Policy responses and statements

Name of organisation:

The Scottish Parliament: Public Petitions Committee

Name of policy document:

PE1019 - Nationwide health promotion campaign to raise patient awareness of the proper use of antibiotics in order to combat antibiotic resistance

Deadline for response:

5 April 2007

Background: At a meeting on 13 December 2006, the Public Petitions Committee considered a petition by Imran Hayat calling for the Scottish Parliament to urge the Scottish Executive to start a nationwide health promotion campaign to raise patient awareness of the proper use of antibiotics in order to combat antibiotic resistance. The Committee agreed to seek the Royal College of Physicians of Edinburgh's comments on the issues raised in the petition.

COMMENTS ON
THE SCOTTISH PARLIAMENT PUBLIC PETITIONS COMMITTEE
Consideration of Petition PE1019:
Nationwide health promotion campaign to raise patient awareness of the proper use of antibiotics in order to combat antibiotic resistance

The Royal College of Physicians of Edinburgh is pleased to respond to the Public Petitions Committee on Petition PE101 which proposes a nationwide health promotion campaign to raise patient awareness of the proper use of antibiotics.

The College is pleased to offer evidence to the Committee on this important and topical issue. The problem of antibiotic resistance has caused considerable concern for some years, and has been high on the Scottish political and medical agenda. This College has made considerable contributions to the discussions and has helped develop a strong and wide-ranging national response, which includes relevant education and training of medical professionals and guidance on good professional practice with regard to antibiotic prescribing (1,2).

This is not a new issue. In 1999, Professor Sir Liam Donaldson launched a £1.3m public awareness campaign to tackle antibiotic resistance and, in Scotland, Susan Deacon, then Minister for Health, launched a similar campaign in October 2000, followed by a second phase in May 2002. In June 2000, the “UK Antimicrobial Resistance Strategy and Action Plan” was published in response to the House of Lords Select Committee report, and the UK Government established a new Expert Advisory Committee on Antimicrobial Resistance. One of the aims of this Expert group was to encourage realistic public expectations for antimicrobial prescribing through a public information campaign and other activities.

There can be little doubt that antibiotic prescribing continues with some prescriptions being unnecessary and, in some cases, potentially dangerous. The evidence of resistance development relates most closely to the bulk of antibiotic use and the inappropriate use of broad spectrum antibiotics for ill-defined or unnecessary reasons.

There is good evidence of a causal link between high levels of antibiotic usage and increase in antibiotic resistance. There is also good evidence that it is possible to limit or reverse the increase in antibiotic resistance through campaigns of education, guidance and monitoring aimed at health care professionals. However, there is very little by way of published evidence regarding a role for a nationwide media campaign to raise public awareness of this issue. The few reports which are available serve only to illustrate the limitations and pitfalls in implementing and evaluating such a publicity campaign (3, 4).

It would be important to ensure the correct message is delivered. The petitioner cites the need to complete an antibiotic course and in some situations this is vital. However, the evidence base on the optimum length of course of antibiotics is limited, and doctors would have some difficulty in demonstrating clearly the evidence for appropriate course lengths in many common infections.

Health promotion campaigns in the mass media need to conform to a number of requirements:

(a) It should be possible to formulate a concise, unambiguous and readily understood message which is relevant to the issue and well-grounded on facts.

(b) There should be reasonable assurance that the media campaign would not cause unintended morbidity and mortality or undue anxiety to individual patients.

(c) There should be a reasonable expectation, preferably based on critically evaluated previous experience, that such a campaign will make a significant contribution towards achieving the intended health benefit for the population.

When considering a mass media campaign to tackle the issue of antibiotic resistance, it would be very difficult indeed to reconcile requirements (a) and (b). As a group of drugs, antibiotics are clearly one of the most beneficial and dramatically life-saving of all medicines used in hospital and community practice. Moreover, for many types of infections, it is essential to start antibiotic treatment at an early stage of the illness. Undue hesitancy or delay in starting therapy with antibiotics for even some seemingly minor infections can and does result in increased severity or avoidable death. The number of patients so affected is small and therefore difficult to quantify accurately, but many practising clinicians would easily recall anecdotal examples. Such examples include necrotising fasciitis following minor skin infections, severe pneumococcal pneumonia complicating viral upper respiratory tract infections and purulent mastoiditis or meningitis following minor middle ear infections.

Most studies which report on campaigns to restrict antibiotic usage stress the benefit to the community in terms of reducing antibiotic resistance rates, but they fail to document any serious adverse consequences that may have occurred to individual patients. This is largely because such adverse consequences are infrequent, and many of the published studies are either too small or are not adequately designed to detect them. There is, however, one large study which clearly documents a link between reduction in antibiotic usage by general practitioners and an increase in deaths due to pneumonia in England and Wales (5).

It is clear, therefore, that there is a balance to be struck between the risk of over-using antibiotics and thereby fostering the global increase in antibiotic resistance on the one hand and, on the other hand, the risk of raising the clinical threshold for using antibiotics so high that individual patients are put at risk of avoidable mortality and morbidity. This is a difficult balance to strike, even for experienced clinicians, and guidance for professionals has to be detailed and nuanced and allow adequate latitude for clinical judgement. When, on occasion, a patient does suffer as a result of withholding or delaying antibiotics, the ethical and legal issues that may arise are largely subsumed under the individual professional responsibility of the prescribing practitioner. It may be a difficult task to formulate a mass media message that will help rather than hinder this difficult balancing act and stay clear of potential ethical and legal pitfalls.

Therefore, in conclusion, the College strongly supports professional efforts to promote rational antibiotic use, and recognises the importance in general of the need for public awareness and public involvement in health promotion. However, the particular campaign that this petition pleads for may raise a number of challenging difficulties - medical, practical and possibly also legal/ethical. The issues are rather more complicated than those involved in, say, the established campaigns against smoking or excessive drinking or the campaign to encourage the use of condoms. These established campaigns promote messages which are unlikely to carry any risk of adverse outcomes. If the Petitions Committee is minded to recommend a public information campaign, further work is required to ensure the campaign is effective, delivers value for money and results in no unintended harm.

References:

1. Scottish Infection Standards and Strategy (SISS) group: Good practice guidance for antibiotic prescribing in hospitals. Journal of the Royal College of Physicians Edinb. (2003) 33: 281-284

2. Nathwani, D on behalf of Scottish Medicines Consortium (SMC). Antimicrobial prescribing policy and practice in Scotland: recommendations for good antimicrobial practice in acute hospitals. J Antimicrobial Chemotherapy (2006) 57(6):1189-1196

3. Lambert MF, Masters GA, Brent SL Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother. 2007 Mar;59 (3):537-43.Epub 2007 Feb

4. Goossens H, Guillemot D, Ferech M, Schlemmer B, Costers M, van Breda M, Baker LJ, Cars O, Davey PG. National campaigns to improve antibiotic use. Eur J Clin Pharmacol. 2006 May; 62(5):373-9.

5. Price DB, Honeybourne D, Little P, Mayon-White RT, Read RC, Thomas M, Wale MC, FitzGerald P, Weston AR, Winchester CC. Community acquired pneumonia mortality: a potential link to antibiotic prescribing trends in general practice. Respir Med. 2004 Jan; 98 (1):17-24.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[4 April 2007]