Simple UTIs aren’t simple, says doc


doctor makes "stop" gesture with hand - ama

Doctors continue to oppose Queensland’s trial of pharmacist provision of UTI treatment, with one GP warning of “landmines”

Following the Queensland Government’s announcement last month that pharmacists would be able to provide short-term treatment for simple UTIs under the state-wide trial, doctor groups lashed out at the concept.

The RACGP and national AMA both warned that such a move could lead to “superbugs” via over-provision of antibiotics for such infections, while Dilip Dhupelia, president of the Queensland branch of the AMA, called the move “irresponsible and reckless”.

Now Dr Rob Park, a GP on Queensland’s Sunshine Coast, has weighed in, writing in a doctor publication that “this decision in the wrong hands can lead to people getting hurt”.

He gives three examples of patients presenting with a potential UTI: a young woman with stinging on urination who may have chlamydia; an older woman with her “regular UTI” who may have lichen schlerosis; and a middle-aged man with dysuria whose true condition could be revealed with an “appropriate rectal examination”.

Many more such “landmines” exist, he warns.

“GP learners have years of training specifically in clinical reasoning and the diagnostic method, but even they find this diagnosis difficult to do safely without years of experience and pattern recognition,” he writes.

“Now, imagine if we removed their ability to ask sensitive questions, tied their hands behind their back to stop them from examining the patient, disabled their access to order and follow up test results, gave them no practical hospital experience caring for the complications of UTIs, and dramatically reduced their clinical reasoning training.

“Essentially this is what we are doing by allowing pharmacists to write antibiotic scripts for UTIs.”

In discussing the suggestion that pharmacists contact the 13-health telephone service or access My Health Record, or refer patients to their GP, Dr Park says this could just be “adding a dangerous middle step that again leads patients back into the GP’s office?”

“UTIs are easy? No, they are not.”

Last week, after NSW Health Minister Brad Hazzard rejected a PSA proposal that that state implement a similar trial, PSA state president Professor Peter Carroll told the AJP that the Queensland trial model, and that being proposed in NSW, was patient-centric.

“It’s not a contest between the GP and the pharmacist,” he told the AJP. “It’s both, working collaboratively for the health of the community.

“It’s about the appropriate short-term use of trimethoprim, a drug specifically recommended for the treatment of acute UTIs, and allowing the lady to have relief from her symptoms. It doesn’t stop her going to the GP the next day or in two days’ time.”

Meanwhile AMA Media continues to criticise pharmacist provision of antibiotics for simple UTIs on social media.

 

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9 Comments

  1. Are you guys misusing my quotes?

    I agree with medicos 100%. Unless our universities change the structure of our degrees to include compulsory clinical residencies then I believe we should be steering clear from diagnosing. (Even then, I would probably still think we shouldn’t be diagnosing.)

    If you want trimethoprim, then just appendix M it. Of course, this is just part of the grand plan to get the foot in the door for autonomous prescribing when we as a profession are not equipped/ready for it.

    I’m curious to what proportion of Australian pharmacists even wants this to happen?

    We’re great at what we do already. Focus on that and solidify our position in the healthcare system.

  2. John Wilks
    07/05/2019

    The advocacy of UTIs as entry point for pharmacist prescribing is an inappropriate clinical condition to select. Our hospital recently had its first case of multidrug resistant E coli. It was resistant to Bactrim, Augmentin DF, ciprofloxacin, cephalexin etc.
    It was only treatable by meropenem 2gm TDs.

    The treatment of a uti without microbiology assessment is a bacterial resistance driver and should therefore be opposed.

  3. B Lee
    07/05/2019

    I do not agree with pharmacist prescribing antibiotics only and purely due to scope of our knowledge. Having said that, GP’s reasoning of the opposition due to ‘superbug’ is funny because they are the ones who are prescribing unnecessarily. One example, GP prescribing lower dose than reference and guidelines for “weak infection” which I found it extreme and way out of standard.

    • Hi B,

      That’s a valid point. That’s where pharmacists come in and make sure that they are prescribing to best practice. We can also have a role in monitoring, surveillance and education.

      The fact that doctor and pharmacist groups are at war, only adds to our detriment that doctors may not value our very useful input.

      We should be working together. #StrongerTogether

  4. Doc Rob
    27/05/2019

    Wow, found I have been quoted here – Dr Rob Park. My comments are simple – they are situations where I would not feel comfortable prescribing antibiotics without examining a patient, taking a full history, chasing up previous UTI results, knowing their past history, being able to directly follow the patient up in a few days for further consults etc etc. I wouldn’t feel comfortable doing it – and I am not sure most pharmacists would be comfortable being put in that position either!

    Am I good at my job? Damn right I am. I am a well trained and confident GP. But I wouldn’t suggest for a single second that I fully understand some of the complex pharmacodynamics of certain drug interactions, understand the complex rules and regulations regarding appropriate medication management, nor can explain medication compliance and drug management, anywhere near as well as my local pharmacist. They all look like white pills to me. And why? Because that is not my primary training or experience.

    And that is why I pester poor Alistair (our next door pharmacist) on a regular basis! I respect HIS training, expertise, and experience. Mutual respect and collaboration is what we need. Not pharmacists suggesting to prescribe antibiotics for UTIs because it is ‘easy’ nor GPs recommending that they should be able to dispense because it is just ‘handing out a packet’.

    Both are inappropriate suggestions coming from a place of misunderstanding of how each role works

    • Jarrod McMaugh
      27/05/2019

      Doc Rob, I think one of the issues are the very large assumptions that are being made by medical groups about the application of these policies.

      It seems to be that these comments come from a fear that there is a switch that gets flicked, and all of a sudden, the policy is enacted, and be damned with process or clinical frameworks or collaboration or communication……

      • Doc Rob
        27/05/2019

        Perhaps. But we are all generally in agreement that this is fundamentally a bad idea. Phamacist colleagues, and even most of the comments here, suggest this is the case. Thus the clinical frameworks collaboration communication bits – are somewhat irrelevant to the discussion.

        It is simply the same principle as GPs dispensing. It is fundamentally a bad idea. Could there be some frameworks collaboration and communication strategies to keep the pharmacist in the loop – sure. But is it worth even pursuing those if most GPs i’ve spoken to also do not want to perform a role we know there is someone better suited and trained to do.

        Interestingly, do you think pharmacists would think that expanding GP roles to generics dispensing would be a good fundamental idea? I doubt it. And nor do I.

        • Complete agreement with your sentiments here.

          Objectively, the idea does not provide a net benefit to the patient. There are definitely other avenues which allow for an “ease of access” argument.

          The push here (in my opinion) is the end goal to amend legislation pertaining autonomous prescribing rights. This will be a limit breaker for pharmacy.

          For better or worse? And how many of us even want this? Diagnosing a potentially threatening ailment is best left with the doctor. I’m happy for you to do your thing and I’ll do mine.

          Mutual respect and collaboration. #StrongerTogether

        • Jarrod McMaugh
          31/05/2019

          “But we are all generally in agreement that this is fundamentally a bad idea”

          I guess that means there is no contentious issue here then? If everyone agrees that it is a bad idea…. then what is your concern?

          Dr Rob, can I ask if you are familiar with how pharmacist prescribing models currently work in jurisdictions where it exists?

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