Antimicrobial resistance and sepsis: A delicate balance
Dr Steve Granier, RCGP Clinical Lead for TARGET
So we are having Federation pre-Christmas drinks in the King’s Arms and the conversation turns confessional. Josh has signed a pledge at www.antibioticguardian.com but admits to seeing his GP and resorting to amoxicillin after four weeks of dedicated nasal douching and steroid drops for his dogged sinusitis: “In two days the sinus pain and chronic cough were gone. It was miraculous.” “If we are trying to reduce antibiotic use we are just wasting our time because of all the antibiotics used in animals,” says Lucy, another GP partner, "and what about the sepsis guidance - this is encouraging us to treat more patients"
Human or animals first: who uses more antibiotic? According to The Joint Report on Human and Animal Antibiotic Use more than half of all antibiotics are used in human medicine1.Vets are aware of the problem of antibiotic resistance; they are doing their bit and have achieved massive reductions in critically important antibiotic use. Primary care clinicians prescribe eighty percent of antibiotics in humans so if there is a problem, we must fix it.
What about Josh’s sinusitis? Should he have used antibiotics? While antibiotics remain one of medicine’s greatest advances, we need to use them wisely. We prescribe antibiotics 1) to treat patients’ symptoms and 2) to reduce complications, but just how effective are they? For most respiratory tract infections taking antibiotics makes people better between eight and 24 hours more quickly than not taking them. Eight out of 10 people with sinusitis get better within 14 days without treatment and using antibiotics may have a tiny benefit of up to 24 hours, but mainly in those whose symptoms have already lasted more than a week and, even for those with nasty purulent discharge, eight people need to be treated to resolve symptoms in one2.
What about complications? Serious complications are rare and “delayed/back-up” antibiotic prescriptions for sinusitis reduce complication rates to 1 in 10003.
For most, the tiny benefit, if any, from antibiotics is outweighed by the one in five people who get diarrhoea, vomiting or rash or the chance that they or a family member may become ill from a more serious antibiotic resistant infection. The risk of having an antibiotic resistant infection is 2 times greater if you have had antibiotics in the previous three months, and is even greater with multiple courses.
But, for those at higher risk of complications and those like Josh with particularly severe symptoms that are not responding to time and paracetamol then “delayed/bck-up” antibiotics are a good option. We need to give clear advice on how long to wait (at least 4 to 7 days for sinusitis) and what to look out for before starting antibiotics or seeking help to rule out serious illness such as sepsis. The sepsis guidance can help us to be better clinicians by making us more thorough in our clinical assessment and identifying those who need additional care, advice or safety netting. The resources in the TARGET and Sepsis Toolkits and the Treating Your Infection leaflet can aid diagnosis, improve communication with patients and provide clear safety netting. For all the most up-to-date evidence listen to the free www.target-webinars.com and consider how you can help fix these problems.1
UK One Health Report: Joint report on human and animal antibiotic use, sales and resistance, 2013. HM Government
Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008; 371:908-914.
Little P, Moore M, Kelly, J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ. 2014;348:g1606.