Issue 5 / 16 February 2015

AFTER years of urging patients to finish their full course of antibiotics, GPs are now being encouraged to tell most patients to stop treatment when they feel better.

Two articles published in this week’s MJA explore opportunities to combat increasing levels of antibiotic resistance in community and hospital settings, with both emphasising opportunities to discontinue therapy.

In a Perspectives article, Professor Gwendolyn Gilbert, of the Marie Bashir Institute for Infectious Diseases and Biosecurity at the University of Sydney, wrote that there was no risk, but “every advantage” in stopping a course of an antibiotic once  a bacterial infection had been excluded and “minimal risk” if signs and symptoms of a mild infection had resolved. (1)

“There is a common misconception that resistance will emerge if a prescribed antibiotic course is not completed”, she wrote.

For most infections, there was no solid evidence for the recommended duration of therapy, while for many syndromes associated with bacteraemia, studies showed no difference in outcome when shorter courses of antibiotics were used, Professor Gilbert said.

“In practice the optimal duration of therapy depends on clinical syndrome, the causative organism, whether source control is possible and the patient’s response to therapy.”

Professor Chris Del Mar, professor of public health at the Centre for Research in Evidence-Based Practice at Bond University, Queensland, agreed, saying that for most acute respiratory and urinary tract infections, GPs should tell patients to stop taking an antibiotic once their symptoms subsided and discard the remainder.

“The old mantra about finishing a course of antibiotics was based on an assumption that unless you eradicated the infection it could come back and you would need another course of antibiotics, but there is no evidence for this except in a few very specific illnesses such as tuberculosis”, he told MJA InSight.

Professor Del Mar said he hoped that, in time, Australia would move towards a system where GPs prescribed the exact amount of antibiotic required, specific to the individual patient and their illness.

Greater cooperation was needed between GPs at the local level to agree on which antibiotics would be prescribed for which illnesses, to reduce the risk of antibiotic resistance developing in certain locales, he said.

“The problem of antibiotic resistance is primarily generated in primary care, where three-quarters of all antibiotics are prescribed, often unnecessarily, but the consequence is greatest for the hospitals, where antibiotics are most needed for things like surgical prophylaxis”, he said.

New research also published in the MJA has identified several barriers to implementing successful antimicrobial stewardship (AMS) programs in Australian and New Zealand tertiary paediatric hospitals. (2)

The study of 14 hospitals found only two used automatic stop orders for antimicrobials — “a potential area for intervention”, according to the authors.

It identified lack of education of hospital staff, and lack of pharmacy and medical staff dedicated to AMS as the two main barriers to effective AMS in paediatric hospitals.

The authors suggested part of the problem was proving the cost-effectiveness of AMS activities in paediatrics, given outcomes used in adult hospitals such as incidence of Clostridium difficile infection were not useful in the paediatric setting.

Professor Madlen Gazarian, a consultant in paediatric clinical pharmacology and therapeutics and honorary associate professor in the School of Medical Sciences at the University of NSW, broadly agreed with the authors’ conclusions. However, she told MJA InSight that the types of education and resources needed to improve antibiotic use “are broader than what is being suggested”.

For instance, she said, any effective AMS team needed to include not just clinicians such as infectious diseases physicians, AMS paediatricians or pharmacists, but also health professionals with a mix of broader expertise in therapeutics and quality use of medicines, clinical practice improvement and implementation science.

“Crucially, clinicians need to understand why a change is needed and that any changes initiated result in improvements in outcomes relevant to clinicians and patients”, she said.

“This is where clinically meaningful data collection for use in audit and feedback comes in. Yes, such audits can be time consuming and resource intensive, but they have been demonstrated to be effective in influencing prescribing behaviour when used as part of multifaceted strategies.” (3)

Professor Gazarian said the MJA study seemed to assume that having an AMS program was “a good thing in and of itself”. However, she emphasised the need to have better data on the actual outcomes of various AMS programs and more study of the characteristics of effective programs.

 

1. MJA 2015; 202: 121-122
2. MJA 2015; 202: 134-138
3. Pediatrics 2012; 129: 334-342

(Photo: Jenn Huls / shutterstock)

7 thoughts on “Stop antibiotics: experts

  1. CKN Queensland Health says:

    This is a topical issue I have 2 commnents:
    1. I think the message that should be made is that antibiotics should only be prescribed if there is good clinical judgement that the infection is bacterial and not viral
    2. I would suggest that the respected authors provide references to studies of bacterial infections that have shown that cessation of antibiotics as soon as there is clinical improvement is of more benefit than harm
    3. Until this is clearer I would suggest clinician continue to advise patients to complete the course to avoid recurrence of the bacterial infection and avoid antibiotics where infection is likely to be viral in origin.

  2. Kanaka Rachakonda says:

    Currently the Antibiotic Stewardship in public Hospitals is still in an advisory role. To make this more effective each and every Clinical department should nominate one champion to work in liaison with the stewardship team and achieve consensus decisions for their speciality. Also there should be a wide utilisation of markers such as Procalcitonin  to de-escalate the antibiotics or to monitor the effectiveness of antibiotic therapy with emphasis on source control; especially the latter is important in a post surgical environment. Also, we need to invest in rapid molecular identification techniques such as PCR for early identification of offending organism and institution of appropriate antibiotics with a plan for de-escalation. Surgical antibiotic prophylaxis protocols should be carefully monitored.

  3. Alexandra Bernhardi says:

    I think one issue if we want to succeed with prescribing less antibiotics is to revise the PBS system.

    Currently for any healthcarecard holder/CTG eligible patient /pensioner it seems far cheaper to fill a script for antibiotics than investing money in non antibiotics (such as evidence based plant derived over-the-counter medicines, e.g. the product “Kaloba” has reasonable evidence to improve acute bronchitis/sinusitis, but it gets devalued as it is not subsidised and you get it over the counter.)

    We need to change the psychology of the patients – currently they think, just whatever comes on a PBS ( and is therefore often cheaper for them ) can work for their illness.

  4. Simon Shepherd says:

    This is good news, and not necessarily new news. There has been ‘evidence’ to suggest this approach for some time. It very nicely supports the good practice of patient review too, which allows the decision for cessation to be the clinicians rather than simply patient defined.

    Of course the biggest inhibitor to changing clinician behaviour will be changing attitudes and beliefs, but in this instance not only for clincians, but also patients –  who are now also used to the mantra of ‘complete the course’. The prescription for success, will of course, likely be marred by resistance…   tres (C.) difficile...

  5. Paul Dessauer says:

    Kassam has highlighted a key issue;

    I think the message that should be made is that antibiotics should only be prescribed if there is good clinical judgement that the infection is bacterial and not viral

     

    Anonymous writes; “e.g. the product “Kaloba” has reasonable evidence to improve acute bronchitis/sinusitis, but it gets devalued as it is not subsidised and you get it over the counter.)”

     

    A more accurate assessment is that “There is weak evidence that an extract from the root of the Pelargonium sidoides could shorten the length of respiratory tract infections and relieve symptoms. Yet this remedy can have side effects, for example stomach and bowel problems”.

    See; http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014902/

    and;

    http://www.quackometer.net/blog/2008/09/kaloba-cold-cure-how-mhra-condon

     

    I would question the assertion that patients “think, just whatever comes on a PBS ( and is therefore often cheaper for them ) can work for their illness“. I would suggest that most members of the public trust that products which are TGA apporved and which are subsidised under the PBS have strong evdience to support their use.

     

  6. Dr Oresti Mellios says:

    I understand why blame for common antibiotic resistance like penicillins is laid at the feet of general practice but please explain why , on a current practical level, resistance to the 3rd and 4th tier antibiotics resulting in VRE, MRSA etc are not laid at the feet of hospitals. I have never heard or read a statement saying the necessary or indiscrimate use of vancomycin or methicillin, where the real practical problem of current antibiotic resistance lies is due to hospital practices. 

    from …. miffed or nose out of joint !

  7. Anonymous says:

    In the evoluton of antibiotics prescribing practices, who gave the original recommendations as to length and strength of course of treatment?

    1. Was it possibly the antibiotics manufacturers in their best of intentions? So many years ago for the originals…
    2. The manufacturers… now many years later directly (legal) and indirectly (black market) supplying antibiotics to the agriculture industry…
    3. What is the broadest market? Animals and agriculture. What do you do to sell more product in animals?
    4. Fund research showing misuse in humans (perhaps as a wild guess 20% of the weight volume of the end use of these chemicals versus 80% in animals) creates resistance. Oh my!
    5. Demonize doctors and their non compliant patients for a problem engendered by farmers seeking more profitable herds – herds – of animals. But the farmers are in position to dictate length and strength of treatment… so pushover doctors and noncompliant patients must be the problem since farmers use the correct dose and duration with their herds because they control it not the herds and the farmers know what they are doing even though they are treating every animal and nit just those that are ill, and aren’t veterinarians
    6. Protect true profit center first: agriculture.
    7. Maintain baseline human profits from maximal volumes of doses sold to patients;propagate ideally all pills must be taken or resistance will ensue.
    8. Through all of the above,continue creating resistant bacteria world-wide through the consequence of overuse, expanding the overall market on both fronts (human and animal excretions)
    9. Innocently or venally think there will always be more and different, more effective and less host-harmful antibiotics (product pipeline) – and sell this idea to stockholders
    10. Reap the rewards when as a top pharma exec you have to amputate a relatives limb because we are out of antibiotics. But hey you’ve got a pension and stock options so you can take of the relative.

    I ranted. But I simply cannot believe misuse in or by patients is to blame.

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