This is a revised (for clarity and to update it), version of a post of the same name from a couple of years ago. Parts of this post – for the third time today – appear in others, in slightly different forms. I make no apology for this as people don’t always read other posts, or read them in sequence, so may have missed the information.
We are routinely told that one of the reasons for the rise of antibiotic-resistant infections like MRSA, in hospitals, is the over–prescribing of antibiotics. As someone whose life has depended on antibiotics (I have Stage 4 COPD), for as long as they’ve been available to the public (which is longer than most people realise – they date from about 1953, when Penicillin became widely available – prior to that, and afterwards too, as it was cheaper, the sulphonamide drug M&B kept me alive), I’m not convinced.
Whenever I’ve been admitted to hospital – or even when I’ve hung around outpatients for too long (time was when an OPD visit would tie up half a day, easily) – I’ve always come away with an infection I didn’t go in with – they’ve always been there in some form. It would be surprising if they were not, given that the average patient has very little concept of hygiene.
In my case, it would normally be a respiratory infection (my weak spot), though on one occasion, almost 50 years ago, it was a tissue-consuming post-operative bug that took many months of daily, and painful, treatment to clear up. A matter of scraping off the necrotic tissue and soaking the raw wound in a strong sterilising solution – about as much fun as it sounds – before applying an antibiotic dressing. Looking back, I can’t understand why systemic antibiotics weren’t used to supplement the topical application. MRSA-like pathogens certainly aren’t as new in a hospital environment as NICE would like us to believe.
Throughout the eighties, I had doctors who had no worries about providing me with stocks of antibiotics to take at my discretion – it reduced their work-load and meant I could treat infections as soon as they appeared. It was a system that worked very well, but came to an end in the early nineties when one of them moved on, and the other retired. It was clear, though, that I was in a minority, and most of my peers didn’t get this treatment.
I began to notice, in the early 90s, when I had to attend the surgery every few weeks with a spate of respiratory infections, that the quantities of antibiotics prescribed had been drastically reduced – never any more than 7 day’s worth, and at the lowest available strength, and 3 a day instead of 4 (not GP parsimony, but in the advice in the British National Formulary – the GPs’ drug bible – how much influence NICE has on that advice, I don’t know, but I suspect a lot).
For me and, I suspect, for most people with a cycle of chronic respiratory infection and re-infection, this proved inadequate. True, it would knock back the infection but, after a few weeks it would rally and reappear, and I’d be back at the doctor’s again.
Some years earlier, in 1980, and again in 1981, I had two long bouts of infection (three months+), that refused to go away. During both events I was treated with small quantities of antibiotics, and had to re–attend the surgery every week or two for a new prescription of a different antibiotic. Eventually, Erythromycin did the trick, but I’m pretty sure any of its predecessors would have done so at a high enough dose, for long enough.
I believe that had I been treated then – as I was in the late eighties, by a different doctor – with massive doses of drugs (for example, then I had a stock of 3gram sachets of Amoxyl, taken 3 times a day – hugely effective), my recovery would have been much faster in both cases, and I think I would have been able to continue working for longer. I also believe that I was left with a legacy of bacteria that were resistant, to a degree, to many of the antibiotics I’d taken.
It’s quite clear from those two experiences, that under-prescribing is a very real problem and has been for a long time, with no reason to assume it’s not common.
In the early 2000s, antibiotic prescribing took a turn for the worse, and it became almost impossible, for me at least, to get treatment without submitting a sputum sample for laboratory analysis. In theory this should have taken 24 hours, in practise it often took a week. Aside from meaning I spent a week getting worse, it meant I had to make yet another trip to the doctor to get my prescription which, all too often, was for a drug that I knew would disagree violently with me – for some reason the lab’s recommendation was always for a very new drug – quite possibly the one the last drug company rep had been pushing – and not for more established drugs that I knew would get the job done without harming me in the process.
It reached a farcical peak when, having had the usual week’s worth of meds, which hadn’t worked, I went back for more, only to be told I would have to submit to another sputum test! It was at that point I realised that the health of the patient has ceased to matter, and stupidity and cant, had taken over – we were, effectively, carrying the can for all the alleged over–prescribing. I believe now as I believed then, that this is a crock, and used by NICE as a lever to cut down antibiotic prescribing.
As an aside, in my experience, older doctors are more likely to prescribe more generously than youngsters, and ignore NICE’s whinging. A state of affairs which won’t be allowed to continue http://ronsrants.wordpress.com/2008/12/10/nice-rules-literally/
In 2004, realising that I could legally import drugs for my own use, I started buying my own supplies of 500mg Amoxyl caps. This meant I could tackle an infection as soon as it reared its ugly head, before it had time to make me ill (trust me, if you’ve lived with respiratory infections your whole life, you learn to recognise the signs of an incipient crisis several days before it actually makes you ill, or it would be apparent to a GP). I take one every eight hours when needed (very occasionally two) – not just for a week, but for as long as it takes.** In the last four years, I’ve only needed to see my GP once, with a bug that wasn’t susceptible to Amoxyl, so the facts speak for themselves.
Or, if I catch it early, just for a few days, though I’m currently recovering from pneumonia, and getting to the end of a three-week course. A few days or several weeks – the bottom line is I can take them for was long as proves necessary, with zero hassle. And I’ve only needed a doctor 3 or 4 times in 7 years (and one of those was for flu), so I’m doing something right.
To sum up, I think what has happened is that the frequently inadequate prescribing of antibiotics over the past 50 years, coupled with patient ignorance about finishing the course (you don’t stop just because you start to feel better!), was leaving a residue of “stunned” but not killed bugs in patients, which over a long period developed a degree of resistance to antibiotics – a resistance that was passed on to each successive generation, and built up substantial reservoirs of antibiotic–resistant bacteria in the UK population . If this was happening with me, how many thousands of other people were having the same experience? Multiply my experience by that of everybody with probably any form of infection, and under–prescribing may well be the real culprit, not the alleged over–prescribing that has blighted the lives of so many of us who depend on antibiotics for our very lives.
Note: I do know that there is research supporting the over–prescribing theory (but not very much of it), but how different would things have been it anybody had bothered to actively investigate the role of under–prescribing and ignorance-based abuse by patients which, to me, makes more sense? True, it would have been harder, but I don’t care, it should have been done and wasn’t, and the over-prescribing theory was accepted pretty much without question. And that is always very bad form.
The fact is, of course, that dramatically demonising over–prescribing fits NICE’s penny–pinching ethos perfectly**. As I’ve said elsewhere, and frequently, NICE no longer has the best interests of the patient at heart, because they have become the bean counters of the health service. All they care about is the balance sheet – patients, to them, are just a bloody nuisance.
** NICE insist that antibiotics have no effect when it comes to viral infections, and that simply isn’t true. It is true that they won’t affect the virus, but if taken they will militate against opportunist secondary bacterial infections. Which is why, whenever I get flu, I also take antibiotics and very rarely develop anything worse (it’s not flu that’s the killer, more often than not it’s the subsequent bacterial pneumonia).