8 minute read
NEWS ANALYSIS
The NHS is worried about the emergence of strains of bacteria such as MRSA and C. diff that have developed resistance to many antibiotics. The biggest fear is that new strains may emerge that cannot be treated by any existing antibiotics. Health organisations across the world are therefore trying to reduce the use of antibiotics, especially for conditions that are not serious (NHS, 2019).
It might not seem immediately apparent why this is a concern for podiatrists – most don’t prescribe antibiotics (see What proportion of the profession can prescribe antibiotics? on page 11) and the ones that do are very cautious about it. However, Covid-19 restrictions have reduced the amount of face-toface interactions between clinicians and patients with foot problems and a problem that already existed is getting worse.
The root of the problem
It starts with the patients, says Katrina Waller, who has more than 34 years of experience in podiatry. Before setting up
ANTIBIOTICS
Resistance isn’t futile
Covid restrictions have increased the risk of overprescribing and the incorrect prescription of antibiotics to patients, but what can podiatrists do?
Compleet Feet in Hampshire in 2007, she worked for 12 years full-time at the Ministry of Defence’s Royal Hospital Haslar until its closure. ‘As a podiatrist, it’s frustrating that the public doesn’t seem to be aware that they should see the appropriate health professional,’ says Katrina. ‘If patients have a problem with their feet, they tend to make a GP appointment. If they have an ingrown toenail, for example, the GP would take a look and probably prescribe antibiotics.’
Jacob Penkethman agrees. The principal diabetes podiatrist and independent prescriber at Cambridgeshire and Peterborough NHS Foundation Trust says it’s unusual to fi nd anybody who presents with an obvious ingrowing toenail who hasn’t been prescribed antibiotics from their primary care physician, or other non-podiatrist prescriber. ‘As many symptoms of an ingrowing toenail can mimic infection, it usually leads to antibiotics being prescribed inappropriately,’ says Jacob. ‘For clinicians who aren’t used to seeing them, their fi rst step will be to prescribe antibiotics.’
The problem even extends to post-nail surgery. ‘If we perform surgery and apply phenol to stop the nail from growing back again, this can also mimic signs of infection, which leads to GPs initiating antibiotics for a healthy healing wound,’ he says. ‘From an ingrowing toenail standpoint, there is a massive overuse of antibiotics in my opinion.’
Covid impact
Lockdowns have exacerbated the situation, says Katrina: ‘It’s been diffi cult to get a face-to-face appointment with a GP. When set up and orchestrated well, a virtual appointment can suffi ce for many medical problems, but there are many fl aws: no physical examination, no observation of patient mood, and not being able to do simple diagnostic tests.
‘Patients are left at risk and issues can be missed. Overprescribing of antibiotics is just one of the issues. Covid may have brought this to the fore, but it was apparent before March last year. It’s not only ingrown toenails, it might be a broken chilblain or bursitic corn. It’s a concern because as podiatrists we have so many dressings to mitigate the need for antibiotics.’
Jacob, who has worked across two trusts since the pandemic began, has also seen an increase in ‘unnecessary’ antibiotic prescriptions. ‘This was much less common pre-Covid,’ he says. ‘This is because clinicians sleep easier at night having been overcautious, as opposed to missing a possible infection which could lead to amputation. This is particularly true for patients with a history of diabetic foot problems. Therefore, in my opinion, virtual consultations are not the best way to assess patients, as they can lead to elements being missed – for example, ischaemia – which can have detrimental consequences.’
Covid also had an impact through the cancellation of non-urgent hospital appointments and the reluctance of many high-risk patients, who would have routinely been seen for long-standing ulcers or preventative management and observation, to attend face-to-face appointments.
‘As a consequence,’ says Jacob, ‘many patients presented at crisis point when their infections were much more severe. This often meant that longer courses or multiple combinations of antibiotics were required, which may not have been necessary if the infection had been reviewed sooner.
‘Granted, their infection would still have needed antibiotics; however, some of these mild infections could have been managed with lower doses and shorter courses.’
Other complications
While there is no real safe substitute for a face-to-face consultation, patients today can send photographs or show their foot problems on screen. However, fi rewalls sometimes block attachments and a screen image may not show the full extent of a problem.
Debbie Coleman, diabetic foot coordinator at Homerton University Hospital in East London, was approached recently by one of the hospital’s vascular access nurses who wanted to arrange antimicrobial stewardship training for the podiatry team, as it requires an interprofessional eff ort across the continuum of care.
The aim of the training is to improve patient outcomes and reduce the spread of multiresistant organisms by modifying prescribing practices and reducing the use of antimicrobials, particularly antibiotics. Debbie says: ‘If antimicrobial resistance (AMR) isn’t addressed, it is estimated that 10 million people globally per year will die due to it by 2050. This is 1.8 million more than cancer. Currently, 33,000 people die each year from antimicrobial infections across Europe alone’ (Cassini et al, 2018; O’Neill, 2014).
She adds that the training was designed more for healthcare professionals from a nursing or medical background working in an acute setting, but it still provided an excellent overview of the problems of AMR. She adds: ‘It was also a good reminder to the team about the importance of thorough assessment of the patient with suspected infection and the need to take appropriate samples early in treatment.’
The race against time
There are
42
antibiotics in clinical development
11
have the potential to treat WHO’s critical threat pathogens
33
thousand people die each year from antimicrobial infections across Europe alone
10
million people a year could die around the world due to antimicrobial resistance by 2050
What proportion of the profession can prescribe antibiotics? 3.5%
can prescribe as independent prescribers
4%
can prescribe as supplementary prescribers
50%
of HCPC-registered podiatrists are POM-A and POM-S annotated
Another issue facing remote medicine is that antibiotics are often prescribed without appropriate microbiology. Jacob says: ‘Not all antibiotics cover every infecting organism. Flucloxacillin is often prescribed but it won’t cover complex anaerobic and gram-negative infections and patients won’t have up-to-date swabs and tissue samples to aid prescribing decisions.’
Some patients can be treated for weeks with antibiotics that may be ineffective or resistant to the infection organism. Jacob also explains that if a patient requires courses of antibiotics for six weeks or longer, it is sometimes not until week four or fi ve that somebody conducts a swab or tissue sample that fi nds the infection is resistant to the antibiotics that they’re taking. ‘We often fi nd that our patients with chronic long-term infections are resistant to multiple antibiotics,’ Jacob says. ‘It’s usually because they’ve had an array of antibiotics that have not been targeted appropriately, or they’ve been taking them for so long that it has led to competitive overgrowth of other species and polymicrobial infection.’
With a lack of face-to-face contact, Jacob says that his team relies to some extent on what patients tell them. ‘There are certain red-fl ag words. These include “red”, “hot”, “swollen” and “infection”. If picked up by an administrative member of the team, they would highlight it to the diabetes team or one of the advanced podiatrists, who would then make a decision. If there were any concerns, the patient would be offered a face-to-face appointment within 24 to 48 hours.’
What can the profession do?
With regard to ingrowing toenails, Jacob says he’s had many conversations with GPs. ‘Much of the problem comes from a lack of understanding about referral processes,’ Jacob says. ‘Some GPs don’t think that podiatry is commissioned to provide ingrowing toenail surgery. Delayed referrals are extremely common. I’ve seen patients that have had as many as eight courses of antibiotics in one year before being referred to podiatry.’
RESOURCES
NICE guidance on antimicrobial stewardship: bit.ly/NICE-antimicrobial-stewardship NICE systems and processes for eff ective antimicrobial medicine use: nice.org.uk/guidance/NG15 Government antimicrobial resistance resources: bit.ly/Gov-AMR-resources
Free e-learning and resources from e-Learning for Healthcare: bit.ly/eLfH-AMR Review of clinical eff ectiveness of antibiotics: bit.ly/reviewantibiotic-eff ectiveness
Katrina says that it’s diffi cult to speak to GPs. ‘I would love our profession to work more closely with GPs to let them know that patients should really try to come to us.’ During Covid, she visited all the GP practices in her area, offering to help them with any issues they had with foot care. ‘I even offered reduced rates. They never took me up on it. Perhaps they would be more receptive if we were NHS, but they don’t tend to work very well with private practitioners.’
Jacob acknowledges that his own antibiotic knowledge was limited when he fi rst qualifi ed and he didn’t really appreciate concepts of antimicrobial stewardship until his master’s degree. ‘When I mentor staff,’ he says, ‘the understanding of antibiotics and resistance is low. I would certainly support more training on antibiotics and resistance, particularly for undergraduate students.’
Katrina says that the increase in antimicrobial stewardship programmes to reduce antibiotic prescriptions in recent years can only be a good thing (see Antimicrobial stewardship at London’s Homerton Hospital, left): ‘Bacteria is becoming resistant to many of the older antibiotics, making it harder to treat bacterial infections,’ Katrina says. ‘In addition, Covid-19 is a viral infection that weakens the body to cause secondary bacterial infections. Strong antibiotics are required to fi ght these life-threatening infections. If they don’t work on a patient because they have developed antibiotic resistance, then we have a real problem.’
