A FORTNIGHT ago, I identified 10 facets of the “antibiotic problem”. It is now incumbent on me to offer 10 solutions.

Look beyond easy targets

Doctors, in particular GPs, have become easy targets for all and sundry. As has already been highlighted by some readers last time, antibiotics are pumped out in tons in the food and agriculture industries. The antibiotics then find their way up the food chain, into the soil, into the waterways, around and around, again and again. The same reasoning applies to hormones, pesticides, cytotoxics and other chemicals.

Veterinaries also need to be scrutinised; the antimicrobials dispensed by them fly under the radar compared with doctors.

So, the first answer is to define the problem better and more fairly. Doctors may well be the tip of the iceberg. But other industries are huge influencers and floating just below the surface.

Medical student education

Many doctors and medical students in Australia have opinions on the state of our university medical schools.

A common lament that I have heard is the paucity of anatomy teaching. While I agree that few students can readily distinguish the ilium from the ileum, I have graver concerns when it comes to microbiology and therapeutics.

Over the past two decades, I have had the immense pleasure – admittedly mixed with a smidgen of pain – of teaching scores of students from many universities, many states and many countries. My impression is that their knowledge of infectious diseases and pharmacology generally could be greatly improved.

In my view, undergraduate schools are not spending enough time teaching these two preclinical sciences. Graduate schools mainly accept students with a science background; however, I find that the entrants tend to study immunology, biochemistry, molecular biology and physiology. I rarely hear a student talk of undergraduate training in microbiology or pharmacology.

Students need to learn more about the differential diagnosis of fevers and raised inflammatory markers. They also need to know that antibiotics (and all drugs) can be delivered in many formats, including topical, intrathecal, intramuscular, inhaled and intranasal as well as in tablets and intravenous injection.

Infectious diseases are a casualty of problem-based learning and leaving students too much to their own devices. Self-directed learning is wonderful once some core knowledge is deposited into the cranium. However, it may be that genetic diseases, cancer, surgery, cardiovascular disease and emergencies are more enticing to the medical student and that universities may need to make more effort to instill a grasp of the pharmacopoeia of infectious diseases.

Specialist training and careers

Specialist training in infectious diseases and microbiology is long and tough and can be done via the pathology pathway or physician pathway or both. Training and careers are very much tied to big hospitals and big laboratories.

We need more of these experts to decentralise into the community setting and be more visible and approachable for clinicians outside of the teaching hospitals.

Vaccination

Simple arithmetic! More vaccination equals less infection and, therefore, fewer antibiotics.

Probiotics

A massive area of growth and interest. All I can say is “watch this space”.

Microbiology testing and reporting

There have been huge changes in testing and reporting protocols in the past two decades.

Faster cultures, gene amplification and immunohistochemistry have literally revolutionised the way we practise.

It is up to us to keep up to date with which tests to order and how to interpret them. Microbiologists should strive to report in user-friendly fashion, incorporating guidance on clinical significance and antimicrobials.

Bedside rapid tests – such as those for bacterial meningitis, influenza and sepsis – could be used more, especially in rural and remote locations.

Government

We cannot escape the microbes and we can’t escape the government! A stroke of a pen by a Health Minister could help in the following ways:

  • Requirements to obtain authority scripts could be used more to deter overuse of antibiotics. It’s a pain to get an authority script and that’s the whole point. We need deterrents.
  • Given most antibiotics are so cheap, many could be taken off the Pharmaceutical Benefits Scheme (PBS) and made private script only.
  • Quantities and repeats need an urgent overhaul. Pack sizes and repeat rules have not kept up with guidelines. Why have antibiotics in set pack sizes anyway? Why can’t the clinician decide the quantity without causing so much grief for the pharmacist and patients? Pharmacists prefer not to have to break packs, and many prefer to stick to the PBS quantities. Most doctors regrettably just fall into line and don’t want to rock the boat. A good example was mentioned the last time I wrote on this: trimethoprim for female urinary tract infections. The PBS offers a pack of seven. Why not a pack of three?
  • More antivirals should be listed on the PBS, especially those used to treat influenza. I repeatedly have patients complain they cannot afford oseltamivir. The result is children taking more days off school, workers taking more sick leave and elderly people risking hospital admission.
  • Vaccines need to be PBS listed, to fall in line with government vaccination guidelines.

Hospitals

The national medication chart has a space for prescribers to write the reason for a drug. A simple rule would be not to give an antibiotic if a reason is not provided. Vague reasons like “infection”, “fever” and “I said so” should be disregarded.

In my experience, in hospitals it is often too easy to give a high-powered antibiotic and too hard to find a basic antibiotic. The reasons are complex, but often boil down to habits of the particular department, habits of the pharmacists, and nurses preferring drugs that are quicker and easier to administer.

Defensive medicine

And being seen to be doing something is exactly what the lawyers like.

There have been cases where doctors following guidelines are still found negligent.

In future, we will also have to watch the health funds and the effect of managed care. This will put pressure on hospital doctors – surgeons especially – to overuse antibiotics in order to supposedly minimise complications and readmissions. This could end up being more frightening than the lawyers.

Update guidelines

Let’s make the guidelines open access and free. That way there’s no excuse!

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

 

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4 thoughts on “Ten solutions to the antibiotic problem

  1. Jarrod McMaugh says:

    The point about hospital charts and I cluding I fixation should be expanded to include all prescriptions for antibiotics.

    Not it can this ensure that many of the issues from the first article are addressed (underdosing, incorrect active ingredient, course longer than required) but it can also address issues where antibiotics are used when not indicated (especially viral infection toons, but also self-luminous infections)

    Pharmacists have a clinical role to play – to ensure the judicious use of medications. For antibiotics, this role is becoming critical to undertake, since these medications are likely to become ineffective in the next 1-3 decades. Providing the correct information to a pharmacist to ensure they can fulfil this role should be mandatory.

  2. Jarrod McMaugh says:

    Apologies for the spelling errors – typing on a phone isn’t always the best option.

    Below is the same response corrected

    The point about hospital charts and including indications should be expanded to include all prescriptions for antibiotics.

    Not only can this ensure that many of the issues from the first article are addressed (underdosing, incorrect active ingredient, course longer than required) but it can also address issues where antibiotics are used when not indicated (especially viral infection, but also self-limiting infections)

    Pharmacists have a clinical role – to ensure the judicious use of medications. For antibiotics, this role is becoming critical to undertake, since these medications are likely to become ineffective in the next 1-3 decades. Providing the correct information to a pharmacist to ensure they can fulfil this role should be mandatory.

  3. Nadine Hillock says:

    While I agree with some of Associate Professor Iannuzzi’s ‘ten solutions to the antibiotic problem’, I do not agree with removing antibiotics from the PBS just because they are cheap. This would simply have the effect of making access more difficult for those in lower socioeconomic groups, when they potentially may have a greater incidence of conditions for which antibiotics would be appropriate. The suggestion of changing the benefit to authority only would be preferable, as the hassle of obtaining authority can be used as an ‘excuse’ for the prescriber, for not prescribing antibiotics. It is important in our quest to reduce excess, that we don’t remove access.
    I am also opposed to the suggestion that listing oseltamivir on the PBS would be a solution to the antibiotic problem. While there is some evidence that oseltamivir may improve outcomes in hospitalised patients with severe community acquired pneumonia, there is no strong evidence of clinically significant benefit in adults or children with viral respiratory infections in the community. The Cochrane review (Jefferson et al, 2014) suggested that oseltamivir reduces the time to alleviation of symptoms by just over half a day (from 7 days to 6.3 days), but over half of the included studies had a high risk of selection bias. Listing oseltamivir on the PBS would only lead to inappropriate prescribing of antivirals, rather than antibiotics, exposing patients to unnecessary side effects for little gain.

  4. Anonymous says:

    Oh by the way, Promote research on new antibiotics!
    Respect the original innovator – don’t use substandard antibiotics that brew resistance and the list could go on.
    The ‘iphone’ of antibiotics will make all the above ten meaningless- that’s exactly what the ams squad doesn’t want happen.

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