I studied Medicine at St Thomas’s hospital and then trained in public health and epidemiology at Public Health England and the London School of Hygiene and Tropical Medicine. I did my higher degree at UCL
Asides from my medical degree and a Fellow of the Faculty of Public Health, a Fellow of the Royal Society of Biology, my MD was in use of electronic health records to understand common infections.
I have worked both at Public Health England for a number of years in the Respiratory Section, Nottingham University as a Lecturer in Public Health and Joined UCL as a Senior Lecturer in Infectious Disease Epidemiology in 2001.
I currently am Professor of Infectious Disease Epidemiology at the Farr Institute of Health Informatics at UCL where I lead a group of researchers focussing on influenza, acute respiratory infection, tuberculosis, antimicrobial resistance, healthcare associated infection, viral genomics, the link between infection and chronic disease and infections in socially marginalised groups such as the homeless, drug users and prisoners.
University College London
Tell us about your work on antimicrobial resistance?
My work on antimicrobial resistance has focussed on using electronic health records to understand prescribing of antibiotics. Without these records it is impossible to see how often antibiotics are being prescribed for different conditions. The work shows that guidance on limiting antibiotic prescribing for minor infections has had very limited impact and that GPs continue to prescribe to over 50% of minor respiratory infections where the guidance would suggest this is usually not necessary. There is a great deal of inter-practice variation with some prescribing much less frequently than other, suggesting important scope for change. We are currently conducting research to understand which patients get lots of antibiotics. This seem stop be showing us that a small proportion of patients account for a high proportion of the antibiotics prescribed. The patients with lots of prescriptions tend to be more likely to have underlying chronic illness such as Chronic Respiratory disease or diabetes, or are smokers. We have also conducted research trying to understand how frequently the more severe complications of minor infections are and to examine the impact of antibiotics on this and estimate the numbers needed to treat to prevent one complication. For example our paper looked at quinsy and rheumatic fever following sore throat, mastoiditis following otitis media, pneumonia following upper and lower respiratory tract infection. The risk of such complications was very very small (and virtually non-existent for rheumatic fever in recent times). Antibiotics did decrease these already very small risks but we estimated that around 4000 courses of antibiotics needed to be prescribed to prevent a single complication. A notable exception to this was the risk of pneumonia following lower respiratory tract infection where the numbers needed to treat were considerably lower. We hope that this sort of work can provide some reassurance that it is safe not to prescribe but also focus attention on situations such as chest infections in the elderly where antibiotics are more justified. We have also conducted research showing a clear link between GP antibiotic prescriptions and resistance in urinary tract infections. Prescribing increases the risk of resistance in the individual receiving the prescription, but over a period of a few months the risk drops back down again. Interestingly, a high proportion of resistance occurs in people without a history of antibiotic prescription in the last few years suggesting that resistance can spread between people readily. We think there is a need for much more research of this type but currently primary care records do not contain good data on resistance so this would require large scale record linkage studies. We have been doing research looking at the risk of antibiotic resistant urinary tract infections in nursing homes and can see a marked increase in risk compared to elderly people living in the community. Whilst antibiotic prescribing data in primary care is of good quality this is in stark contrast to data available in secondary care. Most hospitals do not collect this information electronically, but preliminary work shows around 20% of inpatients are on intravenous antibiotics at any one time. There is a need for much better collection of antibiotic prescription data i hospitals to understand this better. I have also led research on the community burden of respiratory infection to understand how much of it is self-managed without consulting the GP. For most respiratory infections only about 10% of people consult with others self managing their symptoms with over the counter medicines. We have been looking at this for sore throat and we can see that the decision to consult is driven by duration and severity of symptoms rather than other factors such as social class. We think there is important further scope for encouraging people to safely self manage their illness without going to their GP but note there has been very little research on interventions outside of the primary care setting.
How does your work make things better for patients?
We hope to raise awareness of the overuse of antibiotics and inform debate amongst GPs, the public and policy makers. Our work clearly demonstrates that we could safely reduce antibiotic usage and highlights that respiratory infections are almost always minor self limiting conditions that do not need an antibiotic and do not need a visit to the GP. We do recognise that these decisions can be difficult but hope that our work will contribute to a societal reevaluation of our relationship with antibiotics such that we treat them as a precious and limited resource that should be reserved who need them.
What are the best 3 things you've seen in Primary Healthcare to combat antimicrobial resistance?
I was very impressed by the TARGET antibiotics toolkit and it’s focus on communication of risk to explain why antibiotics are not being offered.