PUSHY middle-class patients who put pressure on GPs to prescribe antibiotics for the cold and flu virus are accelerating resistance to the drugs, doctors have warned. The World Health Organisation has estimated that drug resistant infections will kill ten million people a year by 2050 and described the crisis as a “global health emergency”.
When antibiotics are no longer effective, modern medical procedures – including many surgeries, caesarean sections, joint replacements and chemotherapy – will become too dangerous to perform because they leave patients more susceptible to infection.
Leading consultants said healthcare in Scotland would be similar to the ‘Victorian era’ when a third of children didn’t reach adulthood and thousands of adults died from illnesses which only became treatable following the discovery of penicillin in 1928 by Scottish physician Alexander Fleming.
The Scottish Antimicrobial Prescribing Group (SAPG) monitors prescribing figures and runs an ‘antimicrobial stewardship programme’ – a scheme to ensure appropriate use of the drugs through education and infection control.
However, it has been claimed “educated middle-class” patients in Scotland with a cold or flu virus are demanding antibiotics. antibiotics are useless against the flu, and should only be prescribed for bacterial infections. However, SAPG says overworked GPs are handing over prescriptions to get pushy patients out of their surgeries.
The number of patients with flu in Scotland rose dramatically in January, according to the latest figures from Health Protection Scotland (HPS). First Minister Nicola Sturgeon said levels of winter flu are four times higher than in the same week of last year. Of 53 people admitted to intensive care, eight have died, including 18-year-old midwifery student Bethany Walker from Applecross in the Highlands. The majority of flu cases are believed to be the H3N2 strain known as ‘Aussie flu’.
Consultant microbiologist Adam Brown, who is the clinical lead for microbiology at NHS Highland, said he has never before seen a strain as virulent as Aussie flu. “It’s hit really hard. It’s certainly the worst flu I’ve seen since I qualified as a doctor in 1997. It’s a nasty strain.
“It’s covered by the vaccine, but it doesn’t seem to be particularly effective against this strain. It’s not just the hospitals that are seeing a huge amount of cases, it’s GPs too.”
Prescribing antibiotics for flu is “probably more common than it should be”, according to Brown, but he admitted it’s “sometimes a case of needs must” during a flu epidemic, and “you divvy out the resources as best you can”.
One doctor, who asked not to be named, said patients often demand antibiotics from GPs when they don’t need them. “It’s middle-class people who have a bit of education and who have done a bit of background research and who have decided they want antibiotics and they’re not going to leave until they get what they want,” said the doctor. “When you’re a GP and you’ve got seven and a half minutes to see each patient, and you’re eight hours into a 12-hour day, and you haven’t stopped to use the toilet or have lunch, eventually you get ground down. So sometimes it’s a technique to get people to go away.”
Another GP, who works in the east end of Glasgow, and also asked to remain anonymous, said: “Patients often come in with an agenda to get antibiotics and they can become angry and frustrated when they are refused. The expectation is that antibiotics are the answer and when patients leave without them they can be very unhappy. It’s our job as GPs to educate them but we have a lot of work to do to change attitudes.
“If we explain the risks and they still want them can use our clinical discretion and prescribe them to preserve the relationship, which is built on trust, but we are under so much pressure from health boards not to overprescribe.”
A senior source at a Scottish health board admitted: “It’s often the most persistent patients who are prescribed antibiotics.”
Dr Ian Gould, a consultant microbiologist at NHS Grampian, said “excessive and inappropriate” antibiotic use is a key driver of antibiotic resistance. He said: “The good old NHS struggles along and everyone’s cash-strapped and short of resources. I’m sure there are improvements we could make in antibiotic stewardship and we could use less inappropriate antibiotics for treating patients.”
Gould compared a post-antibiotics world with the “Victorian era” when the infant mortality rate was “20 or 30 per cent before the age of five and maybe only three in five children would see adulthood”.
He added that in a world with widespread antibiotic resistance “modern medicine as we know it wouldn’t exist. The antibiotic era has seen a tremendous drive in diagnosis and treatment of patients with debilitating illnesses like cancer. The diagnostics and treatments make patients much more susceptible to infection. You couldn’t give these treatments without antibiotics to protect the patients. You couldn’t do any major surgery either. Healthcare as we know it would be totally different”.
Brown added: “If we get something that’s resistant to all of the drugs we really are going back to the pre-antibiotic era where people would die of appendicitis or would die after childbirth or die of a urinary tract infection. And that’s terrifying. If things carry on the way they are, by 2050, we could be looking at serious resistance levels. If we stick our fingers in our ears and pretend nothing is happening by 2050 Scotland could have a serious problem but there are lot of people working very hard to prevent that.”
Brown, a member of the SAPG, said the drive to reduce antibiotic treatment is having some success. He said the number of antibiotic prescriptions in primary care for the first quarter of 2016 was down 3 per cent when compared to the first quarter of the previous year. Data for 2017 won’t be available until mid-2018, according to Brown.
He said: “It might not sound like a big reduction but when you consider how many antibiotics are prescribed in Scotland on a daily basis, 3 per cent is a big reduction. It wasn’t the case that GPs were prescribing antibiotics like Smarties because they didn’t know what else to do, it was more a case of tightening the guidelines to give GPs the tools to give alternatives to antibiotics.”
However, Brown added that inappropriate prescription of antibiotics was “an inevitable impending progression towards resistance happening”.
One of the big issues is that while viruses mutate to develop immunity to the drugs, few new antibiotics are being developed. Gould said: “There has really been a big gap in development [of antibiotics] in the last 20 years”.
Brown added: “The thing about these bugs is they’re very promiscuous and will pass on the genetic data for resistance not only to their offspring but to neighbouring bugs too. We do get to the stage where there are an increasing number of resistant organisms and we don’t have any new classes of antibiotics in the pipeline.”
The World Health Organisation has confirmed no new antibiotics currently in development are expected to be effective against the most dangerous bugs, which is “putting the achievements of modern medicine at risk”.
The “last line of defence”, according to Brown, is drugs called carbapenems. He said: “They kill a lot of bugs and up until recently we didn’t see any resistance to them. But in 2003 we started to see resistance to these carbapenems. In Scotland we are better off than many places in the world but we have seen a slow and steady increase of cases of these bugs.
“In 2004 we saw two cases that had mechanism to be resistant against carbapenems, then in 2016 it was 73. It’s still not a huge amount but it’s a significant increase.”