War on superbugs is putting elderly people at risk of sepsis





The war on superbugs is putting elderly people at risk of dying with sepsis, experts have warned.

GPs are under intense pressure to reduce the number of antibiotics they give out, in a bid to stop infections becoming resistant to treatment.

The NHS offers local health boards additional payments if they bring down their prescription rates, and doctors are in turn pressured to give drugs to fewer patients.

GPs have been repeatedly told they risk creating a ‘public health catastrophe’ by doling out too many drugs – and at one point in 2015 they were even warned they could be struck off for overprescribing.

A study published in the British Medical Journal suggests this pressure may be putting vulnerable people at risk.

The findings suggest that older adults (especially men aged over 85) should start taking antibiotics as soon as possible after diagnosis to prevent serious complications

The findings suggest that older adults (especially men aged over 85) should start taking antibiotics as soon as possible after diagnosis to prevent serious complications

It reveals elderly people are regularly being denied antibiotics for infections, raising their chance of sepsis eight-fold and doubling their risk of death.

The study contains the biggest acknowledgment to date that the campaign against overuse of antibiotics may be having disastrous unintended consequences.

The Royal College of GPs welcomed the study, warning that family doctors are being put in an impossible position.

It said GPs are ‘publicly vilified’ for too-readily giving out drugs, but know that witholding the drugs can be a ‘matter of life and death’.

The new study, led by experts at Imperial College London, assessed the medical records of 157,000 English pensioners diagnosed between 2007 and 2015 with urinary tract infections (UTIs) – one of the most common reasons for antibiotics to be prescribed.

The academics found 22,500 people – about 7 per cent of the total – were not given antibiotics at all.

And another 19,300 – some 6 per cent – had to go back to their GP a second time before they received a prescription, with a delay of seven days.

PATIENTS ARE TAKING ANTIBIOTICS FOR TOO LONG 

Patients who manage to get a prescription for antibiotics are given them for too long, researchers say.

GPs often issue antibiotics for longer than the duration set down by Public Health England.

Experts from the University of Oxford and Brighton and Sussex Medical School examined antibiotic duration for 13 infections from 2013 to 2015.

The conditions included ear infections, sinusitis, sore throats, coughs, bronchitis, pneumonia and cystitis.

Antibiotic treatments for upper respiratory tract infections, ear infections, coughs and bronchitis accounted for more than two thirds of the total prescriptions.

Of these, 80 per cent or more of the treatment courses exceeded guideline recommendations, which are set at five days for most respiratory and ear infections, researchers found.

More than half of the antibiotic prescriptions for cystitis in women were also for longer than the recommended three days.

Those who were not given antibiotics were at an eight-fold increased risk of developing sepsis compared to those given antibiotics straight away, the researchers found.

And they were twice as likely to die as a result.

Of those who had a delayed prescription – a common tactic used to reduce antibiotic use – the risk of sepsis increased seven-fold and the risk of death rose 16 per cent.

The researchers estimated that for every 37 patients not given antibiotics one case of sepsis would occur that would not have been seen with immediate antibiotics.

The academics stressed that even this increased risk remains small – those who were not given antibiotics had just a 2.9 per cent risk of developing sepsis.

But they said pressure on GPs is driving the problem.

‘The question remains as to why a significant proportion – about 7 per cent – of vulnerable older patients had a diagnosis of UTI but were not prescribed antibiotics,’ the academics wrote.

‘It could be patient or doctor choice, but it is also possible that antimicrobial stewardship programmes and quality premium payments are encouraging a culture of more judicious antibiotic use.

‘Public Health England recently reported a 13.2 per cent reduction in antibiotic prescribing in primary care between 2013 and 2017.’ They added: ‘A decline in antibiotic use may… harm vulnerable older populations who are already more likely to develop UTI related complications and bloodstream infection.

‘Our findings suggest that GPs consider early prescription of antibiotics for this vulnerable group of older adults in view of their increased susceptibility to sepsis after UTI and despite a growing pressure to reduce inappropriate antibiotic use.’ 

Study author Professor Paul Aylin, whose team’s work was funded by the research arm of the NHS, said: ‘Although antibiotic prescribing must be controlled to help combat the increasing problem of antibiotic resistance, our study suggests early use of antibiotics in elderly patients with UTIs is the safest approach.’ 

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, said family doctors are being put in ‘an incredibly difficult position’.

‘We are under huge pressure not to prescribe – and publicly vilified when we are deemed to do so too readily – yet, we know that in some cases antibiotics are a matter of life or death,’ she said.

‘Getting the balance right every time is extremely challenging.’ She acknowledged the ‘huge threat’ of antibiotic resistance and said the drugs are not a ‘cure-all for every illness’.

But she added: ‘Antibiotics are also important, life-saving drugs and it’s vital that doctors are not deterred from using them when they think it’s appropriate to do so.’ 

Experts have long warned ‘antibiotic prohibitionists’ may deprive patients from getting vital treatments. 

Professor Alan Johnson from Public Health England, who collaborated on the research, defended the drive to reduce use of the drugs.

‘Antibiotic resistance is a major threat to public health that is being driven by the overuse of antibiotics,’ he said.

‘Current recommendations suggest healthcare professionals take a number of different factors into account when deciding whether to prescribe antibiotics immediately or consider deferring antibiotics for patients with a suspected urinary tract infection.

‘This study highlights the importance of taking age into account when making clinical decisions about antibiotic prescribing in order to reduce the risk of complications. 

‘This work will help doctors target antibiotic use more effectively and improve patient wellbeing.’

WHAT IS SEPSIS?

Sepsis occurs when the body reacts to an infection by attacking its own organs and tissues.

Some 44,000 people die from sepsis every year in the UK. Worldwide, someone dies from the condition every 3.5 seconds. 

Sepsis has similar symptoms to flu, gastroenteritis and a chest infection.

These include:

  • Slurred speech or confusion
  • Extreme shivering or muscle pain
  • Passing no urine in a day
  • Severe breathlessness
  • It feels like you are dying
  • Skin mottled or discoloured

Symptoms in children are:

  • Fast breathing
  • Fits or convulsions
  • Mottled, bluish or pale skin
  • Rashes that do not fade when pressed
  • Lethargy
  • Feeling abnormally cold

Under fives may be vomiting repeatedly, not feeding or not urinating for 12 hours. 

Anyone can develop sepsis but it is most common in people who have recently had surgery, have a urinary catheter or have stayed in hospital for a long time.

Other at-risk people include those with weak immune systems, chemotherapy patients, pregnant women, the elderly and the very young.

Treatment varies depending on the site of the infection but involves antibiotics, IV fluids and oxygen, if necessary.

Source: UK Sepsis Trust and NHS Choices



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