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Human medical practice

Dr Neil Powell describes the challenges he has faced in diagnostics and antimicrobial stewardship from a human medical perspective.
So Neil Powell, I’m a consultant antimicrobial pharmacist at the Royal Cornwall hospital. And I also sit on a Cornwall One Health group which was set up in 2014 to try and work collaboratively with the animal and environmental sectors together to sort of tackle the AMR issue. So the sort of things we look at in hospital, or the sort of challenges we face, are when patients get admitted to hospital with symptoms, shortness of breath, for example– we don’t really know what’s causing those symptoms when those patients come through the front door. So there’s lots of diagnostic uncertainty at the beginning. So we do tend to give broad spectrum antibiotics for the things that we don’t really know what we’re treating.
So that’s the first challenge we’re faced with. The second challenge is, once we’ve made a diagnosis of pneumonia, for example, we need to then target the antibiotic therapy, sort of, to that infection, to that organ. And better still, once you’ve grown a bacteria, target the antibiotic to the infecting organism. So that’s another challenge we sort of face. But clinicians are quite well bought into that, and we’re quite good at doing that. The next thing is switching people from IV antibiotics to oral antibiotics. We tend to start people on IV antibiotics when they come through the front door of the hospital. So we just switch them from IV to oral once they’re improving. So that’s another challenge for us.
And the other sort of final challenge, really, in terms of antibiotic usage is once we’ve made a diagnosis, and we know what we’re treating, is to make sure we give the shortest possible antibotic course we can. So they’re the things we work on. And then the other challenge outside of that is when we start antibiotics in people, we don’t really know what’s causing their symptoms, so we start antibiotics. But once we’ve ruled infection out, we need to then stop the antibiotic in those patients. So that’s another big piece of work that we work on here, along with many other hospitals in England.
Yeah, so I think for the GPs, for example, I think they have slightly different challenges to what we have in hospital. The first sort of challenge, I would say, is they have very short appointment slots to see patients, I think 10 minutes to see patients. And that doesn’t really give you enough time to discuss alternative to antibiotics with patients, potentially. So giving an antibiotic might be a quicker option than actually discussing the merits and the limitations of an antibiotic for an individual patient. The second challenge is that there isn’t much, if any, patient follow-up. So in hospital, you have a patient in bed, with the luxury of going back to review those patients to review the progress.
And that offers us an opportunity to stop antibiotics early, whereas in primary care, they don’t have that opportunity. There’s no patient recall to then look at their syptoms, see how they’re doing, and maybe stop antibiotics at that stage. Diagnostics is a challenge in primary care, as it is for us in hospitals. A diagnostic test that would help GPs differentiate between viral and bacterial infections, that would be a really big game changer for primary care. But the similarity that we do have with primary care is around course lengths again. We know we can give shorter course lengths for antibiotics in primary care, and there is room to do that.
In secondary care, we can review patients and stop antibiotics and give them shorter courses if they’ve responded. But in primary care, they don’t have that luxury of shortening the course if they’ve responded, so they tend to give longer courses just in case because there won’t be a review. So they’re the main challenges.
So there are diagnostics available. This is very much an emerging field with lots of new diagnostics coming through, a lot of money being pumped into research and development diagnostics. But it’s very difficult to get those diagnostics, then, into the hospitals. Some of these rapid diagnostic tests have been studied in small studies, and they’ve demonstrated safe antibiotic reduction, or they’ve demonstrated effective narrowing of antibiotic spectrum antibiotics, which has positive impact on reducing the use of resistance pressure. But they haven’t been studied, then, in further larger studies to demonstrate health economic impact.
And that’s been one of the barriers, I think, to implementation– that, and the high upfront cost of getting the diagnostics into the hospitals and then incorporating those diagnostic tests into patient pathways and lab processes. So there are many barriers, and it’s a recognised problem in human health. And the Chief Scientific Officer has set up a national diagnostics collaborative to try and unpick some of these issues and try and facilitate adoption of diagnostics into hospitals.
In the video above, Neil Powell, a consultant antimicrobial pharmacist at the Royal Cornwall Hospitals NHS Trust, shares his experiences in antimicrobial prescribing, from a human medical perspective. While you’re watching the video, think about how these challenges could relate to the challenges in veterinary practice that you’ve seen in the previous steps.

Challenges to achieving antimicrobial stewardship in a hospital setting:

  • Empirical prescribing of broad spectrum antimicrobials prior to a diagnosis.
  • Targeting antibiotic therapy to the infected tissue.
  • Switching people from IV antibiotics to oral antibiotics once they’re improving.
  • Giving the shortest possible antibiotic course once a diagnosis has been made.
  • Stopping antibiotic treatment once an infection has been ruled out.

Challenges to achieving antimicrobial stewardship in a community setting (for example, a GP surgery):

  • Very short appointment slots to see patients – not enough time to discuss alternatives to antibiotics.
  • Very little patient follow-up and therefore no capacity to change antibiotic treatment halfway through.
  • Longer courses of antibiotics have to be given because they cannot follow-up to see how the patient has responded to antibiotics.
  • Lack of diagnostic tools, so limited initial knowledge of what you are treating.

Challenges in diagnostics:

Diagnostics is an emerging field with lots of new technology being invented. However, it is very difficult to then get these into hospitals and incorporate them with patient pathways as there is a high cost associated with the use of specialised diagnostics tools.

So why is this relevant?

Use the comments section below to discuss how this relates to veterinary practice. What are the similarities and differences between the challenges described here and what you see where you work?
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Antimicrobial Stewardship in Veterinary Practice

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