Volume 1

Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology.

  • Great Britain. Parliament. House of Lords. Science and Technology Committee.
Date:
1998
Catalogue details

Licence: Open Government Licence

Credit: Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology. Source: Wellcome Collection.

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    accepting the guidelines perfectly, the majority moderately well, and some doctors on the far side of the curve hardly paying any attention to them”. The Royal College of General Practitioners (RCGP) stand by their profession: “Given the context of diagnostic uncertainty, current prescribing practice of GPs is in general more beneficial than harmful in the care of individual patients” (p 166). However, “There is sufficient evidence of widespread variation in the utilisation of antibiotics to suggest that there is scope for further reduction of their use by some practitioners”. Dr Davey is more sceptical about GP prescribing. “We have intense debates about whether children with otitis media should receive antibiotics, or people with sore throats. But our work would suggest that the majority of patients to receive antibiotics...just have runny noses, where there 1s no evidence that they benefit” (Q 265). 2.7. There is no equivalent to PPA data for hospitals (DH p 342); all one can say for certain is that hospitals dispense a much smaller volume of antimicrobials than are prescribed in general practice. According to the Department of Health, 15—20 per cent of hospital expenditure on drugs goes on antimicrobials; and around one in-patient in four receives at least one course of antibiotics. The AMM produced, by different routes, two different “ballpark” figures: on the one hand, |—2m daily doses per year in English hospitals, or on the other the significantly higher figure of something under 5m in the whole United Kingdom (p 9). 20-30 per cent of hospital usage of antimicrobials is for prophylaxis against infection during surgery; and, according to the AMM, “courses given are often longer than necessary”. Dr Davey also has doubts about current practice in this area (p 152; QQ 267, 272): “At the moment I do not think we have sufficient debate about what level of benefit [in terms of reduced risk from infection] justifies the use of antibiotics”.'° Towards more prudent use 2.8 The AMM believe that, by a significant and sustained campaign of education, it might be possible to eliminate the “small proportion” of United Kingdom GP prescribing which they believe to be completely unjustified, and to reduce the larger proportion which “is perhaps not founded on the best evidence-based practice but may be justified by medical, cultural or psychological reason”. They warned us, “The continuing legitimate use of antibiotics in humans may still sustain and might even increase the amount of resistance’’'®; to say nothing of resistance continuing to be generated in animals, and in humans in other countries where imprudent use persists. However, “the medical profession must put its own house in order before it can expect others to do so” (pp 8-13). On the other hand Dr Davey, who believes that more than half of GP prescribing is justified by nothing more than a runny nose, would happily “let the people with the sore throats get antibiotics but concentrate on the people who do not have any clinical signs which warrant antibiotics” (Q 265). 2.9 These contrasting positions present the question, What constitutes prudence? The RCGP insist that, although doctors have a national, strategic responsibility for public health, this cannot override their primary responsibility to the individual patient (p 167, Q 280). Dr Davey put it more bluntly: “I would much rather...some people received unnecessary treatment than we end up with somebody dying” (Q 268). Dr McGavock was equally blunt on the other side of the dilemma: “[Over-prescription] is a situation that really must be changed if we wish to preserve the antimicrobial era...it may well go on, but if it does our grandchildren will curse us for wasting this limited human resource” (Q 647). Witnesses have pointed to various ways to resolve this dilemma; we consider them below. Cp BMA: “Antibiotic misuse is common and studies have suggested that up to 70 per cent of treatment courses are unnecessary Or inappropriate. Therapy is often unnecessarily prolonged and prophylaxis is often inappropriate or rie at the wrong time” (p 381). The National Committee for Microbiology also express concern in this area (p 541). Cp Glaxo Wellcome: “The recent lessons learnt from anti-retroviral chemotherapy have demonstrated the very powerful effects that natural selection can have, even when prescribing is entirely appropriate and patients are highly motivated to comply with treatment” (p 407). 16