The art of antibiotic prescribing in general practice

Guest posting from Dr Gillian Deakin,  General Practitioner and author of 101 Things Your GP Would Tell You If Only There Was Time

Beyond the usual medical challenges of appropriate prescribing,  GPs also need skills to ensure that the patient accepts the treatment. Unlike the hospital patient where the patient is largely obliged to accept the prescribed treatments, the ambulant patient will be influenced by anyone from Uncle Bill to that serial killer, Dr Google.  So GPs need to ‘sell’ the prescribed (non) treatment, if their advice is to withstand such opposition.

Certain symptoms strike fear, such as a high or persistent fever, infection ‘going to the chest’ or sputum becoming coloured. Faced with the anxious patient, GPs may be tempted to prescribe antibiotics to allay such fears. Given the patient may not return for review, the hope of monitoring them may be unlikely.

What GPs do have, however, is an ongoing relationship with the patient and, armed with this, can tailor the advice: a sensible patient who understands the nature of a viral infection will accept a prescription with advice not to commence antibiotics unless certain (written) symptoms arise. This is helpful in the patient prone to complications, such as the bronchiectatic. The parents of a first born infant may be reviewed frequently and after hours arrangements clarified. A quick phone call the next day can be very much appreciated. Family dynamics play a role and pressure from in-laws to treat the grandchild with antibiotics needs to be sensitively handled.

Some helpful explanations of symptoms may allay fears:

  • Fever is part of the body’s defence and should not be aggressively treated,
  • Sputum is a sign that the body is fighting back and the white cells are doing their work. In large numbers, they may make the sputum coloured but this alone is not a reason to start antibiotics
  • Cough is the body keeping the lungs clear and is part of recovery
  • Sometimes, the immune system carries on fighting long after the infection has passed. This post-infective cough is annoying but not a concern otherwise.

Physical examination can serve an important role in getting the patient to accept withholding antibiotics.

The doctor uttering pleasure that the fever is quite mild, or how the patient has successfully kept the chest clear with the coughing, that the sputum has a ‘nice lot of white cells’ doing the job for us, all can serve to encourage the patient to accept a wait and see approach.

Guaranteeing review and booking the appointment for the waverer is usually enough to reassure the most anxious.

Understanding that the patient wants to be symptom-free perhaps more than infection-free should focus the consultation of the patient with a standard upper respiratory tract infection. There is evidence that psychological support enhances recovery, so every patient with a lurgy should be able to leave the consultation feeling heard, understood, reassured and encouraged that they can manage. That may prevent doctor-shopping for antibiotics and also ensure timely review if recovery does not occur as anticipated.

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