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Technology, not instinct, should guide antibiotic prescribing. A Q&A with Herman Goossens

Quick tests for bacterial infections are out there, but insurers won’t cover them and doctors are reluctant to use them. 

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Herman Goossens, Value-Dx project coordinator, tells us that cutting down on unnecessary prescriptions of antibiotics would help reduce rates of antibiotic resistance. But even though the technology exists, it’s not in widespread use. The VALUE-Dx project set out to find out how much these diagnostic tests would be worth to society in the long run.


Q. Why are rapid diagnostic tests for bacterial infections not being used?

A. 'There are two major issues: the first one is that in most countries in Europe, the tests are not reimbursed by insurers, particularly in community care. And the second problem is that even in cases where the tests are reimbursed, there is still a reluctance among doctors to use them. In certain parts of Scandinavia, tests for strep throat are covered by insurance, for example, but they’re still not necessarily used.'


Q. What’s the argument in favour of reimbursement?

A. 'If we prescribed fewer antibiotics, there would be less antibiotic resistance. We want to show that there’s a societal advantage in reducing resistance, that people are dying of infections due to bacteria resistant to antibiotics, and that infections with resistant bacteria cost money. But that’s not currently considered in the equation. We want to bring on board health economists who can demonstrate the cost effectiveness of the use of rapid diagnostics, and if we can do that, appropriate reimbursement should follow.'


Q. What’s behind the reluctance to reimburse the tests?

A. 'Governments are reluctant to reimburse diagnostic tests in outpatient settings because they’re more expensive than a course of antibiotics. Insurance payers ask why they should reimburse the cost of a test that costs twenty or thirty euros, when an antibiotic only costs three or four euros. But that way of looking at it applies only at the patient level, and we want to emphasise the society level.'

'I think that the complexity and sophistication of the tests is not fully appreciated. A sophisticated molecular test can detect maybe twenty or thirty pathogens, which is quite amazing, but the insurers are only willing to pay the price to cover the  cost of these tests. The just don’t consider the technology very valuable.'

'It’s a very difficult discussion. The other challenge is that centralised labs want to protect their business. We think it would be so much better to use the test where the patient is actually being seen by the doctor - in the emergency room, the physician’s office, and maybe even in the future, home testing. This is where labs make their profit so there is a lobby that resists point-of-care diagnosis.'


Q. Why are some doctors so willing to prescribe antibiotics even if they doubt they’re necessary?

A. 'We’re bringing social scientists in to help us better understand this, but a typical case would be someone with a cough and fever of around 38 degrees arrives in the doctor’s office feeling unwell. If it’s an elderly person, there’s a chance that they have pneumonia, which is a disease that kills. In places like southern and eastern Europe they would probably be prescribed an antibiotic. Doctors don’t want to take the risk. However, there are rapid tests available that can detect the bacteria that cause respiratory infections, or biomarkers that demonstrate that the patient has a bacterial infection."

'It’s so easy to prescribe an antibiotic so why wouldn’t you just do it? Imagine a doctor in a small village tells a patient that they will be fine without antibiotics and their symptoms will pass in a few days, and then next thing you hear is that the patient was taken to hospital and died of a lung infection. The doctor’s reputation would be seriously damaged. In a competitive system where we have a fee-for-service setup, you’re not going to take a risk.'


Q. Do you notice a difference in attitudes towards antibiotic use in recent decades?

A. 'I see a change in mentality in younger doctors. For big pharma, antibiotics are no longer big business. They can’t make a lot of money anymore because reimbursement is low, and they no longer put as much pressure on doctors to prescribe them. A lot has also been done about the kind of unacceptable incentives where companies approach doctors and give them all kinds of trips and nice dinners. That has disappeared to some extent. We also spend more time in teaching programmes in universities talking to medical students about resistance and prescribing etc. That’s been happening for the past ten to fifteen years.'

Herman Goossens is the director of the clinical diagnostic lab in the Antwerp University Hospital, and head of a research group at the university. He is the founder of the European Antibiotic Awareness day.  His research covers antibiotic resistance, rapid tests and clinical trials. He is involved in COMBACTE, Drive-AB,  and other projects that are part of IMI’s ND4BB (New Drugs for Bad Bugs) programme, and his involvement mostly concerns diagnostics.

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