the Heath Service is seen by its customers as not supporting their requirements, then resistance to paying for it will tend to increase….

  3. Just to be clear, resistance would develop even if antibiotics were not over-prescribed. Lowering prescription rates merely lowers the pace at which resistance emerges.That’s evolution for you.

    The Greek problem also exists in Asia. In at least one country here the more drugs a doctor prescribes the higher his or her income because government payments to doctors are linked to the price and quantity of the drugs prescribed. There is thus an unhealthy incentive for doctors to prescribe drugs, including antibiotics, unnecessarily.

    Efforts are under way to find new antibiotics which can kill resistant strains of bacteria; fungi derivatives look promising. But resistance to these will eventually emerge too. It’s an arms race with no end in sight.

    • Good point. There was talk some years back of crocodiles being a possible source as they live with severed limbs in filthy rivers. Wonder what happened there.

      • Yes, Michael, crocs and alligators may be a good source too. But the science and research take time – I’ve seen reports about this exciting possibility dating from 2008 – the antibiotic properties of croc blood are so powerful that they may have to be attenuated for human use.

  4. I’m not a doctor but my experience with people in all walks of life suggests that they use the word antibiotic as a synonym for medicine: they have no knowledge or understanding of different ailments and their treatment. Public ignorance in every area is massive and cannot be overestimated.
    Hippocrates emphasised the importance of healthy diet, exercise and environment. A lot of minor infections could be avoided if people avoided touching handrails and handles in public places, and if they washed their hands as often as hospital staff do. Maybe one answer would be to offer some sort of package – pocket hand sanitiser with some sort of palliative throat medicine. It’s a hopeless task trying to educate people. It’s not the lack knowledge, it’s that they have the completely wrong knowledge firmly fixed in their heads.

    • A counsel of perfection Michael? Supermarket trolley handles, escalator handrails, bus grab-rails, shop-door handles, food packets, in fact pretty well everything in life out of home. Then we get into our cars and pass contamination to the steering wheels, and if we go to a garage or have an MOT someone else touches the car’s controls. Yes, wash hands before handling food, that is the obvious simple precaution, provided we have not contaminated the tap! OK, change the taps to quarter-turn style. But we must not become paranoid about the whole of life, or live in a sterile cocoon.

      • Some good ideas there George! People with compromised immune systems already take more care and from my experience it’s an effective way of avoiding most infections.
        I really think the problem is the terminology. Anti-biotic has come to mean Super-Dooper-Cannot-Fail-Medicine to a lot of people. Maybe we need some other impressive term that covers a paracetamol and a day off work.