AMR Voices Series: When the drugs don’t work

“I’m sorry, but the treatment’s not working.”

Author: Dr Ranj Singh, National Health Service (NHS) Emergency Paediatrician & TV Presenter, UK

These are the words that nobody wants to hear. Especially if you are the parent of a sick child. Yet increasingly, there is a real concern that we might have to start using them. In fact, some of us already have.

I work in Emergency Paediatrics. Infections are probably the commonest thing we see. There’s a naive sense of security in all of us that, no matter what, we will always be able to treat whatever infection it is. Meningitis, cellulitis, pneumonia, urine infections, even sepsis. We think we will always have something to use.

Parents and carers think the same. There’s no way that they’ve considered that their child might have a resistant infection. They either believe their child needs antibiotics (sometimes they expect them!), or they trust that whatever the cause we will have a treatment. Fortunately we’ve all made some progress in dealing with the former. Various education campaigns have taught people that most infections don’t need antibiotics at all. This isn’t just a success for the public. Healthcare staff are changing their practice too and not resorting to the ‘have some just in case’ approach, which many of us have been guilty of.

Strictly Come Dancing, Ceebies presenter, Dr Ranj Singh, wearing a blue smock shirt smiling at the camera

However, the message about the latter still hasn’t completely sunk in. When I started medicine 20 years ago, there was always a stronger antibiotic we could use if something didn’t work. We prescribed them like smarties. Now, I think twice before even starting them because I don’t want to contribute to the growing issue of antibiotic resistance.

I don’t ever want to tell a parent that we’ve run out of options. And I don’t want to live in a world where we have to routinely accept that there may be infections we just can’t treat.

Luckily we don’t see a huge amount of problematic antibiotic resistance in children in the UK. Often it’s picked up incidentally (for example, we routinely screen patients on admission or if they are in intensive care units). If picked up, we have systems to isolate, reduce risk and mitigate. But this may not always be the case, and we have to constantly remind ourselves to be vigilant in treating significant infections, yet at the same time, be mindful of over-treating and adding to the problem.

Unfortunately, deciding when antibiotics are required has never been easy – especially in children. The signs are harder to interpret, we can’t do lots of invasive and unpleasant tests because that’s not fair, plus we don’t want to take chances. It’s even more tricky during a pandemic. We’ve seen patients come in really sick with Covid-19, but equally, it could be sepsis due to a bacterial agent. Or, rarely, it could even be both.

The situation is further made complicated by children’s physiology. Interestingly, most children who get Covid-19 won’t get extremely unwell (which differs from older adults). So if they are really poorly, it’s probably not Covid-19 at all.

So we’ve tried to adapt by reinforcing guidelines (NICE) have great guidelines on the management of fever in kids and when to think about antibiotics), routinely calling parents to check on progress at home after discharge and then reassessing if needed (rather than giving that ‘just in case’ script), as well as improving our own diagnostic systems. Our department invested in point-of-care testing to get rapid blood results to help us differentiate the benign viral illness from the potentially serious bacterial infection. Our hospital laboratories also upped their testing capacity and capability. I like to think we’ve done a reasonably good job, but that’s because I work in a Trust that has the means and resources to do so.

Sadly this isn’t the case across all of the NHS.

At the same time, I’ve continued to use whatever platform I have to spread awareness amongst the general public. I worked on a campaign around AMR with Public Health England a few years back. The same messages still apply and I continue to dish out that advice: not everything needs them, don’t use them unless advised or essential, and let’s preserve them for as long as we can.

Sadly these messages seem to have gotten lost during the pandemic.

The focus worldwide on Covid-19 means that other infectious agents don’t get as much press or headspace right now. So we either run the risk of missing important infections, or treating inappropriately. Let’s be honest, more children will likely die from other infections than Covid-19 in 2020 (yes, that’s a bit of a simplified look, but the figures are true). But they’re still there and we need to be mindful we don’t forget them, whilst not slipping into bad habits again.

Maybe it’s time for a renewed focus on non-Covid-19 infections. Perhaps it’s time for more public health campaigns to remind us. However, these have to be balanced with guidance for everyone on when antibiotics are the right choice. In a Covid-19-dominated world, if a virus is responsible for us all making better antibiotic choices, then at least something good might just come out of all of this.

AMR Voices

Between July and November 2020, the Longitude Prize reached out to contacts around the world to connect with people living with – or who have experienced – drug-resistant infections, to better understand how the Covid-19 pandemic is shaping their lives. The team also spoke to medical professionals, doctors and pharmacists, to capture their perspectives. Combined, the stories shared in this report provide the reader with a first-hand look at how the antimicrobial resistance (AMR) and Covid-19 agendas meet and what people living with resistant infections or have overcome them think needs to be done. We will be sharing this as a series for the next few months. You can find all the stories published thus far here.

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