Since the discovery of penicillin by Alexander Fleming in the 1920s, there have been over 150 antibacterial drugs developed and marketed for human or veterinary use. The effect these drugs have had on infectious diseases and population health is remarkable. A once considered serious bacterial infection can now be successfully managed using antibiotics prescribed from the doctor. This was not always the case, as our grandparents may testify: bacterial infections were often fatal and the choices available to manage such infections were limited. Bloodletting for pneumonia, mercury for syphilis, and honey for wound infections were all commonly used approaches before the discovery of antibiotics.
This "golden age" of discovery may, however, soon come to an end, as more and more bacteria are becoming resistant to the antibiotics available to us. It is for this reason that healthcare organisations across the world have been focusing on developing 'stewardship policies' to promote the appropriate use of antibiotics. In England, the situation is no different, and the Department of Health and Social Care has developed an antimicrobial resistance strategy. As part of the plan, doctors have been urged to reduce the amount of antibiotics they prescribe when it is safe and appropriate to do so. As the majority of antibiotic prescribing occurs in primary care settings, such as GP surgeries, healthcare providers working in this setting are set specific prescribing targets.
It is important to establish if the polices are working from an antibiotic stewardship perspective, but also that these polices are fair, and do not penalise communities in the most need of care. Our work aimed to address these questions. To do this, we used antibiotic prescribing data from the NHS, as well as working out the characteristics of the local areas in England using nationally available data sources.
Overall, we found that, in England, the plan to reduce antibiotic prescribing appears to be working: since 2014, antibiotic prescribing has reduced by around 14 per cent. We also found that the prescribing of 'broad spectrum' antibiotics, used to treat a wide range of infections, have also reduced.
When we considered local factors in our analysis, we showed that the most deprived areas of England had the highest levels of antibiotic prescribing. And even when we factored in two long-term conditions – diabetes and Chronic Obstructive Pulmonary Disease – both of which are associated with increased antibiotic use, we still found higher levels of prescribing in the most deprived areas of the country. We also showed that geography was an important factor too: compared to London, all other areas of England had higher levels of antibiotic prescribing – with the East of England, and the North East of England having the highest levels.
You might ask why this is important? Well, that's a good question. Our work shows that in addition to a national strategy to reduce antibiotic prescribing, it is important to consider local needs too. People living in more deprived areas might, for example, have greater health need for antibiotics compared to people living in more affluent areas. National one-sized-fits all targets might not necessarily account for this. If there is greater antibiotic need in deprived areas, doctors working in these areas might be unfairly penalised for prescribing them. This is not fair on the doctors working in primary care, but may also impact on patients too.
The antibiotic stewardship polices appear to be reducing overall antibiotic prescribing, which is a positive thing, although there is still significant variation in prescribing across England. It would be appropriate for future prescribing targets to account for local factors to ensure the most deprived communities are not inappropriately penalised.
The bottom line is if someone is in medical need of an antibiotic, they should be prescribed it, regardless of the characteristics of their local area or where they live.
Adam leads a programme of research that explores how pharmaceutical interventions, including medication, immunisation and screening approaches, can be used safely, appropriately and equitably at a population level.
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"England Map silhouette" by Natasha Sinegina through Creazilla: https://creazilla.com/nodes/2538-england-map-silhouette. You may obtain a copy of the License at https://creativecommons.org/licenses/by/4.0/ (CC BY 4.0).
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