Time for national strategy on antibiotic prescribing

antibiotic prescribing time

Researchers have suggested some practical ideas including default “no repeats” in electronic prescribing, tailored amounts

With Aussie GPs prescribing between four and nine times as many antibiotics as they should be, primary health researchers have called for a national strategy to be implemented as soon as possible.

According to a narrative review, led by researchers from the Centre for Research in Evidence-Based Practice at Bond University, the antibiotic resistance crisis has two substantial consequences:

  1. About 1,600 people Australians will die directly from antibiotic resistance every year – a number that will get worse until 2050 when deaths from currently treatable infections will overtake total cancer deaths.
  2. The risk that antibiotic resistance will pose to now routine high technology medical care – without reliable antibiotic prophylaxis, procedures such as chemotherapy, bone marrow transplant, major surgery and invasive diagnostic procedures (e.g. cardiac catheterisation) will become too dangerous to perform.

“This crisis is not directly obvious to GPs working in the community,” say the authors.

“Yet, GPs contribute to most of the antibiotic tonnage consumed by humans in Australia.”

Another study published in the MJA found that while antibiotics are not recommended by the guidelines for acute bronchitis/bronchiolitis, GPs are prescribing them in 85% of cases.

Similarly, they are not recommended for influenza, but are being prescribed in 11% of cases.

“There are several reasons why GPs overprescribe for acute respiratory infections,” suggest the authors of the latest study.

“It is difficult—and often impossible—to separate apparently innocuous [infections] from the early stages of very serious ones … and GPs tend to play it safe.

“GPs value the doctor-patient relationship and may assume that not prescribing antibiotics threatens this relationship. Moreover, time-poor GPs may perceive that it is quicker to finish a consultation for an acute respiratory infection with an antibiotic prescription.

“There may be also financial concerns, such as not wanting to lose a patient.”

What would a national strategy look like?

Overall antibiotic prescribing targets should be set, although researchers say these targets are likely to be “controversial” and “unwelcomed” by GPs worrying about safety.

Interventions that may support GPs to reduce prescribing antibiotics include:

  • Changing the default to “no repeats” in electronic prescribing (with an option to override when clinically indicated);
  • Changing the packaging of antibiotics to facilitate tailored amounts of antibiotics for the right indication;
  • Restricting access to prescribing selected antibiotics;
  • Providing feedback to clinicians about their prescribing rates compared with normative data of their peers (this has already been trialled through a letter sent by Australia’s Chief Medical Officer);
  • Educational visits involving face-to-face education of prescribers by trained healthcare professionals;
  • Delayed prescribing where GPs can write an antibiotic prescription but advise the patient not to have it dispensed unless there is deterioration;
  • Shared decision marking for antibiotic use, and the use of decision aids;
  • Voluntary audit and feedback activities, for example, NPS MedicineWise’ free electronic audit tools available to GPs.

With a diversity of potential interventions that can be used, having different modes of action are likely to be “additive and possibly synergistic”, with effects accumulating slowly over the years, say the authors.

“Data from Sweden, which has had a concerted drive against antibiotics in general practice to become one of the lowest antibiotic prescribers in the world, show that the gains are incremental, a steady few percentage reduction over many years.”

Currently the Medical Research Future Fund has prioritised an initial $5.9 million to support antimicrobial resistance research – although what proportion of this will focus on reducing antibiotic use in the community remains to be seen, the authors conclude.

Medical Journal of Australia 2017; online 23 Oct

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1 Comment

  1. Jarrod McMaugh

    Delayed prescribing is a great option.

    Writing prescriptions for the specific quantity is also important. This will make the “take the entire course” direction mean something again. We should never have gotten in to the habit of dispensing set pack sizes for antibiotics.

    Prescribes should also be required to include an indication on all antibiotic prescriptions. This will serve two purposes:
    1) Prescribers will overnight stop giving antibiotics to demanding parents or for upper respiratory infections (viral or bacterial) – caving in to conflict of interest will be less of an issue.
    2) Even if an antibiotic is written for these issues, pharmacists will have a clinical justification to question the validity of the script, therefore providing an opportunity for the pharmacist to discuss the need for antibiotics with the patient and the prescriber.

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