I write as a humble jobbing GP incapable of sound clinical practice without instruction, guidance, and supervision from the National Institute for Health and Care Excellence (NICE), my clinical commissioning group, my colleagues, or by reading today’s newspapers. Despite practising medicine for 40 years, it is apparent to all that I am still incapable of differentiating a minor viral infection from a potentially more serious bacterial one.
I am profligate with my antibiotic prescribing, and am personally responsible for “antibiotics resistance being as grave a threat as terrorism” (Sally Davies, chief medical officer for England). I’m the go-to guy to blame for this threat to the “survival of the human race” (Mark Baker, director for clinical practice at NICE).
And yet I do sometimes feel that I am being made the scapegoat for a phenomenon that may not be entirely understood, but for which a simple, practical hypothesis seems compelling. A scenario not unlike that for global warming, where we have endeavoured to reduce our carbon emissions in the UK for decades only to find that last year was globally the hottest on record.
So this week’s “naughty boy” diktat from NICE sent me straight to the detention room where I had to write a thousand lines of “I must not be an antibiotics resistance denier.” However, instead I came across an article published in The BMJ only five months ago. It looked at antibiotic prescribing in primary care from a slightly different perspective; one of antibiotic failure when used in first line treatment in four common areas: upper respiratory infections, lower respiratory infections, skin and soft tissue infections, and acute otitis media. The overall failure rate for treatments rose in absolute terms from 13.9% in 1991 to 15.4% in 2012 or, to put that another way, over a 20 year period up to 2012, antibiotic failures rose by 1.5%.
The most commonly used antibiotics in the study were the venerable amoxicillin, penicillin V, and flucloxacillin. Now I’m no clinical research physician, and I am certainly no statistician, but I reckon that the parameters of this excellent study could be used as surrogate markers for antibiotic resistance for S. pneumoniae, S. aureus, H.influenzae, and other common bacterial pathogens—and yet such resistance in a clinical setting seems to have progressed at a glacial pace. An increase of 1.5% over 20 years hardly extrapolates to Armageddon by 2050.
I then looked at overall prescription numbers for antibiotics. Undeniably, there has been a jump in the past three years, yet the number of antibiotic prescriptions issued in 2014 (41.6 million) is exactly the same as that for 1998. A blip is not synonymous with a trend.
Finally, I cannot help looking at my own experience in general practice over 30 plus years. GPs see many cases a week of potential viral or bacterial infections. Using our clinical judgement we prescribe antibiotics for some of these cases. Regardless of aetiology, most get better. In truth I cannot remember the last time I admitted a patient to hospital with an unresolving infection. The antibiotics I use now are 95% unchanged from those I used in the 1980s.
And so, despite all the “overwhelming evidence” to the contrary, I find that I remain an antibiotics resistance denier. The only regret that I have in being so is in seeing the confidence and self-esteem of a once proud profession being yet again maligned by—and I am being charitable here—well meaning but alarmist sound bites emanating from a national body such as NICE.
Jim Sherifi has worked as a GP in East Anglia since 1980, and has held a number of roles within GP education and compliance. He spent four years as an executive search consultant, aka “headhunter,” in the commercial sector.
Competing interests: None declared.