I recently gave a talk on antibiotic prescribing in primary care, and had a great discussion with many of the general practitioners (GPs) who attended the course (on a separate note, it is not at all clear that the best people to talk to GPs about antibiotic prescribing in primary care are hospital-based infectious diseases physicians).
The case that generated the most discussion was as follows: a young, previously healthy woman presented with high fever (39 degrees Celsius) for 2 days associated with dry cough and a bit of sore throat and runny nose. Clinical examination was unremarkable except for fever and a mildly injected threat.
The participants were asked:
- Who would prescribe antibiotics for this woman? (None)
- Did they think some of their GP colleagues would prescribe antibiotics for her? (Quite a number raised their hands)
The final question: if this young woman was prescribed 5 days of moxifloxacin by a colleague, felt better after two days, then asked on a professional basis whether she could stop the antibiotics, what would they recommend?
Rather to my amazement, every participant recommended completing the entire course of the broad-spectrum fluoroquinolone antibiotic!
Even though none of the GPS (there were over 50 in the room) would have prescribed antibiotics in the first instance, none would also recommend stopping antibiotics once a hypothetical colleague had prescribed them.
Somewhat nonplussed, I walked my team of medical officers through this scenario a few days later during post-round coffee. These are medical officers posted to the hospital’s department of infectious diseases, and presumably had received some teaching on antibiotic prescription. I was no longer so surprised that everyone stoutly recommended completing the remaining 3 days of moxifloxacin, despite claiming that they would not have prescribed antibiotics in the first place.
The first reason both GPs and medical officers gave for completing the course of antibiotics was that failure to finish antibiotics would “result in antibiotic resistance developing”. This is actually a myth that would be useful to dispel – after all, more days of antibiotics = more antibiotic selection pressure = ultimately more issues with antibiotic resistance. But I suspect that this concept of “completing the course of antibiotics” is so deeply ingrained in doctors (at least locally) that it would take quite a major educational and cultural effort to change this practice. It remains a key recommendation on the World Health Organization “prescription” to stop antibiotic resistance (although not updated since 2015).