Patients’ requests for antibiotics - how to manage expectations

Patients may sometimes insist on obtaining a prescription for antibiotics during their consultation and react negatively when their request is turned down. We suggest ways to manage patients’ expectations to help reduce antibiotic use.

A Medical Protection survey¹ earlier this year found that while nearly 70% of GPs in England found the Public Health England campaign ‘Keep Antibiotics Working’,² was useful, almost a third (32%) still frequently experienced anger or frustration from patients when advised that antibiotics are not needed.

It would not be surprising if nurse prescribers experience this too.

Unnecessary prescription of antibiotics contributes to the spread of resistance.³ Antibiotic resistance is a worldwide problem, a threat to global health4 and may have catastrophic consequences as more people may die of minor infections that can no longer be treated by antibiotics. Therefore, tackling rising antibiotic resistance has been highlighted as an international priority.⁵

Across healthcare organisations there are various campaigns and strategies which aim to change prescribing practice in order to slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection. Yet it seems that the message about the use of antibiotics is still not getting across.

Although most members of the public have heard of 'superbugs' such as MRSA, their limited understanding of what antibiotics can and cannot do, as well as the seriousness of antibiotic resistance, is one of the main barriers to changing patients' behaviour. Practice nurses play a pivotal role in contributing to combating microbial resistance; by educating patients about the proper use of medications and avoiding unnecessary prescriptions.

TWO-WAY COMMUNICATION

At a time where patients have information at their fingertips and with 47% of patients using ‘Dr Google’ prior to their consultation,6 many will approach the consultation with some knowledge. Nurses should encourage patients to be cautious about self-diagnosis via the internet. It is also not unusual for patients to speak to family and friends to compare diagnoses and care options. It is therefore more important than ever for practice nurses to be able to close the gap between meeting their patient’s expectations and what is possible in reality.

Identifying the patient’s expectations, clearly addressing those expectations throughout the consultation and involving the patient in decisions, can assist the practice nurse to manage any unrealistic expectations early on.

Patients who are prescribed antibiotics for a minor illness, such as an upper respiratory infection (URTI) – which in most cases is self-limiting and does not require antibiotics – are more likely to request antibiotics the next time they develop the same illness. This further intensifies antibiotic resistance and increases medicines wastes. URTIs account for more than 60% of all prescriptions issued in UK primary care.^7,8

A key aspect in controlling the unnecessary use of antibiotics is to ‘break the chain’ in the patient’s beliefs about the effectiveness of antibiotics for minor illnesses such as URTI.

Have an open discussion with the patient and provide them with sufficient information about the nature of the proposed treatment, including rationale and anticipated benefits. An explanation should be given of why the recommended treatment – and not depending on antibiotic use – is preferable.

Make sure that they understand any possible complications; it is recommended to practise ‘safety-netting’ during the consultation by clearly informing them what to do if the patient’s symptoms worsen.

Delaying antibiotic use and asking the patient to return should symptoms fail to improve may also reduce the use of antibiotics for self-limiting conditions. Providing self-help information and leaflets have also been found to be useful.^9–11

If the patient is unhappy with a nurse’s decision not to prescribe antibiotics, the nurse could offer a second opinion with a GP. It is crucial that all discussions with the patient are clearly documented in the patient’s record.

PROFESSIONAL RESPONSIBILITIES

The NMC Code states:¹²

‘Always practise in line with the best available evidence

‘To achieve this, you must:

• Make sure that any information or advice given is evidence-based, including information relating to using any healthcare products or services, and
• Maintain the knowledge and skills you need for safe and effective practice’

Besides being aware of the professional Code, nurses must keep up-to-date with other guidance regarding antimicrobial prescribing such as the NICE guideline for the effective use of antimicrobials (including antibiotics) in children, young people and adults.¹³

Please note that the NMC’s Standards for medicines management¹⁴ is due to be withdrawn this month (July 2018). The NMC has decided that it is not within its remit, as a statutory regulator, to provide clinical practice guidance of this nature. However, the NMC is working closely with the Royal Pharmaceutical Society to update the Professional Guidance on Safe and Secure Handling of Medicines in all Care Settings,¹⁵ which NMC believes could provide a model for future guidance on medicines management.

SUMMARY

Nurses should be prepared to explain and justify their decisions and actions when prescribing, administering and managing medicines. Documenting the reasons for the decision carefully, as well as recording details of the discussion with the patient, will be helpful in the event that the patient pursues a formal complaint.

REFERENCES

1. Medical Protection survey, 2018. https://www.medical

protection.org/uk/for-members/press-releases/press-releases/phe-antibiotics-campaign-welcomed-by-gps-but-a-third-still-experience-anger-over-prescriptions

2. Public Health England’s national campaign: Keep Antibiotics Working. http://antibioticguardian.com/keep-antibiotics-working/

3. Costelloe C, Metcalfe C, Lovering A et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and metaanalysis. BMJ 2010

4. World Health Organization. Antimicrobial Resistance: Global Report on Surveillance, 2014. http://www.who.int/mediacentre/

factsheets/fs194/en/

5. Davies S. Annual report of the Chief medical officer 2011: Infections and the Rise of Antimicrobial resistance. London :Department of health, 2011

6. Medical Protection survey, 2016. https://www.medical

protection.org/uk/about-mps/media-centre/press-releases/press-releases/almost-one-in-two-(47-)-use-dr-google-before-gp-consultations

7. Williams SJ, Halls AV, Tonkin-Crine S, et al. General practitioner and nurse prescriber experiences of prescribing antibiotics for respiratory tract infections in UK primary care out-of-hours services (the UNITE study). J Antimicrob Chemother 2018;73:795-803

8. Gulliford MC, Dregan A, Moore MV et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open, 2014;4:e006245

9. Bunten AK & Bunten MKD. Patient information can improve appropriate antibiotic prescribing . Nursing in Practice, 2015. https://www.nursinginpractice.com/article/patient-information-can-improve-appropriate-antibiotic-prescribing

10. RCGP: TARGET Antibiotic Toolkit http://www.rcgp.org.uk/

targetantibiotics

11. Patient information can improve appropriate antibiotic prescribing https://www.nursinginpractice.com/article/patient-information-can-improve-appropriate-antibiotic-prescribing

12. NMC Code. https://www.nmc.org.uk/standards/code/read-the-code-online/

13. NICE NG15. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use, 2015 https://www.nice.org.uk/guidance/ng15

14. NMC. Standards for medicines management https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-medicines-management/

15. Royal Pharmaceutical Society: Safe and Secure Handling of Medicines in all Care Settings. https://www.rpharms.com/making-a-difference/projects-and-campaigns/safe-and-secure-handling-of-medicines