Blog posts

Seek advice from a qualified healthcare professional before taking antibiotics

By Dr Timothy Rawson, Clinical Research Fellow, Esmita Charani, Senior Lead Pharmacist and Dr Enrique Castro Sanchez, Academic Research Nurse all from the Faculty of Medicine, Department of Medicine

Antibiotics are a powerful resource that allows us to safely perform surgery, treat cancer with chemotherapy, and recover from infections that over 100 years ago would have killed even the fittest among us.

We are seeing however, a dramatic increase in infections with bacteria resistant to the killing effects of antibiotics (termed drug-resistant infections). These are antibiotics that until recently used to be effective. These resistant bacteria make many infections more and more difficult to treat – in some cases causing patients to die because we no longer have antibiotics that are able to manage the infection.

A major driver of drug-resistant infections is the overuse and misuse of antibiotics. We outline some of the key reasons for this below.

Firstly, some health problems cannot be treated with antibiotics, and it is important to know which ones they are. In some cases, health problems that can be treated with antibiotics need consideration about the right antibiotic for each person. For example, it would be important to consider whether people are taking other medications, whether they have got any other health problems, and even their preferences.

Talking to a health professional helps build relations that are proven to be essential for the experience of people related to antibiotic use. We now know that whilst patients are eager to receive more information about their use of antibiotics, previous experiences about having antibiotics prescribed (or not) gradually imprints expectations about antibiotics. Therefore, having the opportunity to discuss antibiotics with a healthcare professional may also have an impact on future attitudes and expectations when you feel unwell.

As all medications, antibiotics can have negative side effects that may be important to your current and future health. Often without previous discussion with a healthcare professional, it may be difficult to forewarn patients about such side effects and what to do should they appear. The ability to be able to warn someone about certain antibiotics may encourage them to keep taking them if they experience the side effect, or even ensure that they seek help immediately in rarer cases.

The conversation between healthcare professionals and patients about antibiotics are shaped by many factors that are not just related to health. These can reflect cultural beliefs and traditions, expectations, power relations between professionals and patients, the skills that the patient may have to deal with health problems, as well as social circumstances. Patients may feel compelled to access, or request antibiotics as a quick solution to a health problem that may prevent them from going to work. However, antibiotics are not always the solution and in some cases may worsen the problem due to the side effects that patients experience.

Conversations with healthcare professionals allows people to receive useful information about self-care measures that can resolve symptoms and prevent further health problems. For example, painkillers, fluids, and rest may be all that is required to deal with a cold. Being up to date on influenza vaccination, and washing hands thoroughly and correctly could ensure that the risk of catching infections is much reduced.

Studies show that whilst citizens are in agreement with healthcare professionals that the main reason causing drug-resistant infections is antibiotic use, they are not aware of the range of factors driving antibiotic use. Therefore, facilitating opportunities for these conversations to take place would be beneficial to raise awareness and optimise antibiotic use.

Encouraging citizens to engage with professionals in conversations about antibiotics would require that professionals embrace communications approaches and skills that result in meaningful and actionable information for patients and ultimately shared-decision making. Considering that the information related to infections is difficult to understand and process in the time allowed for typical consultations in primary care and due to the limited familiarity of the average citizen with scientific jargon/language, such conversations may be difficult. However, through the use of information aids  and a greater understanding of what information patients desire, we may be able to facilitate meaningful engagement with decision-making even in the most time pressured of situations.

In summary, we all have a role in using antibiotics more responsibly, through better communication approaches that encourage shared-decision making between citizens and healthcare professionals.

Using the evidence-based approach to better antibiotic stewardship

By Chris Bird, MSc Health Policy student at Imperial College and Project Manager in the System Engagement Programme at NICE

This week marks World Antibiotic Awareness Week, the theme of which is to seek advice from a qualified healthcare professional before taking antibiotics.

Antibiotic resistance (AMR) is one of the biggest threats to global health, food security and development in our world today. Antibiotic resistance leads to high medical costs, prolonged hospital stays and increased mortality.

It’s a subject brought home to me as I was lucky enough to study my MSc in the very same historic buildings at St Mary’s Hospital where Alexander Fleming first discovered the miracle of penicillin. This was the first ever antibiotic with capabilities to revolutionise world healthcare by eradicating the scourge of gangrene and tuberculosis. Skip forward to today and the availability of effective antimicrobials are estimated to add approximately 20 years to human life expectancy.

AMR describes the process by which microbes become resistant to the common range of antibiotics used in human and animal health to combat infection. Excessive use and inappropriate prescribing of antibiotics, coupled with a lack of research and development into the identification of new antibiotics have combined to produce a significant threat to world population health.

The UK’s Chief Medical Officer (CMO), Dame Sally Davies has referred to AMR as a ‘ticking timebomb’[i] with potential consequences for the nation’s health, so serious that the issue has been logged on the UK’s cross-government national risk register.

 

Risks and costs 

Where antibiotics can be bought for human or animal use without a prescription, the emergence and spread of resistance is made worse. Similarly, in countries without standard treatment guidelines, antibiotics are often over-prescribed by health workers and veterinarians and over used by the public.

As the late great U.S President John F. Kennedy once said, “There are risks and costs to action. But they are far less than the long term risks of comfortable inaction”.

Kennedy’s words are as relevant and compelling today as they ever were. If we as a society opt for comfortable inaction and if AMR is left unchecked, a time in the not too distant future could come where the risks of infection are too high to perform treatment in common fields of medicine such as cancer, orthopaedics and birth by caesarean section. For urinary tract infections, antibiotic resistance is now already commonplace[ii].  Our health systems and all the progress made in advancing patient outcomes could come to a grinding halt.

 

Taking steps to address the challenge

In the UK, the National Institute for Health and Care Excellence (NICE) is the independent body responsible for producing the nation’s guidance and advice to improve health and social care. Recent guidance addresses the specific threat of AMR and the changes in practice required to tackle it. Encouraging system-level change at this scale has its challenges. And yet incremental change by the thousands of individual healthcare professionals, taken collectively – with the support of the general public, has the potential to make significant and meaningful progress in this global fight.

One of NICE’s guidelines targeted at the general population, covers awareness-raising on how to correctly use antimicrobial medicines (including antibiotics) and the dangers associated with their overuse and misuse. It aims to change people’s behaviour to reduce antimicrobial resistance and the spread of resistant microbes.

Another NICE guideline is targeted at prescribers. It covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of AMR and ensure that antimicrobials remain an effective treatment for infection.

While antimicrobial stewardship work has always been part of medicines optimisation, the NICE guideline is intended as a tool to enable change and focus on these issues. We have positive examples in our Uptake and Impact report of where frontline healthcare professionals have done so with encouraging results.

In Northamptonshire, GPs received a large number of broad-spectrum antibiotic co-amoxiclav prescription requests from podiatrists. This was addressed by training podiatrists on antimicrobial stewardship, and including antibiotics in their toolkit as independent prescribers. This encouraged ownership of the prescribing and resulted in a reduction in the prescribing of co-amoxiclav, cephalosporins and quinolones as a percentage of antibiotics from 11% to 8% (Nene and Corby CCGs, March to October 2016), which the GPs largely ascribed to the medicines optimisation work with podiatrists.

In Southampton, providing one to one support had the biggest impact in changing prescribing behaviour. Specific patient examples were discussed with individual prescribers. Data for 12 months up to July 2016 showed that cephalosporins, quinolones and co-amoxiclav prescribed as a percentage of all antibiotic items reduced from 13% to 11%.

 

A global call to action

AMR is a worldwide problem and we know that evidence-based NICE guidance has the ability to influence innovation and change in practice, not just at home but by clinicians, prescribers and the general population in countries overseas. Take the opportunity given by World Antibiotic Awareness Week to consider NICE’s guidance. Think how you might use this to change and improve your own practice, and strive to be a better antibiotic steward for this and future generations.

If you are a healthcare professional or prescriber using NICE guidance to deliver good practice in antibiotic stewardship, NICE would like to hear about. Tell us about the work you’re doing by completing the submission form here. 

[i] The Independent. Resistance to antibiotics is ‘ticking time bomb’ – stark warning from Chief Medical Officer Dame Sally Davies. 2013. Available at: http://www.independent.co.uk/news/science/resistance-to-antibiotics-is-ticking-time-bomb-stark-warning-from-chief-medical-officer-dame-sally-8528469.html

[ii] NICE. Antibiotic resistance is now “common” in urinary tract infections. 2017. Available at: https://www.nice.org.uk/news/article/antibiotic-resistance-is-now-common-in-urinary-tract-infections?utm_medium=social&utm_source=twitter&utm_campaign=espaurnews

Antibiotic resistance is a true global health issue

By guest blogger, Paul Kiet Tang, Senior Assistant Editor at The Lancet*

AntibioticsSince its discovery and widespread use, antibiotics have been marvelled as a panacea that has revolutionised modern day medicine. Routine surgical procedures, childbirth, and open wounds are no longer associated with high risks of mortality from infections. However, the overuse and misuse of these drugs have led to increased concerns of antibiotic resistance worldwide, with up to 700,000 people dying globally from antibiotic-resistant infections. In the final 2016 report of The Review on Antimicrobial Resistance from the UK Government and the Wellcome Trust, this incidence was projected to increase to 10 million people per year by 2050, costing the global economy up to 100 trillion US dollars and pushing about 28.3 million people into extreme poverty. These statistics must not be ignored if health-care professionals, stakeholders, and governments worldwide are to avert this catastrophic outcome.

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Pharmacists – the new guardians of breast cancer care?

By guest blogger Chanice Henry, Editor, Pharma IQ

In the fight against one of the world’s most widespread diseases, new research has found that pharmacists are key in the optimisation of medical treatment for breast cancer patients.

Breast cancer is the most common cancer that occurs in women. In 2012 there were 1.7 million new diagnoses ­– which equated to 12% of all new cancer cases. Less than one per cent of breast cancer develops in males.

Despite its prevalence, death rates from this form of cancer have been consistently declining over the past 25 years due to better awareness and advancing treatment options. Now authors of recent research are advising the involvement of pharmacist as a bridge between physicians and patients to improve therapy outcomes.

A first line of defence

Researchers have suggested that it is productive for pharmacists to address the worries and concerns of the patient.

The study by C. C. Dang et al notes that: “Pharmacist-led pre-chemotherapy counselling improves patient knowledge and understanding of the chemotherapy regimen received.”

In other areas it has been noted that the involvement of the pharmacist in parts of the primary health care system can have positive impacts on drug costs and the length of hospital stays.

Industry understanding of the disease

Like all cancers, breast cancer develops due to a DNA mutation that drives the haphazard reproduction of breast cells into a malignant tumour.

Although there is no definitive cause for the trigger of breast cancer, experts propose that certain life events may increase the risk of its onset.  These include, exposure to radiation from medical treatment, use of hormone therapies and menopause.

North America, Sweden and Japan boast an 80% breast cancer survival rate, however the rate plummets for countries with less financial clout. This is understood to be down to the lower level of early detection programs for breast cancer in these regions.

The World Health Organization (WHO) notes early detection and diagnosis as the “cornerstone of breast cancer control”.  Detection measures include awareness of the signs and symptoms of the condition and screening programs to identify those who may have a susceptibility to the disease. (more…)

The state of mental health in the UK: Where are we going wrong?

By Erin Hallett, Head of Alumni Relations, Imperial College Business School  

Today is World Mental Health Day.

Every year on 10 October healthcare professionals, advocates, patients and other stakeholders come together to raise awareness of global mental health issues and encourage efforts in support of mental health. The World Federation for Mental Health has set this year’s theme as mental health inthe workplace.  

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Advancing patient outcomes through technological innovation – from science fiction to science fact

By IGHI guest blogger, Chris Bird, PG student from the MSC in Health Policy at the Centre for Health Policy and Project Manager in the System Engagement Programme at the National Institute for Health and Care Excellence (NICE)

At a recent conference I was lucky to listen to a guest lecture by Dr Kevin Fong. Kevin has a long standing interest in human space exploration and space medicine and has worked with NASA’s Human Adaptation and Countermeasures Office at the Johnson Space Centre in Houston. He’s travelled the world to meet medical innovators and has produced interesting documentaries for television showing the extreme scenarios in which healthcare and technology can be applied to further human survival.

Innovating through battlefield medicine

Listening to Kevin inspired me to go away and discover more about how innovations in battlefield medicine have gone on to benefit wider society.

Such are the advances in emergency medicine on the battlefield in recent years that many soldiers who previously would have succumbed to their injuries are now often going on to be so-called ‘unexpected survivors’ as found by the National Audit Office’s assessment into the quality of treatment on military operations. In many cases they survive with complex and highly specialised needs.

One of the most common injuries resulting from recent military engagements in Iraq and Afghanistan has been limb loss. Many soldiers have become multiple amputees as a result of maiming from improvised explosive devices. In the past such survivors would have been constrained by their physical condition and the limits of technology available to give them some form of mobility.

Engineering meets medicine

Today, advances in prosthetic limb replacements mean that science fiction has become science fact. Devices that 20 years ago were only the stuff of science fiction movies are now benefiting veterans in real life today. Specialist providers of prosthetics and orthotics such as the Hanger Clinic in the US are at the forefront of efforts to meld the best practices of engineering, science and healthcare to devise prosthetic solutions that empower their patients.

Recent innovations to prosthetics include gyrostabilisers to provide better balance and support. These devices known as microprocessor-controlled prosthetic knees (MPKs) have an in-built battery powered computer which senses the mode and level of activity the user is undertaking and adjusts swing and stance and the vacuum that grips the user’s residual limb to match this activity. People using an MPK have reported improved individual mobility and independence and greater freedom to undertake activities. Prince Harry’s Invictus Games have served to highlight the incredible achievements that these veterans, supported by advanced prosthetics such as MPKs can realise as a result of these advances in emergency medicine, technology, physical and mental rehabilitation.

So how do we get those innovations out to people in wider society, but living with similar disabilities who might benefit from their application?

Specialised commissioning

In the UK National Health Service (NHS), its specialised commissioning team are now overseeing the provision of MPK devices to restore quality of life to around 500 people per year. Resource stewardship in an era of stretched finances requires policy makers to ensure that money in new innovations is invested wisely. For these new treatments, complex decisions have to be made about which ones represent the best value taxpayers and clinical effectiveness for patients. NHS England has found the MPKs to be a cost-effective innovation for the NHS’s specialised services given the range of improvements that can deliver to a patient’s overall health and wellbeing.

NHS England’s Specialised Commissioning through Evaluation (CtE) Programme (with a budget of £25m) is testing an approach to evaluating further potentially promising specialised treatments, for which there is currently insufficient evidence to supporting routine commissioning (funding) within the NHS.

For each CtE scheme, new data is collected within a formal evaluation programme, undertaken with the National Institute for Health and Care Excellence (NICE), potentially leading to the development of a new or revised national clinical commissioning policy for future access.

Amongst promising new innovations currently at the CtE’s data-gathering stage is the Second Sight Argus II Retinal Prosthesis – ‘bionic eyes’ to tackle inherited blindness where an implant in the patient’s retina is linked to a camera mounted on a pair of glasses. This camera sends wireless signals direct to the nerves which control sight and are then ‘decoded’ by the brain as flashes of light.

Boldly going….

It’s often the case that science fiction forecasts what the next technological innovation will be. Looking at the latest offerings in cinema – from the artificially intelligent synthetic beings of Ridley Scott’s Alien and Blade Runner franchises to the advanced medical diagnostics and regenerative medicine of Star Trek, the future of medicine looks an exciting place to be.

At the recent Expo, NHS Medical Director Sir Bruce Keogh noted exciting new evidence that artificial intelligence will have the capability to read x-rays within four years. It continues to be the role of health service policy makers today to ensure the conditions are in place for these innovations to be tested and if found to meet value and outcomes thresholds, realised for the benefit all those whose lives may be enhanced by them in our healthcare systems.

Follow Chris Bird on Twitter – @TheChrisBirdy

Discovering the medicines of tomorrow: Four lessons from failed Alzheimer’s research

By guest blogger Chanice Henry, Editor, Pharma IQ

Even though drug development for Alzheimer’s Disease has a steep failure rate, the lessons learned from failed trials are of great benefit to future research.

Alzheimer’s is the most common form of dementia – the irreversible loss of memory and other cognitive functions which eventually makes daily tasks unmanageable.

As the life expectancy of the world’s population grows, the Alzheimer’s is becoming more common. Estimates suggest that  the number of affected US patients will climb from 5.3 million to almost 14 million by 2050.

In the fight against this disease many have dedicated their careers to revolutionise how the neurodegenerative disease is diagnosed and handled. Recent studies have created artificial intelligence that can identify the presence of Alzheimer’s two years before a doctor.

Progression has been made in the understanding of this progressive brain cell failure with “..promising targets for next-generation drug therapies under investigation in current research studies” according to the Alzheimer’s association.

However, the failure rates are high when it comes to creating new medical treatments to stop, slow or prevent Alzheimer’s. Between 2002 to 2012 there was a reported 99.6% failure rate within drug discovery for this condition.

Jeffrey Cummings notes that researchers have a duty to make sure that both the physical and financial efforts behind these failed trials are not in vain as they have a lot to contribute in the battle against Alzheimer’s.

Some key lessons from failed trials to incorporate into today’s R&D pipelines:

Animal models aren’t reliable indicators of toxicity of efficacy in humans

Animal testing has long played a key role in the development of drugs and the understanding of how diseases function. However, animal models also have critical translation issues when results are compared to human trials. (more…)

Using the value-based approach to overcome challenges facing healthcare systems in the U.K and Rwanda

By IGHI guest blogger, Chris Bird, PG student in the Centre for Health Policy and Project Manager in the System Engagement Programme at the National Institute for Health and Care Excellence (NICE)

Systems under pressure

Rwanda and the developing world face even more acute pressure on frontline healthcare services.

Health systems around the world face the twin pressures of a rising demand for services, coupled with financial pressure on resources to deliver them. For publicly-funded universal health services in developed countries such as the UK’s National Health Service (NHS), new investment is at an all-time low. Funding for the NHS in England has seen a real-terms rise of 4.4% over 6 years, meaning that the average annual rise was just 0.7% per year. Traditionally NHS funding had averaged at 4% per year.[1]

At the same time in the developing world, pressure on frontline services is even more acute from challenges ranging from natural disaster, population displacement, communicable disease and often scarce availability of healthcare resources and skills to respond. Innovation is the best hope for policymakers and clinical leaders to meet and sustain the WHO’s Millennium Development Goals (MDGs) that aim to address the fundamental inequality in health outcomes between the developed and developing world.

Meeting the challenge with a value-based healthcare approach

In the face of these competing pressures on healthcare systems, Michael Porter of Harvard Business School argues that the time has come for a fundamental new strategy, which represents a shift away from the supply-side model of health care organisation towards a more patient-centred system focussing on achieving best outcomes at the lowest cost. It is termed the ‘value-based healthcare’ (VBH) agenda.

Central to delivering VBH is the Integrated Practice Unit (IPU). An IPU brings all related healthcare professionals together, organised around a given condition, in a multidisciplinary setting, having geographic reach and removing the need for the patient to travel around a variety of different services to access appropriate care interventions. The IPU team takes responsibility for the full cycle of care for the condition including inpatient, outpatient and rehab. It measures outcomes, costs and processes for each patient using a common information platform. (more…)

How health and voluntary sector services can work together collaboratively to improve health and wellbeing in later life

By IGHI guest blogger, Chris Bird, PG student in the Centre for Health Policy and Project Manager in the System Engagement Programme at the National Institute for Health and Care Excellence (NICE)

In today’s fast moving world, we need to constantly adapt to keep up. But what about those people in later life who might struggle to do so?

We live in a world where society is ageing. Falling mortality rates, particularly in the over 65-year age group coupled with low fertility rates in the younger population are leading to a society which is growing older[i].It is also true that conventional care delivery is often based around admittance to institutionalised hospital care which is both costly and can be inefficient as professionals, bound by silo working, fail to achieve either best value or best care for patients[ii].

The National Institute for Health and Care Excellence (NICE) has developed a quality standard which addresses the need for the National Health Service (NHS) and other sectors to work together to identify mental health and independence issues in older people. This an important step for those who would benefit from a helping hand but can’t find it themselves.

The integrated care pathway

Working with Age UK’s Integrated Care Team to evaluate their personalised integrated care programme, I have seen first-hand how the essence of this standard can be put into practice locally and improve older people’s wellbeing for the better. Age UK delivers an integrated holistic service for older people. It’s aimed at those with complex and long-term health problems.

Working with GPs to identify those who are eligible for the programme, (typically those who have had 2 or more unplanned hospital admissions and have 2 or more long-term conditions), Age UK is able to set individual’s up with their own “independence coordinator”.

After a series of home visits to get to know the person better, the coordinator helps create some personal goals. These can range from visiting a coffee mornings, to arts and crafts lessons, to a day out at the seaside – it depends on the person and what is important to them.

Over the course of this three-month personal intervention programme, independence coordinators monitor changes in their clients’ wellbeing through use of the Warwick and Edinburgh Mental Wellbeing Scale (WEMBWS). (more…)