The article by Purssell (2005) is well presented and certainly makes you reflect on what is currently happening in the healthcare arena. There are numerous examples in today's hospital setting in which symptoms and infections have been over treated resulting in the development of antibiotic resistant bacteria such as methicillin resistant Staphylococcus aureus (MRSA), Glycopeptide resistant Enterococcus (GRE) as well as numerous others. It is not all bad news; the discovery of antibiotics and immunization against infectious diseases has been estimated to have added approximately 20 years to the average lifespan of humans in developed countries. The problem of increased antimicrobial resistance has also brought a number of risks such as health care associated infections (HCAIs). The infectious disease strategy Getting ahead of the curve (Donaldson 2002) sets out the government's desire to reduce the burden HCAIs. This was made more specific in the release of Winning Ways (Department of Health 2003), which identifies key targets to be met by hospitals to reduce rates of infection. The decision making model proposed by Pursell (2005) would certainly help to combat the increasing threat of rising antimicrobial resistance, the challenge is whether it could be implemented in the current NHS environment.
Purssell (2005) proposes that it may sometimes be prudent for patients to express their symptoms, as this is a form of adaptive behaviour and may actually benefit the host in defending themselves against invading pathogens. For example, should we treat a patient with diarrhoea or leave it to run its own course? As Purcell mentioned in the proposed model it may be of benefit to treat patients with diarrhoea, especially if the risks outweigh the benefits, although this is dependant upon a correct diagnosis and risk assessment, which requires experience and time to undertake, attributes not always present in the busy health service. A failure to correctly deal with symptoms may result in a major hospital outbreak leading to devastating effects in terms of loss of bed days, increased morbidity and mortality (Khan & Cheesbrough 2003).
In the hectic world of healthcare patients often present with multiple symptoms, which may require treatment to prevent mortality. A patient may present with a cough as a symptom, which as Purcell identified may have both an adaptive and manipulative aspect, this may develop into the disease pneumonia, which requires treatment. The diagnosis of disease such as pneumonia is sometimes difficult and often unpredictable (Basi et al. 2004) and delays in effective treatment will affect outcomes. One of the problems of starting broad-spectrum antibiotics before a diagnosis is the development of antibiotic associated diarrhoea, which leads to another symptom and disease. Yet is it acceptable to not treat a symptom when the cause is not always present or obvious? Again this is down to an appropriate assessment of the patient being undertaken including the pros and cons of treating symptoms.
Looking at suggestions proposed by Purssell on the treatment of symptoms it was interesting to note the lack of discussion on the impact of the proposed decision making model would have on the recent Department of Health health-care associated infection targets such as blood-borne MRSA infection rates which are to be halved by 2008 (Department of Health 2004). MRSA is highly resistant to most commonly used antibiotics therefore is a good example of a pathogen showing adaptation traits to its environment. The current UK strategy is the ‘seek and destroy’ approach in the treatment of patients found to be colonized or infected with MRSA (Duckworth et al. 1998). Unfortunately many patients do not realize that they are carriers of these bacteria as often there are no signs and symptoms present, although we attempt to decolonize these patients in an attempt to reduce its spread and achieve MRSA bacteraemia targets. This is at odds with Purssell (2005) treatment model, where it could be argued there is little to be gained in actively treating symptoms that is not causing the host any harm. The current national strategy of treating patients with or without symptoms may in the long run increase the antibiotic resistance problem if appropriate care is not taken (Wilcox et al. 2003).
Purssell has made reference to the limitations of some medical interventions in certain areas, e.g. fever, indeed as already discussed it may not always be in the patient's best interest to treat all symptoms. It could be argued that this approach bears some resemblance to the arguments of Illich (1977), who identified some of the limits of modern medicine. Illich in his arguments believed that death, pain and sickness are part of being human and these cultural values have been destroyed, instead leaving people to rely on medicine in order to cope with these events. This again can be related to the inappropriate use of antimicrobials, especially in the community setting where patients visiting the doctor with viral ailments expect to be issued with antibiotics. One of the key factors required in the proposed infection and treatment model is the education of the public into the negative effects of inappropriate treatment of symptoms may have on society. The development of facilities such as NHS Direct will help to reassure the public that it is not always necessary to seek treatment for minor symptoms but caution is always required as symptoms can change rapidly.
Purssell makes reference to the over treatment of some medical conditions, the challenge is to get the balance right. The adoption of the infection and treatment model would certainly make healthcare practitioners aware of striking the right balance before treating symptoms, although for this to be effective educating the public is a prerequisite otherwise patient pressure and expectations will prevent this from being used effectively.