It’s not cancer
It was interesting to see that Antimicrobial Stewardship made it to the front page of the Sydney Morning Herald (hat-tip to Krispin Hajkowicz – twitter – for letting me know it was actually on the front page), although I’m equally interested in the fact that it occurred through the lens of political controversy over the New South Wales Health Minister (Jillian Skinner). New South Wales Health has been in the media recently about the ongoing controversies about chemotherapy under-dosing and the recent tragic death of a neonate (and ongoing disability in another) associated with a nitrous oxide / oxygen mix-up.
The New South Wales Opposition clearly smells blood, and the media are amplifying the story and have obviously gone digging, and have turned up what is obviously one of Royal North Shore’s antimicrobial stewardship reports. As you would expect for media coverage of this sort of report, it cherry-picks the worst number (35% compliance with some aspect of the stewardship policies – it doesn’t say which part) and buries later in the text that there have been “significant improvements” and that RNS in fact passed its accreditation with merit.
None of this comes as any particular surprise to those of us that work in the field. Overall at a national level, around 30% of antimicrobial prescriptions are “inappropriate”, when assessed by antimicrobial experts against the national guidelines. Note that the main reasons for inappropriateness are unnecessary, overly broad or prolonged therapy (around 60% of inappropriate prescriptions) and that “under-treatment” – that is, too-narrow-spectrum or incorrect prescriptions are much rarer (around 5% each; in 5 years of doing these audits in my hospital, I’ve found only two patients who were under-treated).
Now it’s easy to say “well, yes, but this isn’t cancer chemotherapy under-dosing, the consequences are much less serious”. At an individual level, this may well be true (I’m not really across all the details of the chemo-dosing stuff) – I’m certainly not trying to down-play the importance of it.
But something that everybody needs to remember is that your lifetime risk of getting a cancer diagnosis is somewhere near 50/50. Some people will be unlucky enough to get more than one, but on average, it means that about half of you will, at some stage, get a cancer somewhere. This might include “minor” ones like skin cancers which can be surgically cured, or could necessitate chemotherapy.
A report that I completed last year for my health-service looked at the burden of disease due to infection. I found that 13% of our hospital admissions were primarily for a diagnosis which was an infection, and that these admissions accounted for 15% of the costs of our health service; almost $50million / year. Including patients with infectious secondary diagnoses, these figures increased to 44% of patient-days and 38% of costs.
Outside of hospital, the Antimicrobial Use and Resistance in Australia (AURA) report found that nearly half of Australian citizens were prescribed an antibiotic in 2014. I’m sure that the lifetime prevalence of being prescribed an antibiotic must approach 100% (although there’s obviously no data on this, like there are with cancer registries).
So again, I’m not down-playing the disease burden of cancer, or the fears that these patients (or their families) must surely have that their cancer will come back, or that their survival was needlessly shorter due to the dosing scandal. But overall, the threat to people from antimicrobial resistance (for example, by having your joint replaced and it getting infected with a bug that isn’t covered by the antibiotic prophylaxis) is much greater than that posed by chemo dosing; or cancer generally, and certainly of dying of a tragic error with an oxygen cylinder.
I look forward to antimicrobial resistance getting front-page media time as a public health issue in its own right, rather than as a “gotcha” from the political editor detailing the calls to sack an embattled minister. Sadly, I think there are only a few specialist health journalists left who could do it justice; their numbers have been whittled down and replaced with FOI-warriors and live-tweeters.