‘Superbugs’ have hit the headlines again. As the 193 countries of the United Nations pass round the pen and sign a declaration to rid the world of drug-resistant infections, the UK’s chief medical officer, Prof Dame Sally Davies, has remarked, “now the real work begins”.
It’s certainly a very real problem, which, if not effectively tackled, could see simple infections becoming untreatable with the drugs we have now. Of course, much real work has already been done and I want to put the spotlight today on a wonderful example, in which Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More has been used to change clinical practice.
What needs to happen to reduce antibiotic use?
The government-commissioned review into drug-resistant infections led by Lord O’Neill and published this year, stresses the need for a two-pronged approach to reducing antibiotic prescribing. We need to make use of rapid diagnostic tests to identify those who truly need antibiotics and we need to improve knowledge and understanding, so that clinicians and patients can make responsible decisions together about antibiotic use.
Doctors and patients working together
Richard Lehman has blogged here about a Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More that found that when doctors and patients are encouraged to discuss whether antibiotics are needed for an A health condition (or episodes of a health condition) that comes on quickly and is short-lived. More respiratory infection (ARI), fewer are prescribed. There are some really useful decision aids out there to help with these discussions, like the one used in this video.
Both doctors and patients alike need to feel confident about their decisions, and this is where evidence-based diagnostic tests come in.
Rapid diagnostic tests
Obviously, if you go into your GP surgery feeling grim with an acute cough, you won’t want to be waiting days and days for a lab test to come back to see whether or not you need antibiotics; you’ll want something that can come up with an answer on the spot, some clinical information that can help the decision to prescribe or avoid antibiotics.
Two years ago, a Cochrane review (which I blogged here) found promising evidence that a simple test (C-Reactive Protein, or CRP) using blood from a finger prick and ready in just a few minutes, could identify whether a patient with an ARI is likely to have a serious bacterial infection. Antibiotic prescribing was 22% lower in the group that had the test and there was no difference in how long patients took to recover.
Michael Moore, Professor of Primary Care Research and National Champion for Antimicrobial Stewardship at the Royal College of General Practitioners, mentions this review in a podcast accompanying a NICE guideline, discussing the recommendation that the CRP test should be used for those going to their GP surgeries with an acute cough. About 60% of the time, patients presenting to their GP with a chesty cough and a diagnosis of lower respiratory tract infection will be prescribed antibiotics, he notes, and “the evidence is quite clear that this doesn’t help most people”. He goes on to say,
“The evidence shows that if you use a CRP test…it can help reduce antibiotic prescribing. It improves the confidence of the GP and the patient in the consultation that there isn’t a significant infection going on… For those people who have a low result you can be really pretty confident that they don’t have pneumonia.“
Evidence into practice
An enterprising team at Attenborough Surgery in Bushey, Hertfordshire, led by Advanced Nurse Practitioner Liz Cross, took this evidence and the NICE recommendation and launched a pilot project to reduce antibiotic prescribing for people with respiratory infections. Patients were offered the CRP test and those not prescribed antibiotics, or offered a delayed prescription, were given written self-care advice. The results were impressive.
- 70% of patients presenting with a suspected lower respiratory tract infection had low levels of C-Reactive Protein (CRP <20mg/L)
- Prescription of antibiotics was reduced by 23% (8% of patients were prescribed antibiotics on their first visit during the winter that CRP testing was introduced, compared with 31% the previous winter)
- Unscheduled follow-up visits within 28 days for patients who were not prescribed antibiotics fell by more than 50%
“The test gives us the confidence we need to be able to sensibly restrict antimicrobial prescribing, while making sure those who really do have an established bacterial infection get the antibiotics they need.”
They also noted that patients felt more accepting and reassured when not prescribed antibiotics:
“Another great thing about carrying out these four-minute tests is that they also give the patient confidence that they are getting the treatment they need despite having no antibiotic prescription, so they are less likely to come back to the surgery for further reassurance. We saw a fall of more than 50% in unscheduled follow-up visits by these patients.”
The Attenborough Surgery was awarded £10,000 “acorn” funding in the 2015/2016 NHS Innovation Challenge Prizes, which they will use to roll out the point-of-care CRP test system to 10 additional GP practices this winter. In May 2016, the GP surgery staff led workshops at Westminster to demonstrate to MPs and peers the practical action they are taking to address antimicrobial resistance.
The Attenborough Surgery’s change in practice demonstrates how evidence can be used to underpin new ways of delivering care that meet the needs of both patients and providers while reducing unnecessary use of antibiotics. This is at the heart of both the UN’s call to action and the Choosing Wisely movement, which aims to promote conversations between patients and their healthcare providers to help them choose care that is evidence-based, safe and truly necessary.
There is more work to be done. Better information is critical, both the clinical information that rapid diagnostic tests can provide and better understanding of responsible antibiotic use. We need evidence and education, and we need them now. Armed with these, we stand a better a chance in the war on superbugs.
With grateful thanks to my colleague Anne Eisinga, Information Specialist, who provided all the information for this blog.
Sarah Chapman has nothing to disclose.
References and links can be found here.