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NICE urges doctors to curb ‘inappropriate’ antibiotic prescribing

Healthcare professionals should cut back on the ‘inappropriate’ prescribing of antibiotic treatments, to help curb rising resistance to the drugs, according to new guidance from the National Institute for Health and Care Excellence (NICE).

As a “last resort”, doctors who keep overprescribing could be referred to the regulator, the General Medical Council (GMC), NICE said.

The health watchdog warned that, despite considerable guidance that prescribing rates of antibiotics should be reduced, nine out of 10 GPs say they feel pressured to prescribe antibiotics, and 97% of patients who ask for antibiotics are prescribed them.

In order to tackle this, NICE has recommended setting up multidisciplinary antimicrobial stewardship teams working across all care settings. Under the proposals, these teams should be able to review prescribing and resistance data frequently and feed this information back to prescribers.

The teams should also be able to work with prescribers to understand the reasons for very high, increasing or very low volumes of antimicrobial prescribing as well as provide feedback and assistance to those who prescribe antimicrobials outside of local guidelines where this is not justified.

It was noted that if successfully implemented, NICE’s latest guidance could help to reduce antibiotic prescribing by 25% - accounting for about 10 million antibiotic prescriptions. Nationally, 41.6 million antibiotic prescriptions were issued in 2013-14 at a cost to the NHS of £192m, the watchdog added. About 80% are prescribed within general practice, with the rest split between hospitals and dentistry.

Professor Mark Baker, director of the Centre for Clinical Practice at NICE, said: “Antibiotics are prescribed in circumstances when they are unlikely to do the patient much good.

“I don’t think there is a lot of bad practice in general practice but it is clear that the reduction in antibiotic prescribing that we expected to see when our 2007 guideline on upper respiratory tract infections was published has not happened.

“The rise in inappropriate prescribing comes in the face of successive attempts by NICE and by government to reduce it that simply haven't worked. Some of it is about the pressure put on GPs. Despite that pressure, prescribing an antibiotic when you know it’s unlikely to do the patient much good is not good practice.”

Prof Baker suggested that, as a last resort, if doctors regularly over-prescribe medicines despite peer-to-peer support and NICE guidance, then “reporting them to the GMC might be a last option”.

“As the Chief Medical Officer has said, antibiotic resistance poses a ‘catastrophic threat’ to the health of the nation,” he said.

The Department of Health added that tackling the overuse of antibiotics is a global issue that affects everyone – government, patients, doctors, dentists and vets treating animals – not just GPs.

“In order to make sure we have effective antibiotics for generations to come, we are raising global awareness of the dangers of resistance to antibiotics and providing tools for GPs to support prescribing decisions,” said a spokesman.

Dr Tim Ballard, vice-chair of the Royal College of GPs, added that the new NICE guidance to prescribe the right antibiotic at the right dose at the right time is a “sensible mantra” and “one that GPs try to abide to wherever possible”.

He added, however, that “we need a societal change” in attitudes towards the use of antibiotics and any suggestion that hard pressed GPs – who are already trying to do their jobs in increasingly difficult circumstances – will be reported to the regulator is “counter-productive” and “unhelpful”.

“If this were to happen, we would be looking to the General Medical Council to support any GP or other health professional who finds themselves on the receiving end of complaints or criticism about decisions made over the prescribing of antibiotics,” he said.

“The College welcomes the team approach to ensuring that antibiotics prescribing is done appropriately and responsible, and the opportunity for reflection that is advocated in this guidance, as long as it is implemented in an open and supportive way.

Niall Dickson, chief executive of the GMC, stated that the regulator’s  prescribing guidance makes it absolutely clear that doctors should only prescribe if they are satisfied that this would serve the patient’s needs.

“Where they consider that the treatment would not benefit the patient, they do not have to provide it,” he said. “We would certainly hope that the annual appraisal, which forms part of the revalidation cycle, provides a valuable opportunity for a doctor to reflect on all aspects of their practice including their prescribing and we would expect that doctors would undertake any further training that might be identified as part of that process.”

Dickson also noted that doctors “can, and do, face sanctions for mis-prescribing”, although the law dictates that each case has to be considered on its merits to determine whether the doctor’s actions pose a risk to patients or confidence in doctors.