Charlotte Hays is a busy working mother. She admits that she knows antibiotics don't work for coughs and colds, but that doesn't stop her from going to her GP to get them for minor infections. "I know about antibiotic resistance, but it's a bit like climate change - it's someone else's problem," she says. Hays, it seems, is not alone in this attitude. Despite multi-drug-resistant tuberculosis challenging healthcare workers globally (although it is not yet present in the UK) and evidence that other harmful bacteria are becoming resistant faster than we can create new drugs, antibiotic use is on the rise again.
Hays puts her reliance on antibiotics down to her busy schedule. "I can't wait for the illness to take its course. I want antibiotics to make it go away."
Recent research led by Dr Andrew Hayward, a senior lecturer in infectious disease epidemiology at University College London, found that, despite official guidelines, GPs are prescribing too many antibiotics for common infections. His survey, published in the Journal of Antimicrobial Chemotherapy, showed that antibiotic prescription varied widely according to the condition, with 44% of upper respiratory tract infections (coughs and colds), 64% of sore throats over 80% of chest infections and sinusitis receiving prescriptions for antibiotics.
"The majority of simple coughs, colds and sore throats are viral, and those that are bacterial only benefit a little from antibiotics because they will get better anyway. GPs are prescribing more antibiotics than necessary for these conditions," Hayward says.
The reasons for this trend are complex. "Historically, antibiotics have been seen as a harmless way of treating people, even though the evidence for their effectiveness on some infections hasn't been great," says Hayward. "Doctors are also concerned about the risk of complications [the infection spreading from localised to systemic] even though such a risk for most common infections is low."
Adding to the confusion is the fact that people may sometimes be given an antibiotic not to treat a virus, as it will have no effect on the virus itself, but to help prevent bacterial infection when the body is weakened. People with underlying conditions, such as chronic bronchitis, asthma or heart disease, are more susceptible to such complications.
"I don't think there's a doctor in the country who would say they've always prescribed antibiotics because they're 100% sure the person has a bacterial illness," says Dr Anthony Harnden, a GP and expert in antibiotic prescribing at Oxford University. He points to recent changes in the way out-of-hours GP services are delivered and walk-in centres as reasons for the increase. GPs are not necessarily familiar with them and it's more difficult to have an informed consultation about the pros and cons of a treatment. "Children appear ill especially at night because their fevers are higher. Perhaps doctors are more likely to give them antibiotics in that circumstance," he says.
There are other circumstances in which GPs may feel pressured into prescribing antibiotics. "Most GPs have had their arm twisted to prescribe in situations such as examinations or weddings," Harnden says.
Hays admits she has done exactly that. "My 17-year-old son had a sore throat and was finding it difficult to swallow. It was during his exam period and I felt I had to do something. I could feel myself putting pressure on my GP even though I knew it would probably get better on its own."
One tactic GPs have adopted is what they call "delayed prescription". This involves the doctor writing out the prescription but advising the patient not to cash it immediately or take the medicine unless they feel a lot worse within the next 24 to 48 hours.
"There's quite a lot of research," says Harnden, "that suggests delayed prescription of antibiotics is a useful prescribing strategy for the doctor, who can reassure the patient they are taking their illness seriously, but don't feel they need antibiotics at the moment. This strategy has been shown to reduce antibiotic consumption."
But if someone does feel that they have been wrongly prescribed antibiotics, Fleming suggests that they should be direct. "They should ask in their opinion how likely it is that they've got a bacterial infection rather than a viral infection. That will then at least engage the doctor on the issues," he says.
Research also suggests that the way antibiotics are used might contribute to an increase in resistance. So while doctors need to prescribe correctly, it is up to the patient not to misuse them. Different antibiotics are used to treat different bacteria and doses able to kill or stop the bacteria vary, so people should avoid taking their medical treatment into their own hands. "If you have an antibiotic prescribed, you should use it for the complete course of treatment. If you are haphazard about dosage regimes and you don't completely eradicate the germ concerned, a resistant organism is more likely to develop," says Dr Douglas Fleming, a GP and director of the Disease Surveillance Research Unit at the Royal College of GPs in Birmingham.
A recent survey for the Health Protection Agency found that 10% of people have unfinished courses of antibiotics tucked away in cupboards at home. Nearly half these people kept them in case of future need and 18% of these had taken the drugs without medical advice. The worst offenders tend to be better educated, younger, female, and more knowledgeable about antibiotics.
Dr Cliodna McNulty, the author of the study, says: "One explanation may be that well-educated people are confident that they can make their own decisions about antibiotic drug use, and this may be particularly relevant when their infection is less severe or appears to have cleared up."
If, however, you are not feeling better after completing a course of antibiotics, you should insist on having tests, says Dr David Livermore, an antibiotic resistance expert at the Health Protection Agency. "Ask to be informed of the bacteria found and the antibiotics to which they were resistant or sensitive," he says.
But he warns that it is important to be open-minded about taking antibiotics. "Expecting never to take an antibiotic is as inappropriate as wrongly demanding one for every cough or cold," he says. "If someone has a contagious infection, such as tuberculosis or gonorrhoea, they run a high risk of passing their infection on to other people."
