Dear Prime Minister,
We applaud the government’s initiative of empowering community pharmacists to prescribe medicines for some common illnesses in order to reduce GP workload, cut waiting lists and alleviate the pressure on the NHS.
However, we strongly caution the government that unless it is implemented with due consideration given to antibiotic resistance, such an initiative could lead to unintended consequences that would reverse the gains it makes.
Antibiotic resistance describes the situation when bacterial infections no longer respond to the antibiotic medicines used against them. It has already been estimated to cause over one million deaths worldwide in 2019; if no action is taken, this toll may rise to 10 million by 2050, resulting in a cumulative cost of $100 trillion (equal to last year’s global GDP) to the world economy.
Failing to stem the tide of antibiotic resistance also jeopardizes the safety of procedures we rely on in modern medicine including transplantation, chemotherapy, and even child delivery.
Of the seven conditions in your initiative, three – ear infections, sinusitis, sore throats – can be caused by both bacteria and viruses, and viruses are the most frequent cause for all of them. Antibiotics, such as those that would be prescribed by pharmacists, are ineffective for viral infections, and could also contribute to the public health crisis and spread of antibiotic resistance.
How could one prevent inappropriate antibiotic use and the rise of antibiotic resistance that it would lead to? The answer to this question is simple: diagnostics.
The use of accurate and rapid diagnostics combined with patient symptoms will lead to better prescription decisions. A pilot study led by Imperial College London and the University of Manchester in patients presenting with symptoms of respiratory tract infection (RTI) has shown that, armed with a rapid diagnostic test to confirm whether an antibiotic is needed, community pharmacists could supply the correct medicine while greatly reducing the total number of inappropriate antibiotic prescriptions.
The use of rapid diagnostic tests has become the new normal during Covid-19, and we have a timely opportunity to capitalize on this by expanding their use in the context of other infections.
The two things required for the proposed initiative to work without inadvertently escalating antibiotic resistance and increasing the burden on the NHS are investment in the development and uptake of diagnostics and training in their correct use.
The government could use the tender process that was used to provide access to Covid-19 tests during the pandemic to procure the most accurate, yet competitively priced diagnostics specifically for supporting appropriate antibiotic prescribing: there are several hundred available or in development, according to a recently published list.
Incorporating the result of a diagnostic test in the pharmacist’s decision will ensure appropriate medicine use and follow both the World Health Organization’s guidance as well as the government’s own National Action Plan on Antimicrobial Resistance.
Ultimately, there is no silver bullet for addressing the overload on the NHS. Pharmacists would be far better supported in taking on the responsibility of prescribing medicines for these conditions by specific rapid diagnostic tests and appropriate training in their use. This will require upfront investment and may not yield immediate results.
However, implementing the initiative while accounting for antibiotic resistance gives it the best chance of avoiding extremely serious unintended consequences and simultaneously provides an opportunity to strengthen the UK’s healthcare innovation ecosystem as well as the NHS.
- Till Bachmann (Professor of Molecular Diagnostics and Infection, Infection Medicine, University of Edinburgh)
- Robert Beardmore (Professor of Mathematical Biosciences, University of Exeter)
- Esmita Charani (Reader in Infectious Diseases, AMR and Global Health, Institute of Systems, Integrative and Molecular Biology, University of Liverpool)
- Leonid Chindelevitch (Lecturer in Infectious Disease Epidemiology, School of Public Health, Imperial College London)
- Jonathan Cooke (Honorary Professor of Pharmacy, University of Manchester)
- Edward Feil (Professor of Microbial Evolution, Milner Center for Evolution, Department of Life Sciences, University of Bath)
- Elita Jauneikaite (Advanced Research Fellow in Bacterial Genomics and Epidemiology, School of Public Health, Imperial College London)
- Gwenan Knight (Associate Professor and co-Director of the AMR Centre, London School of Hygiene and Tropical Medicine)
- Kathryn Holt (Professor and Co-Director of the AMR Centre, London School of Hygiene and Tropical Medicine)
- Catrin Moore (Senior Lecturer, Infection and Immunity Research Institute, St. George’s University of London)
- Jack Olney (Executive Director, Center for Health Economics & Policy Innovation, Business School, Imperial College London)
- Charlene Rodrigues (Consultant in Pediatric Infectious Diseases, Imperial College Healthcare NHS Trust, Research Fellow in Microbial Genomics, London School of Hygiene and Tropical Medicine)
- Nicole Wheeler (Turing Fellow, Institute of Microbiology and Infection, University of Birmingham)
- Doris-Ann Williams (Chief Executive, The British In Vitro Diagnostic Association)
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