The second professional session of the Conference took place on the afternoon of September 13. It was chaired by the President (Mrs Christine Glover) and featured two speakers: Ms Alison Ewing (director of pharmacy, Countess of Chester hospital), who explained the background to the recent Standing Medical Advisory Committee report on antimicrobial resistance, and Ms Gail Thomas (pharmaceutical adviser, South Cheshire health authority), who described what pharmacists could do about the problem at a local level
Ms Ewing opened her speech by reminding the audience how the advent of antibiotics had transformed diseases which were previously feared as killers into minor illnesses.
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Alison Ewing: we must fully understand how antimicrobials work |
She went on to say that in some parts of the world bacteria had developed which were 100 per cent resistant not only to penicillin, but also to erythromycin, cephalexin, methicillin and, indeed, every other antibiotic which she could name except one — vancomycin. Even this last bastion was not infallible, and over the past 10 years strains of multiresistant Salmonella and Staphylococcus aureus (MRSA) had appeared.
The appearance of this problem had been linked with a growing anxiety about it among both the public, through sensational scare stories in the media, and health care professionals. Both the British Medical Association and the Royal Pharmaceutical Society had raised the issue and the subject had been examined by the House of Lords Science and Technology Committee. This crescendo of concern had led the Department of Health's chief medical officer to ask the Standing Medical Advisory Committee (SMAC) to address the issue of antimicrobial resistance.
The committee had been asked to identify emerging problems, point out both good and bad practice in relation to resistance, list priorities for changing practice and, importantly, advise on how such changes might be effectively achieved for both professionals and the public.
Ms Ewing had been appointed to a sub-group of SMAC as a representative of the Standing Pharmaceutical Advisory Committee.
She said that after the first few meetings of the group it became clear that its report was going to be "a mighty tome". The report was directed to ensure that the best practice in antimicrobial prescribing became routine practice. It had been published in September, 1998.
Part of the SMAC remit had been to quantify the extent of the use of antimicrobials, Ms Ewing told the Conference. Of all antimicrobials used, 50 per cent was in humans and 50 per cent was in animals, but only 20 per cent of the usage in animals was by prescription. Many antimicrobials were used as growth promoters in foodstuffs, a usage criticised in both the House of Lords and the SMAC reports. In humans, 80 per cent of antibiotic prescribing was in the community, with 50 million prescriptions issued in England each year, almost one per head of population. There were huge variations in prescribing both within and between health authority areas.
She said that part of the problem was the special status of antibiotics in the eyes of both patients and prescribers. They were commonly used and perceived as being safe and effective for a wide range of conditions, and therefore both doctors and patients had high expectations. A lot of pressure was put on doctors by patients to prescribe antibiotics, whether they were clinically necessary or not.
Following the SMAC report, the National Health Service Executive had issued a Health Service Circular (HSC 1999/049) on resistance to antibiotics. The Government's strategy had three elements: infection control, prudent antimicrobial use and surveillance.
Education campaign
The SMAC report had recommended a two-pronged education campaign, directed at both professionals and the public. The Government was supporting a campaign aimed at general medical practitioners on the theme of "Four things you can do". These were: stopping the unnecessary use of antibiotics for simple coughs and colds, not prescribing for viral sore throats, shortening courses to appropriate lengths, and not prescribing over the telephone without seeing the patient, other than in exceptional circumstances.
This needed to be accompanied by a public education campaign and the introduction of the topic of antibiotic resistance early on in health care professionals' education and possibly even to schools under the National Curriculum.
Community pharmacists would have a key role to play in any public education campaign and there were other ways in which community pharmacists could become involved in appropriate antibiotic prescribing, Miss Ewing said.
First, they should be circulated with copies of agreed local formularies.
Second guidelines should be agreed for the referral of patients from pharmacies to general practitioners, and also from doctors to pharmacists so that symptomatic relief using over-the-counter preparations could be supplied.
Another role might be with the use of "delayed action" or post-dated prescriptions. These would be given to the patient, but only dispensed after a specified period if the symptoms had not resolved. (This suggestion was supported by several speakers from the audience during a discussion session after the presentations.)
However, for all of these roles, if they were to be effective, there would have to be changes in the way in which payments were made to community pharmacists, Ms Ewing said.
Further research was necessary in several areas, she said, principally around the exact duration of antibiotic courses and the impact of non-compliance on the development of resistance.
One final problem which she identified was the provision to prescribers of starter packs of antibiotics, mainly for expensive branded products. In Chester the hospital had produced starter packs of generic formulary antibiotics for use by prescribers in one primary care group area.
Ms Ewing later added that she thought starter packs of heavily promoted products should be banned.
The way in which the South Cheshire health authority had addressed some of the problems identified by the Standing Medical Advisory Committee's report on antibiotic prescribing was described to the Conference by Ms Gail Thomas.
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Gail Thomas: "name and shame" policy promotes changes in prescribing practice |
The health authority area had a population of 675,000 covered by 397 general medical practitioners in six primary care groups. The working group found that in the area an estimated 255,000 consultations per year relating to potential infections took place, an average of 12 consultations per general medical practitioner per week, and that over 466,000 prescription items were ordered at a cost of £1.9m or 3 per cent of the authority's total expenditure, even though the health authority had low rates of antibiotic prescribing and high generic prescribing by national standards.
Examining different categories of antibiotics revealed two particular target areas. The prescribing of cephalosporins showed large variations between practices and the prescribing of quinolones showed large variations and a level of prescribing higher than the national average. Both were high cost items and in the top five prescribed categories.
The health authority had a "name and shame" policy for practices where the prescribing was felt to be out-of-line with the norm and the practices therefore showed considerable interest in the prescribing graphs, particularly when they were at the extremes, Ms Thomas said.
To initiate changes in prescribing practices, primary care group pharmacists had discussed antimicrobial prescribing at joint prescribing and clinical governance meetings and postgraduate training sessions had been arranged.
The formularies for antibiotic prescribing in the community were reconsidered and summary documents containing specific messages about the use of quinolones were circulated to all practices. Antimicrobial prescribing had also been linked into the prescribing incentive scheme and the clinical governance agenda.