Margaret McCartney: Don’t be bullied into prescribing TamifluBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h417 (Published 22 January 2015) Cite this as: BMJ 2015;350:h417
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I thank MacPherson and colleagues for sharing their information, but I feel rather despondent - had NICE and PHE shared a vision of needing better data, it would have been entirely possible to make prophylaxis an 'only in research' recommendation. At this point - several years on - we would have had far better data, a reduction in uncertainty, and a better ability to share the pros and cons with patients. As it is, decent data seem further away, not nearer.
Competing interests: I wrote the article
Margaret McCartney advises general practitioners not to be bullied into prescribing Oseltamivir for residents of care homes (1). Her article calls for Public Health England to reflect on the limited resources available to GPs to assess and prescribe Oseltamivir, and on doctors to robustly question evidence of effectiveness and possible harms. Our experiences of managing outbreaks of influenza among care home residents in Cheshire and Merseyside, England, highlights some of the limitations in Dr McCartney’s arguments, and lends support to guidelines from Public Health England, the National Institute for Health and Care Excellence and recommendations from the Chief Medical Officer.
Between 19th December 2014 to 22th January 2015, 24 outbreaks of influenza-like illness were reported in care homes in Cheshire & Merseyside, with 178 symptomatic and 596 exposed individual residents (Figure 1). Care home attack rates have ranged from 11% to 100%. To date, 76% of care homes have had residents with positive nose and throat swabs for Influenza A (16/21 examined, with three care home results outstanding). Notably, all but one care home had very high rates of influenza vaccination coverage prior to onset of the outbreak. Rates of recent GP antibiotic prescription for symptomatic residents were high, as were hospitalisations of residents as a consequence of respiratory symptoms. Following initial assessments, antiviral treatment and prophylaxis was recommended for residents of 19/24 (80%) care homes, with four of the remaining having most recent onset of symptoms more than 48 hours previously, and one where clinical assessment deemed antiviral therapy to be not appropriate.
Dr McCartney is correct in emphasising that care homes are comprised of individual patients and that individual assessments are required (including renal function, to allow appropriate dosing of Oseltamivir). However, it is also true that care home residents, as a group, are among the most vulnerable to the consequences of influenza, especially when vaccination may not be completely effective. Guidelines recommending the use of antivirals for treatment and post-exposure prophylaxis against influenza are clear in recognising the limitations of the evidence available from randomised controlled trials, highlighting the lack of studies conducted among care home residents and individuals with severe infection. Indeed, observational studies evaluating these patient groups support the use of early antiviral therapy in improving outcomes (2). Additionally, antivirals, in conjunction with infection control measures, have an important role in interrupting transmission of influenza to prevent further infections.
Our experience shows that care home outbreaks can be identified rapidly, and that antiviral treatment and post-exposure prophylaxis can be organised efficiently. Central to our response has been collaborative coordination between Public Health England, community infection control nurses, general practitioners, clinical commissioning groups and NHS England.
It is unfortunate that general practitioners feel bullied into prescribing Oseltamivir. Individual patient clinical assessments should be undertaken in conjunction with knowledge of public health recommendations, which are based on local epidemiology and comprehensive review of evidence, cognisant of the vulnerability of care home residents to infection and adverse outcomes. Not considering antiviral prophylaxis for susceptible and vulnerable residents of care homes not only has implications for the individual, but also for the other residents.
1. Margaret McCartney: Don’t be bullied into prescribing Tamiflu. BMJ 2015;350:h417
2.. Zambon M. Developments in the treatment of severe influenza: lessons from the pandemic of 2009 and new prospects for therapy. Current Opinion in Infectious Diseases, December 2014, 27:6 http://www.ncbi.nlm.nih.gov/pubmed/25333476
Competing interests: No competing interests
The MDU is often asked about the medico-legal implications of guidelines and it might be helpful to clarify our advice. Members ask whether they are bound to follow guidelines, or if there can be circumstances where, after consideration of the individual patient's circumstances, it may be appropriate to depart from them.
Guidelines inform clinical practice but don't dictate it. They do not replace the knowledge and skills of clinicians. Doctors are expected to be familiar with any nationally recognised guidelines that are relevant to their specialty, as well as any local guidelines. This does not mean they cannot depart from guidance in specific situations when they consider it to be in the patient’s interests to do so.
Doctors must be prepared to explain and justify their decisions and actions, especially if they depart from guidelines produced by a nationally recognised body. It is also important to keep a record of the reasons for their decision, including any discussions with the patient.
Doctors are often concerned as to what might happen if something goes wrong and there is a clinical negligence claim following treatment where it was necessary to depart from guidelines. While the fact that a doctor can demonstrate that he or she followed widely accepted guidance, supported by expert opinion, can help towards the successful defence of a claim, it is equally possible to defend cases where a doctor did not follow guidelines because it was not in their patients' interests.
MDU members are welcome to contact us if they need specific advice on the use of guidelines.
Competing interests: No competing interests