Antibiotic Request
Jenny Hammersmith, age 6 months
Name: Jenny Hammersmith
Age: 6 months
Today’s appointment was booked by mum, and she will be attending without Jenny.
Past Medical History:
Admitted with Bronchiolitis one month ago. Required an in-patient stay of 24 hours.
Medication History:
Nil
NKDA
Medical Notes: Nil
Investigation Results: Nil
Presenting complaint:
“I need your help with some antibiotics, should be a quick one for you!”
You are Jenny’s Mum and will be attending without Jenny today at the GP surgery, as you desperately need their help.
Open History: You have booked an appointment with the GP as you really need their help. You have been invited to your brother’s wedding out in Mauritius. This was booked almost 12 months ago, and you really wish to attend - as he is the only brother you have. However, recently Jenny was ‘seriously ill’ requiring a stay in hospital, and needing oxygen for a few hours. You are really very grateful to the GP who saw her and sent her in, and you’re sure that they saved her life. The reason you have come today, as that Jenny needs antibiotics just in case she gets poorly again whilst out in Mauritius, as the place you’re going to is quite remote, and you’re worried about the availability of health care out there.
History if asked: It was around one month ago now that Jenny was very unwell, she started out with a cough / cold, but quickly you noticed that she stopped taking her milk, and she appeared breathless, and her heart rate was very fast. You called this fantastic GP surgery up and saw Dr Ruby, who was fantastic and got Jenny admitted into paediatrics. When there, they gave her oxygen and helped her with her feeding. You don’t know what else she had, but you were told that she didn’t have antibiotics. You were informed she had something called “bronchiolitis”. So harrowing was your experience, that you posted on both ‘Mumsnet’ and ‘Netmums’ where you were reliably informed by others on those websites that antibiotics would have stopped her getting as ill as she did. She has now recovered well, but you don’t want this happening again, so she needs antibiotics to take with her to stop this from happening again.
Social history: Nothing significant of note
Past Medical History: Jenny is up to date with all of her immunisations, she has no other significant past medical history and had an uneventful birth. She has so far been developing normally and has hit the required milestones.
You have booked the whole family to see the nurse in a week for immunisations.
Ideas: You are concerned that any cough / cold will turn into another severe illness. You also feel that antibiotics are the answer to this, as Jenny didn’t have antibiotics last time, and she got a lot worse, to the point of needing hospital admission. You can’t cancel the trip as it’s your brother’s holiday.
Concerns: If Jenny gets another cold, it will worsen just like the last one, and that you won’t be able to access the health care you need out there due to the remoteness of the place, and the inherent language barrier.
Expectations: As per the advice you have received on Mumsnet and Netmums, you are expecting a quick consultation and for someone to prescribe you some antibiotics. You have read on the practice website that such prescriptions may be classed as a ‘private prescription’ and you don’t mind paying.
How To React: If the Doctor is not empathic, and offers little in the way of suggestions, then you will get angry and demand the antibiotics, if they refuse, you will say to them that you will simply book an appointment with someone else and keep doing this until you get antibiotics, as Jenny is the most ‘precious thing in the world to you’, and that no one is going to stand in your way of keeping her safe. Any suggestion to cancel your holiday will be met with hostility, and you will feel as though the Doctor simply doesn't understand you nor your predicament.
If the Doctor is empathetic however, and explains that bronchiolitis is viral, and that antibiotics won’t help. If they also suggest that you try ringing the hotel in advance, or checking with travel insurance, as they can often let people know what the medical facilities are like, and what is available locally, then you will feel happier. You will also accept that antibiotics were not the miracle cure you were led to believe.
Data Gathering & Diagnosis
Positive Indicators
Data gathering was gathered systematically and in an organised way, and was guided by possibility of disease.
Relevant red flags were considered for an unwell child.
Psychological or social information to place the problem in context were completely identified (upcoming holiday)
Adopts a structured and informed approach to problem-solving
Asks about why the mum wants the antibiotics, and explore her health understanding
Attempts to understand the underlying concerns that Mum has, and why she has them.
Negative Indicators
Makes immediate assumptions about the problem
Is disorganised/unsystematic in gathering information
Data gathering does not appear to be guided by the probabilities of disease.
Fails to ask about Red Flags for the presenting complaint (unwell child)
Fails to ask about social or past medical history
Fails to ask about why mum has concerns, and doesn’t seek to understand Mum’s worries.
Clinical Management & Medical Complexity
Positive Indicators
Demonstrates the ability to formulate safe and appropriate management options which includes effective prioritisation, continuity and time and self-management.
The management plan was reflective of current best practice
The prescribing of medications was reflective of current guidelines and best practice (see management section for guidance)
Adequate arrangements for safe and sensible follow-up, continuity, and safety netting (informing Mum what to do should baby become unwell abroad)
Management options were prioritised in regard to perceived risk
Time was spent educating Mum about bronchiolitis, including that it is viral, and debunking inaccurate information regarding antibiotic use to avoid further viral infections
Negative Indicators
Fails to consider common conditions in the differential diagnosis
Does not suggest how the problem might develop or resolve
Fails to make the patient aware of the relative risks of different approaches
Follow-up arrangements are absent or disjointed
Prescribes antibiotics for preventative use
Fails to empower patient with knowledge about viral infections and the lack of evidence for prophylactic antibiotic use
Relating to Others
Positive Indicators
Appropriate or sufficient demonstration of respect/sensitivity during the consultation
Non-judgemental in approach
Sufficient exploration of the patient’s agenda, health beliefs and/or preferences
Sufficient evidence of active listening and verbal and/or non-verbal communication skills
Explanations were sufficiently adapted to the patient’s context and level of understanding
The management plan was sufficiently shared for the patient to understand what they needed to do or the next course of action
Reaches shared understanding with patient
Uses various consultation approaches to overcome communication barriers
Effective negotiation concerning health beliefs and/or behaviours, especially her belief about antibiotic use for viral infections
Adequate ownership of any decisions made
Negative Indicators
Doesn't enquire about patients Ideas, concerns and expectations
Takes a doctor centered approach towards management
Uses an explanation that is filled with jargon, or forgets to explain at all
Doesn't show any sympathy / empathy towards the patient's situation
Fails to empower patient
Is not empathetic towards problem
Fails to recognise the impact of the problem on the patient or their family / dependants
Key Issues
Awareness of NHS policy on prescribing prophylactic antibiotics for patients going abroad
Maintinaing an empathetic approach to the patient despite them beign demanding.
Explanation
Prescribing antibiotics "just in case" of a bronchiolitis recurrence isn't recommended because antibiotics don't work against viruses, which are usually the cause of bronchiolitis. Overusing antibiotics can lead to resistance, making them ineffective when truly needed. It's crucial to use antibiotics only for confirmed bacterial infections. If your baby shows signs of illness while away, it's best to consult a local doctor who can assess whether treatment is needed.
Management:
This is a tricky case, and it all revolves around trying to educate and manage the expectations of a (naturally) worried parent. This case also highlights the danger of using the Internet to gain medical advice.
To pass this case, a number of elements must be successfully navigated. To start with, one must address the mother’s concerns.
Her first concern is that another cold / cough will turn into a life-threatening illness if left unchecked and if not given antibiotics. This is a belief that she has gained through the use of the internet. This should be easy to challenge, as we are all aware that most coughs/colds are due to self-limiting viral illnesses. It would also be appropriate to point out that bronchiolitis is also caused by a virus, and that antibiotics would not have helped Jenny, she would have required medical services with or without antibiotics.
Her second concern is about accessing health care abroad. This can be a concern for many individuals, either due to a lack of familiarity with the country/place they are visiting, or the inherent language barrier involved with travelling. Often it can be helpful to advise patients to try ringing up the hotel / resort ahead of time to ask about what medical services are available locally. Another way of accessing this information might be through the travel insurance company. This may help alleviate some of the mother’s concerns.
The legalities of prescribing ‘just in case’ medication.
Guidelines published by the General Practice Committee (GPC) back in 2013 (see here) state that: “For drugs which are being issued solely in anticipation of the onset of an ailment whilst outside the UK, but for which the patient does not require treatment when the medicine is prescribed”, can be prescribed, but must be a private prescription. They go on to stipulate that “Any doctor can write a private prescription for a patient if they feel it is clinically appropriate and they are happy to take responsibility for that prescribing decision.”
This latter sentence is very important. The GMC expand on this stating:
GMC on prescribing:
1) Doctors are responsible for the prescriptions that they sign and should be prepared to justify any decision to prescribe.
2) Doctors do not have to prescribe treatments that they do not consider to be of overall benefit to patients, even if patients ask for such treatments. However, they should discuss the request with the patient, explain their reasons and advise the patient of their right to seek a second opinion.
3) Doctors should, together with the patient, make an assessment of their condition before deciding to prescribe a medicine.
4) Doctors should explain to patients the likely benefits and risks of treatments, including side effects.
5) Advice should include how to take the medicine and how to adjust the dose.
6) Doctors are responsible for the safe monitoring of medication, including blood tests. If doctors prescribe for patients who are overseas, they should consider how the condition may be safely monitored. They should also consider whether they have appropriate professional protection to treat patients overseas.
Expanding further on this, the advice from Medical Protection services stipulates that doctors should be aware of the risks of prescribing “just in case” medication – as it would be safer and preferable for the patient to seek medical review if they become unwell abroad.
We could therefore surmise, that It might be difficult to justify prescribing “just in case” antibiotics in this case, as if the baby came to harm abroad, the prescribing Doctor would not have been able to make an adequate assessment at the time, and would have no way of knowing if antibiotics was the right course of action.
I'd like to share a personal experience that highlights the importance of this guidance. A 60-year-old patient, prone to diverticulitis flare-ups and often requiring antibiotics, requested a "just in case" prescription for an upcoming trip abroad. Following standard medical advice, I declined. While abroad, the patient experienced stomach pains and sought medical attention. The local GP suggested hospitalisation. She was not happy with this, and asked the local GP to ring me to seek my approval to over-ride this advice. Upon consultation with me, I upheld my decision against prescribing antibiotics against the advice of a local clinician who had examined her. The patient was eventually admitted and diagnosed with a ruptured colon and a significant abscess, requiring surgery and intensive care. This situation illustrates the potential dangers of prescribing antibiotics without thorough evaluation, emphasising the critical nature of adhering to medical guidelines for patient safety. Had she had antibiotics she would have almost certainly taken them instead of seeking appropriate healthcare advise.
Conclusion
To conclude, it would not be considered good practice to prescribe ‘just in case’ antibiotics for this baby. This may not apply to every situation however, in other circumstances it might be different - for example a patient with long standing COPD, who has “rescue antibiotics and steroids” at home. For those individuals, who understand their condition, and know when to take their medication, prescribing “just in case” antibiotics and steroids would be more justifiable, and likely appropriate.
Further Reading:
Last Updated: February 2024