Antibiotic use falling but resistant infections rising: what are clinicians to do?
What are clinicians to do? Primary care prescribers in England have cut the number of antibiotic prescriptions they issue by 17 per cent in the last five years, and yet drug-resistant infections are still increasing (by 9% between 2017 and 2018). No doubt this is a source of immense frustration for many health professionals.
While there has certainly been a problem in the way antibiotics have been prescribed in the past, this latest report from Public Health England (PHE) shows there has been significant progress in changing behaviours and curbing misuse and overuse of these life-saving medicines. Indeed, when we launched the Longitude Prize back in 2014 the picture was very different. A survey of 1,000 GPs revealed that over a quarter (28%) of them prescribed antibiotics “several times a week” even when they’re not sure they were medically necessary.
Yet, there’s only so far we can go when it comes to rowing back on prescriptions, without triggering and incurring unintended consequences. People across the world rely on antibiotics each and every day; we’ve done so for decades. The treatment and containment of serious bacterial infections, from pneumonia and sepsis, relies almost entirely on the availability and use of powerful antibiotics.
It is essential that the right antibiotic is prescribed to the patient the first time they present at a healthcare facility and having access to rapid, point-of-care tests is fundamental to this. A recent report from the World Bank, which focuses on knowledge gaps in the international battle with superbugs, reminds us that though “drug discovery has a crucial role to play in maintaining our ability to successfully treat infections, [but] without addressing the underlying causes of the AMR crisis we will remain on the same broken treadmill, constantly reliving a self-fulfilling prophecy.” One of these key underlying causes of AMR is prescribing without testing first.
''there’s only so far we can go when it comes to rowing back on prescriptions, without triggering and incurring unintended consequences''
Unfortunately, today’s tests are not accurate enough and, for the most part, cannot be done in the clinic and need to be sent off to the lab. We need to urgently accelerate the development of a rapid point-of-care test so that infections are treated with the right antibiotics the first time around. Doctors shouldn’t have to wait for two to three days to find out if an antibiotic will work or not. They deserve better tools that can indicate whether or not a patient needs antibiotics and whether a certain antibiotic will be effective, on the spot, before prescribing it.
Improving diagnostics will slow resistance. The introduction of such tests into frontline care would help stop an infection escalating into a bloodstream infection, reducing both the likelihood of repeat visits to GP Surgeries and admission to hospital. Fewer hospital admissions with people who have out of control infections means less in-hospital transmission of resistant infections. Interestingly, the PHE study shows that antibiotic prescription in hospitals is still increasing, although at a slower rate.
Alongside the development of strong clinical guidelines, we need to create markets for new diagnostics. Today introducing a new diagnostic is a herculean task that requires convincing commissioning agencies that even if overprescribing antibiotics might be a cheaper option, it is a dangerous one in terms of public health. We are going to need commitments to allocate funds to commissioning diagnostic cases. This is what it will take to create this market.
''We need to urgently accelerate the development of a rapid point-of-care test so that infections are treated with the right antibiotics the first time around''
For our part, Nesta Challenges is incentivising developers to create diagnostic tests that enable accurate and affordable testing. The £8 million Longitude Prize will be awarded to test developers that create a rapid test designed to curb the unnecessary use and misuse of precious antibiotics. Globally, there are teams of medical and science innovators that are developing diagnostics that have the potential to transform the way doctors treat infections, from cameras that compare a single image of an infection against an AI enabled database, to chips that plug into smartphones to analyse specks of blood for infection. Rather than three days, they offer the prospect of providing accurate diagnoses within 30 minutes.
The PHE data shows us that though the proportion of infections becoming drug resistant has not increased, the total number of infections has. As such, we must also double-down on infection prevention and control programmes (IPC) in all health and social care settings and break the chain of infection. Something as simple as effective cleaning and hand hygiene can have a demonstrable impact on the quality of patient safety across the health system.
Though it is said that “awareness does not seem to translate easily into changing use behaviour,” it is also an essential part of the puzzle. Commenting on the launch of the PHE report and battle with AMR, Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, rightly acknowledges that: “GPs are already doing a good job at reducing antibiotic prescribing, but it can’t be our responsibility alone.”
Ultimately, if we continue on this path of limited interventions and wishful thinking for a “silver bullet” solution, like the reduction of prescriptions or the introduction of a new antibiotic, without driving wider system change in other areas, clinicians will continue to remain stuck between superbugs and a hard place.
If we are really serious about preserving antibiotics so that we don’t return to the pre-antibiotic age, prescribing “just in case” is no longer an option. Clinicians need new diagnostic tools to prescribe antibiotics with certainty.