Issue 22 / 12 June 2012

SINCE NPS launched its latest campaign against antibiotic resistance earlier this year, there’s one question I’ve constantly been asked: Given it is such a serious issue, why are doctors continuing to write antibiotic scripts when they are not indicated?

There is no question that Australian GPs have become better over time at differentiating viral from bacterial infections, and prescribing rates have come down, particularly after previous NPS antibiotic campaigns.

Despite this, there is clear evidence that antibiotics are overused in Australia. Around 22 million prescriptions are written every year — this puts us well above the OECD average in terms of usage per capita/per day.

Alarmingly, we use antibiotics at more than double the rates of countries at the lower end of the spectrum, such as Sweden and Switzerland. There is no apparent difference in health outcomes as a result, and in these countries antibiotic resistance is at much lower levels than Australia.

The danger posed by antibiotic resistant bacteria is right on our doorstep — highly virulent and transmissible strains of resistant bacteria are being bred in our own backyard. Every year in Australia, more than 1700 people die in hospital from methicillin-resistant Staphylococcus aureus (MRSA).

Resistant infections used to be a hospital-based threat but, disturbingly, we are seeing more of these in previously healthy people who have acquired an infection in the community.

There is a clear correlation between the use of antibiotics and the development of antibiotic resistance, which is why NPS is working with prescribers and consumers to reduce the number of unnecessary antibiotic prescriptions in Australia. Our aim is to reduce antibiotic prescribing by 25% over the next 5 years to bring Australia’s prescribing at least in line with that of other OECD nations.

Our research shows patients often expect, and sometimes demand, antibiotics. The NPS Antiobiotic Resistance Fighter campaign is focused on changing this behaviour in consumers. Changing doctor’s prescribing practices is equally, if not more, important.

GPs and other prescribers are the gatekeepers of antibiotics so ultimately we carry the lion’s share of responsibility in helping to curb their use. We are also right on the frontline when it comes to communicating the issues regarding antibiotic resistance to patients.

As a GP, I am well aware of the diagnostic uncertainty we face at times, and I have certainly erred on the side of caution and prescribed antibiotics “just in case”. I have also given in to patient pressure when their desire to get better quickly, or not get worse, leads them to request antibiotics — again, “just in case” they help. Unfortunately, we have all been blind to the risks associated with this approach.

One of the most important things you can do is take the time to explain to patients why they don’t need antibiotics for their illness, and then provide advice on how to manage their symptoms. It doesn’t always take more time to use patient-centred communication skills during a consultation, and if it does take a couple of minutes longer, the time spent is certainly worthwhile.

If antibiotics are indicated, we need to discuss the importance of taking them exactly as prescribed and mentor patients on the simple hygiene practices they can undertake to stop their infection spreading to others.

Antibiotic resistance has been described by the WHO as one of the greatest threats to human health today. It is a worldwide problem due to globalisation, and human, veterinary and agricultural misuse of antibiotics.

The lack of new antibiotic development is also a major concern, with the drug pipeline for new antimicrobials all but dry.

Australia needs to play its part in the fight against antibiotic resistance. To see a real change we need a consistent effort over time and it’s GPs who need to lead the fight.

Let’s not risk returning to the dangers of a world without antibiotics, where bacterial infections once again become potential killers.

Dr Janette Randall is the chair of the NPS Board.

Posted 12 June 2012

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8 thoughts on “Janette Randall: The resistance war

  1. NathDoc says:

    It’s all well and good preaching to the converted, but is the NPS interested in targeting hospital doctors and specialists?

    Every time I get a fax from the local A&E, the patient with RTI is placed on antibiotics. Yes, I know the patient shouldn’t have gone there in the first place, and these are less experienced doctors, but the overwhelming sense is that the staff feel too harried to argue, hand over the script, & tell the patient to PO back to their GP. No time taken to educate there!

    And it’s no better from the specialists. The patients only come back on antibiotics; & likely steroids too!

    By all means remind us GPs regularly, but keep the patients in mind, & non-GP doctors too.

  2. Andrew Watkins says:

    We face a scary future – there are now organisms in our community sensitive only to Colistin (old, toxic, cheap) and Tigecycline (new, tetracycline, expensive, resistance develops quickly). 4% of tapwater specimens in Delhi are growing such bugs and we have lots of people travelling back and forth.
    Fully agree that we hospital doctors need stricter controls too – it is very easy to treat one’s own anxiety by using “just in case” and it is still an area treated with insufficient rigour (although all are getting better).
    The great unexamined area, however, is agricultural use. Antibiotics are fed by the shovelful to pigs and chickens and regulation is limited. In one study from Germany 60-70% of intensively farmed chickens were excreting high-end multiresistant gram negatives and it would be no surprise were it at least as bad here. There is some evidence that they increase yield marginally (~10%) but the economics of an industry pale into insignificance beside the risk of resistant organisms and antibiotic residues in our diet and wider environment.
    If we do not get serious about this and become politically active we will shortly be living in the post-antibiotic era. There is strong political pressure against change from the representatives of the agricultural sector. The medical profession needs to push this a lot harder than we do. Denmark has introduced strict controls and the sky has not fallen in.
    Imagine going back to an era when it was quite normal for HCWs (i.e. us) to die of occupationally acquired infection! If nothing else, good old self interest should make us think about it.

  3. Dr Phil Watters says:

    After 30 years in O&G I want a badge which says “Don’t blame me for VRE”
    We were taught this approach in the 1970s….too many didn’t either take it in, or pass it on to the next generation. There’s too much reflex use of antibiotics without some critical thinking (ie,no cortical involvement) today. We have become lazy at our and our patients’ peril.

  4. Demelza Lucard says:

    Perhaps the pharmacists should be taking more care. A recent suspected Pertussis diagnosis had me off to the local chemist with my script, but the dispensing instructions advised me to only take half the dose that had been prescribed. When I questioned this, all I was given was a shrug of the shoulder. Two friends, with different diagnoses at different pharmacies, experienced a similar result: the dispensing intructions were NOT correct. How many patients remember the actual doseage instructions (verbal) given by their GP? Most of the time they just follow the dosage instructions on the box.

  5. yvonne149 says:

    I have to agree with Andrew Watkins with respect to the agricultural misuse of antibiotics. This is a huge issue, and is probably responsible for much of the resistance we see. Farmers, even in the USA (what about here?) use large quantities of antibiotics to marginally increase meat yields in their factory-farmed animals. In the USA, use of quinolones by farmers caused rapid development of resistance, despite requests by the CDC that they not use them. It is always very easy to blame GPs. They are not usually politically active, they are fragmented, and are usually too busy to even take note, let alone defend themselves. There is also much misuse of antibiotics in the hospital setting.
    It is time a realistic appraisal is done of the cause of antibiotic resistance, instead of taking the easy way out and constantly blaming GPs.

  6. Sue Ieraci says:

    The agricultural use of antibiotics, and the resulting rise in resistent strains of food-borne organisms, was discussed on ABC radio this morning. It appears that Australia has much more stringent regulation than the US – thankfully. Access to also more controlled in Australia, with vets being required to prescribe/dispense a greater range of antibiotics. Let’s campaign to keep it so!

  7. Anonymous says:

    Antibiotics brought into Australia by visitors appear to slip under the radar.
    Overseas students admit to getting them over the counter in their home countries and use them for seemingly minor viral infections.

  8. syd bell says:

    I think it is unjustified in blaming GPs for the spread of resistant organisms in the community. The evidence is that the mechanisms of development of resistance are complicated but are not related to the use of antibiotics in GP except in very specific circumstances. The criticism that GPs are misusing antibiotics in viral infections is unjust unless there is some method by which the practitioner can quickly distinguish a viral cause from a bacterial cause. One thing is certain and that is that this cannot be done clinically and it requires a POCT to eliminate a bacterial cause. For many reasons, although these tests are available, they have not been introduced into practice.

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