Any GP around the world who’s been in the game long enough is aware that one of the big challenges of the job is to manage patients’ daunting and often unrealistic expectations. In time slots that range from five to 20 minutes—depending on the geographical jurisdiction one is practicing in—GPs do their best to adhere to best clinical practice and to provide quality healthcare under conditions of often great uncertainty and clinical complexity, while at the same time trying to stick to time and avoid litigation. It is often a tall order, and in many countries, GPs are poorly paid and not sufficiently recognised by their peers, society, and politicians for the extremely important work we do.
Recently, two parallel surveys of 1000 GPs and a similar number of patients found that 55% of GPs felt under pressure, particularly from patients, to prescribe antibiotics, even if they were not sure that they were necessary. In the surveys, commissioned by Nesta—the organisation behind the Longitude Prize, which rewards those developing smarter ways of using antibiotics—44% of GPs also admitted that they had prescribed antibiotics to get a patient to leave the practice. What could be seen as even more striking is that about 45% of GPs had prescribed antibiotics for a viral infection, knowing that they would not be effective.
I am not surprised by these findings, reported in a News story on thebmj.com, because a substantial proportion of patients in the survey still thought that antibiotics should be used to treat viral infections. It is often difficult in practice to challenge these patient beliefs. Furthermore, refusing to prescribe an antibiotic when there is no clinical indication could potentially result in detrimental effects to the patient doctor relationship, especially if it is a longstanding one (and doctor patient relationships in general practice often last for decades), and the patient walks in the door with the expectation of an antibiotic prescription.
Clarithromycin is an antibiotic commonly prescribed in general practice, and often comes in handy when patients are allergic to penicillin and penicillin derivatives. But several antibiotics belonging to the macrolide class of antibiotics may delay cardiac repolarisation.
A cohort study of Danish adults who received seven day treatment courses of clarithromycin, roxithromycin, and penicillin V—which was recently published in The BMJ—reports that the use of clarithromycin was associated with a 76% higher risk of cardiac death, while no significant increased risk was observed with roxithromycin. In terms of absolute risk, clarithromycin would account for an estimated 37 excess cardiac deaths per 1 million courses. This paper may have implications for the prescribing practice of GPs around the world, particularly when it comes to patients who have strong risk factors for drug induced arrhythmia.
I often feel that there are many diseases endemic in certain parts of the world that doctors in Europe are not very likely to see during their career, unless they eventually travel or work there. This perception of mine is slowly changing with the massification of global travel. But if you’re still on holidays, or you are seeing patients with fever who have just returned from their holidays in an exotic part of the world, you may be interested in reading a BMJ blog written by two Spanish doctors. They mention that by July 2014, 104 cases of chikungunya (a viral disease transmitted by mosquitoes of the Aedes Aegypti and Aedes Albopictus variety) had already been reported in Spain. Most of the patients had travelled to the Dominican Republic.
Even though doctors tend to be more aware of dengue, which also usually gets more media attention, we should not forget about chikungunya. It has similar symptoms and the same mode of transmission when compared to dengue, but the clinically interesting part is that it causes severe pain in the joints and tendons for several days. And no, it is not treated with antibiotics.
Tiago Villanueva is the editorial registrar at The BMJ.