Dr John Wilkinson
GP Partner at GPS Healthcare, Solihull
I am both a practicing GP and a member of our local Integrated Medicines Optimisation Committee (IMOC), so antimicrobial stewardship is something that I am involved in both with individual patient care and from a strategic point of view. My IMOC role means I get to hear first hand the discussions that result in guideline production and ratification, including our local antimicrobial prescribing guidelines.
Our local guidelines now push for shorter courses of antibiotics when clinically appropriate, and the NICE guideline on acute sore throat suggests a 5-10 day course of phenoxymethylpenicillin. Five days of phenoxymethylpenicillin may be enough for a symptomatic cure, while a ten-day course may increase the chance of a microbiological cure.
As a GP working in primary care, it can be challenging to determine the best course of action for acute sore throat, deciding whether any treatment apart from symptom relief is needed. Tools like FeverPain can be used as a guide, but of course, clinical judgement is important. I recently saw an otherwise fit and healthy 21 year old male with a two-day history of acute sore throat and fever, feeling generally unwell – a common scenario for me and my colleagues in primary care. With a Fever pain score of 5 and considering his presentation, after a conversation with the patient we opted for immediate antibiotics. While being careful to rule out red flags and checking for penicillin allergy I opted for a shorter course of 5 days of phenoxymethylpenicillin.
I reviewed my patient (regarding a different issue) with a telephone call after he had finished his antibiotics, and he was symptom free and back at work. Phenoxymethylpenicillin tablets are hard to take for patients – four times a day, 30 minutes before a meal or at least 2 hours after you have eaten. I know colleagues that would struggle to follow that regimen. It made me wonder whether this gentleman would have completed a 10 day course – would he have stopped taking them ‘early’ anyway? Would he have given them to a friend, or taken them himself at a later date when he felt ill with something else? Would he have put them in the bin or down the sink or toilet? All of these actions are potentially harmful and increase antibiotic resistance.
We often think about the benefits of shorter courses from an antibiotic stewardship point of view, limiting the antibiotic exposure of normal flora, but it is important to consider the benefit to the patient of having to take antibiotics for fewer days. There are still always clinical situations where I will prescribe a longer course, but thinking has moved on and I am keeping up by changing my default position from longer courses to shorter ones in line with local and national guidance.