Volume 1

Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology.

  • Great Britain. Parliament. House of Lords. Science and Technology Committee.
Date:
1998
Catalogue details

Licence: Open Government Licence

Credit: Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology. Source: Wellcome Collection.

    19/112 (page 17)
    Formularies, policies and guidelines 2.10 A formulary is a list of available drugs, or of drugs recommended from among those available; a policy gives guidance or instruction on when and how they are to be used. In the United Kingdom, most hospitals and some general practices have at least a formulary of antibacterials recommended for local use, and some hospitals have antibacterial policies. 2.11 The PHLS presented us with the findings of a survey of clinical audit in hospitals in England and Wales, in the context of MRSA (p 41). They found that formularies vary widely in form and content, and “are drawn up with little involvement of the junior staff; comments are often not invited”; that communication of antibiotic policies to new staff is often poor; and that audit of prescribing is often irregular, infrequent and unstructured. The AMM recommend that all hospitals and general practices should have both formularies and policies. These should be produced in a way which gives the doctor “ownership”; and they should be supported by strong encouragement from the health departments, and by audit. 2.12. Policies may operate at any level, from local to global (RCGP p 167; DH p 344; Petrie Q 669). They may reflect the threat of resistance by recommending rotation or combination of drugs (Davey Q 263, Spencer p 519, Tyrell p 528), or by avoiding certain drugs altogether (PHLS p 52). They may be supported by restrictive reporting,'’ by financial incentives (recommended by Dr McGavock, Q 658) and even by compulsion (resisted by Professor Petrie, Q 674). They may be more or less flexible; Glaxo Wellcome advocate flexibility, “to enable nimble local responses to changes in resistance patterns” (p 407). Box 3 gives examples of good practice in this area which have come to our notice. 2.13. A policy is not a panacea. It must be sound in itself, and must be implemented conscientiously and intelligently. It must also be policed: see below, paragraph 2.34. Dr R C Spencer, of the Public Health Laboratory at Bristol Royal Infirmary, points out that policies depend on surveillance, to indicate what the infecting organism is most likely to be, and what resistances it is likely to exhibit (p 513). We consider surveillance in Chapter5. As for implementation, Professor Percival gave us the example of a policy drawn up for severe community-acquired pneumonia; it was applied to pneumonia of all kinds, and is now blamed for “a tremendous increase in Clostridium difficile side-effects” (Q 104). 2.14 The pharmaceutical industry strongly prefer evidence-based guidelines for appropriate prescribing, rather than crude injunctions to prescribe less. In some situations, they say, certain drugs should be withdrawn, in others they should be used in combination (particularly for TB and HIV) or rotated; in others new and better agents should be used. Guidelines must be based on evidence, which the industry is willing to provide (see Box 11 below). Glaxo Wellcome and SmithKline Beecham make no bones about it: if use of their anti-infective products were restricted beyond a certain point, they would place their investments somewhere else.'* 2.15 Inthe USA, one of the pressures towards imprudent prescribing is fear of litigation. In United Kingdom law, a doctor who prescribes in accordance with a local policy is unlikely to be successfully sued for negligence (Davey p 156). Professor James Petrie of the University of Aberdeen described the British legal position in this area as “reassuring” (Q 674). Dr McGavock expressed himself more concerned about being sued for prescribing too much than for prescribing Restrictive reporting: When a doctor sends a specimen to a laboratory for microbiological analysis and susceptibility testing, the microbiologist must decide what to report. Reporting every bacterial isolate would be unhelpful, since it would include normal flora and contaminants; the doctor is interested only in possible pathogens. Reporting the susceptibility of each isolate to every conceivable antimicrobial would be impossible; in practice, only certain susceptibilities are tested or reported. In the United Kingdom, microbiologists turn these facts of life to advantage. According to the AMM, “Reporting is tailored to what is felt to be appropriate for the individual patient and the wider context, and is often made to be concordant with the hospital’s formulary and antibacterial policies”. GW: “The outcome will be a “deprioritisation” of this area in favour of others” (p 407). SKB: “Inappropriate restrictions...would of necessity cause companies to invest their research effort in other, more profitable, therapeutic areas” (p 475).