The Back of the Medicine Cabinet

Liam Shaw

The UK health secretary, Thérèse Coffey, has announced her intention to make it easier for people in England to get antibiotics. The plans are still vague, but involve patients being able to get some antibiotics directly from pharmacists without a GP prescription. Pharmacists in Scotland have for several years now been able to prescribe antibiotics for uncomplicated urinary tract infections (UTIs). Based on this data, the Department of Health and Social Care believe that such a move in England could save 400,000 GP appointments a year.

When we use antibiotics, we select for antibiotic resistance: the susceptible bacteria are killed and those that remain are the more resistant ones. Until 2014, the recommended antibiotic for initial treatment of uncomplicated UTIs in adults was trimethoprim. This is an old drug, synthesised at Wellcome Research Laboratories and first used in 1962 in Billericay, Essex to treat ‘a married woman aged 19’ who had a life-threatening pneumonia and a temperature of 40.6°C. She survived. In the 1970s, a study at the Royal Free Hospital found resistance levels of 3.2 per cent. It then became a widely-used treatment for UTIs. By 2016, one in three UTI isolates in England were resistant to it.

This high level of resistance led to a shift in prescribing guidelines to recommend a different drug, nitrofurantoin, for first-line treatment. Resistance levels for nitrofurantoin were only 3 per cent in 2016. Nitrofurantoin is an even older drug; the US patent was filed in 1950. Between 2016 and 2020, GP prescriptions in England for nitrofurantoin rose by 40.8 per cent, while those for trimethoprim fell. This switchover seems to have been associated with reduced trimethoprim resistance. It seems inevitable, however, that nitrofurantoin resistance will rise in response to higher use: the principle of natural selection still applies.

We’re going back to other old medicines, too: the cupboard is so bare we’re dusting off the discarded tins at the back. Colistin, an antibiotic which is highly toxic to the kidneys, was all but abandoned for clinical use in the 1980s in preference to less poisonous drugs. Since the 2000s it has become a treatment of last resort for multidrug-resistant infections.

Faced with growing antibiotic resistance, encouraging more permissive prescribing is a strange policy response. It was reported that Coffey had to be convinced by the chief medical officer, Chris Whitty, that antibiotic resistance was a major concern. She also disclosed during a meeting with civil servants that she had in the past given her friends leftover antibiotics from her own prescription, which is technically illegal. Doctors and scientists were quick to condemn the remarks.

Public understanding of antibiotic resistance remains poor thanks to misleading information. The fact that Coffey had leftover antibiotics suggests she didn’t complete the prescribed course, which will have shocked anyone who has been told that ‘completing the course’ helps to prevent resistance. But there’s no good evidence to support it. The simple equation is that all use promotes resistance, so reducing unnecessary use is vital.

Around half of women will have a UTI in their life. It is a painful and acute condition for which the symptoms are obvious, and antibiotics can help. It is therefore a good candidate for protocol-based prescribing in pharmacies – but that assumes the drugs work. The anthropologists Laurie Willis and Clare Chandler have described how antibiotics are used as a ‘quick fix’ for wider problems in healthcare systems such as inequality. Data from Sweden suggest that women of lower socioeconomic status have a higher risk of UTIs.

It may be foolish to look for ideological coherence in Liz Truss’s cabinet, but the idea that pharmacists could prescribe not only antibiotics but other types of medication seems in keeping with a society driven by self-interest. Pharmacists don’t necessarily lack the knowledge or ability, but undermining the role of GPs furthers the fragmentation of the NHS. A study this year showed that patient outcomes are better for people who keep seeing the same GP. Prescribing a course of antibiotics shouldn’t be an isolated consumer transaction; rather, treatment should be part of an integrated system with continuity of care.

Coffey’s handing on of antibiotics to a friend is in keeping with a vision of society that stops at the edge of one’s social circle. Unfortunately, antibiotic resistance is a wider problem. For bacteria, there really is such a thing as society.