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AUSTRALIA’S high rate of antibiotic prescribing needs an all-out public awareness campaign on the scale of quit smoking initiatives, one leading infectious diseases specialist says, amid warnings that the current policy response is woefully inadequate.
Professor Lyn Gilbert, clinical professor of immunology and infectious diseases at the University of Sydney, told MJA InSight that Australia’s rate of antibiotic prescribing was among the highest of the 29 Organisation for Economic Co-operation and Development countries, saying “there are clearly different cultures around antibiotic prescribing”. (1)
“If we can get people to stop smoking by massive advertising and public awareness campaigns, I think we can get patients to stop expecting, and doctors to stop prescribing, unnecessary antibiotic therapy through a similar approach”, she said.
Although the federally funded organisation NPS MedicineWise runs occasional advertising campaigns about the appropriate use of antibiotics, Professor Gilbert said these were tiny efforts compared with what was needed to promote long-term behavioural change.
An NPS MedicineWise spokeswoman confirmed the organisation did not have the budget for large-scale advertising campaigns, but claimed the relatively low-cost efforts to date had had a measurable impact.
Last week, NPS MedicineWise issued all GPs with a report card of their antibiotic prescribing habits compared with their peers to coincide with Antibiotic Awareness Week. (2)
However, the information was derived from Pharmaceutical Benefits Scheme data, so does not include information on the indication for each prescription.
Dr Evan Ackermann, chair of the Royal Australian College of General Practitioners national standing committee for quality care, told MJA InSight: “Unless we are able to measure the context in which antibiotics are prescribed, the report is somewhat meaningless”.
“It is really emblematic of our health system and our superficial regard to the importance of primary care that we have no real, high-quality data to show where inappropriate or excessive use of antibiotic prescribing is occurring”, he said.
“The antibiotic resistance problem is becoming acute, and single, top-down, one-off interventions are likely to have little impact in the end.”
Dr Ackermann said priority should go to antibiotic stewardship programs in general practices to ensure antibiotics were being prescribed “at the right time, for the right reason, and to reduce poor prescribing and adverse events”.
A randomised study in Irish general practices published last week in the Canadian Medical Association Journal found a combination intervention including education, audit reports and reminders improved the quality of prescribing for urinary tract infections. (3)
However, there was an unintended overall increase in antimicrobial prescribing in the intervention arms of the study relative to the control arm.
Professor Gilbert said it was unclear what had caused the spike in antimicrobial prescribing in the study. However, she said that in general if antibiotic stewardship programs led to more appropriate prescribing, then even if there was more prescribing overall, the benefits were likely to outweigh the risks.
She likened antibiotic resistance to climate change, saying both were slowly developing, extremely complex problems wrought by the misuse of resources.
“Although the consequences may not be as dramatic as with climate change, make no mistake that increasing numbers of patients will die as a result of antibiotic resistance”, she said.
A series of articles on antimicrobials published last week in The Lancet considered the global policy response to antimicrobial resistance, noting that antibiotic consumption in 71 countries had increased by 36% between 2000 and 2010, with Brazil, Russia, India, China and South Africa accounting for three-quarters of this increase. (4)
The authors wrote that “our aim should be to maximise the value derived from antibiotics … rather than attempting to minimise resistance”.
(Photo: TEK Image / sciencephoto)
A common misperception made by many (including Horst Herb and Anonymous) is that the US is some “free market” haven. Rather, it is almost as much of a socialised medicine disaster as Australia, which in turn is almost as bad as the UK. All represent variations on the theme of socialised medicine. For those who don’t know, the US system is very heavily government subsidised through Medicare, Medicaid and government-mandated workplace-based health insurance. In fact, less than 15% of Americans (as at 2012) are not covered by the public or quasi-public health insurance system in operation before Obamacare (and even less now). So, please don’t preach to me about “Trump’s America”.
As far as Norway is concerned, so glad you mentioned it. Perhaps you have been listening to Bernie Sanders a bit too much. Norway’s health care system is plagued by rationing, long wait lists and treatment gaps. It is one of the highest cost systems in the world, which Norway can afford only because of its oil revenues. As for drugs, they are not covered by their socialist system! So no wonder resistance is not a problem – its because Norwegians have to pay for their drugs! Which just goes to prove my point: government funding of drugs is the cause of the problem.
It’s plainly obvious – if you make things “free” and disconnect the payer from the user, you get distortions and overuse. Its economics 101. If you set up a pie stall in Pitt Street advertising free pies, guess what, everyone will come and take their free pie. If you get governement to pay for medications, you will get people lining up to get their free drugs. In the case of antibiiotics, that means resistance.
“Liberty Doctor”, on what evidence exactly do you base your statements about PBS subsidy being cause of resistance?
One of the countries with very high medication prices (n some aspects the most expensive prices even) is the USA, where resistance is rife, antibiotic overuse common, … and people paying more than anywhere else for their medication (and for healthcare, and getting a very bad deal for that too in terms of outcome/buck spent).
In contrast, if you look at Norway with an even more socialised medical system than Australia, drug resistance is hardly a problem and antibiotic prescriptions very much aligned with current evidence.
While there are some countries where medication (at least some) is indeed cheaper than in Australia, drug prices here are mostly on the lower end of the spectrum within the developed world – most likely due to the effect of the PBS not subsidising overpriced drugs with little benefit for cost.
I honestly think that the comment above, about socialised medicine , is totally inadequate and missplaced in this discussion. If you don’t like the fact that patients have access to subsidised medications, then you should leave this country and be happy in Trump’s America.
What do you expect when you have a system like the PBS which gives patients free/heavily subsidised medications? When there is no price signal (i.e. effectively free drugs), patients don’t think twice about asking for (and doctors don’t think twice about prescribing) antibiotics. Want to solve the problem of antibiotic resistance (and overuse of drugs in general instead of use of lifestyle measures and commonsense approaches)? Try getting rid of the PBS. Drugs would be a lot cheaper, overuse would be a lot less common and resistance wouldn’t be a problem. But in a world of socialised medicine, zombie industries and cozy relationships between government and drug companies, I don’t think anyone would have the courage to get rid of government subsidies.
As previously mentioned, the campaign should be focused on the general public in addition to doctors.
Many patients can be downright hostile when they don’t get their antibiotics for their viral pharyngitis.
In reply to Stephen Page, veterinarian, according to Ecology and Epidemiology 2012; 2 ;16959, the vancomycin analogue Avoparcin was extensively fed to some farm animals as a growth promoter, although the practice was ceased some years ago, but it did lead to culturing of VRE from some of these animals. I have always believed vancomycin should be saved from usage as much as possible is it may be a last line of treatment. I have only used it a few times in my surgical career, but there is no doubt it is used more extensively in some areas such a cardiology and intensive care.
One if the problems I encounter is a lack of information available about the extent of coverage of antibiotics and what antibiotic to use when a patient reports an allergy. The ‘antibiotic guidelines’ do not give detailed infomation about exactly what organisms are covered, are not freely available when they are needed (you have to pay for them, and outdated copies are usually lying around in our hospital) and don’t offer comprehensive advice on what to use as alternatives. The book itself is also not particularly user friendly in my view.
As an example, I needed to find an alternative surgical prophylaxis for bowel resection when a patient was ‘allergic’ to metronidazole….???? (Who knows if the patient was really allergic to metronidazole but a lot of patients report ‘allergy’ to antibiotics that one has to respect). The hospital pharmacist didn’t know and there were no available guidelines to access…..Dr Google was the best option….far from ideal.
Surely getting comprehensive, easy to follow and freely available guidelines would be a good starting point????
What is needed is a campaign aimed at the general public, in order to change patient expectations. NPS cannot be expected to fund that. Medical practitioners are now mostly very aware of the need to limit antibiotic prescribing, but this is difficult, particularly for GPs, when patients expect a prescription.
It is refreshing to see the medical and veterinary professions working closely on the subject of antimicrobial resistance and both can learn much from each other. There is little talk about relative contributions to the problems of AMR, the focus is on collaboration and solutions. There is no antimicrobial effectiveness crisis in animal health, the old antibiotics generally remain effective and are still the most commonly used.
It is best that the record is correct. In addition to the truths about antimicrobial use there are many misconceptions and myths. Much of the mythology has been allowed to foment by ineffective communication and engagement from those busy with animal health. To clarify the history, vancomycin has never been used in pigs in Australia (for many reasons but one dose would be worth more than the treated pig) and glycopeptides have never been used in Australia to control “the dreaded pig enterocolitis”, presumably clostridial necrotizing enteritis, uncommon in Australia, more frequently encountered in New Guinea. When they were available for use, glycopeptide use was associated with selection of vanA VRE, but never vanB VRE. Interestingly vanB VRE is much more common in humans in Australia than vanA VRE. Where did vanB VRE come from? Glycopeptides have not been used in animals in Australia for more than 15 years and VRE recovered from animals these days is most likely to have a human origin.
Let’s be guided by the facts and continue to work on solutions to what the WHO Director General described – “Antimicrobial resistance is not a future threat looming on the horizon. It is here, right now, and the consequences are devastating.”
In my experience, the craft group that is the most liberal prescriber of broad-spectrum antibiotics (often more than 1 at a time) are the Infecious Diseases physicians. It seems that they are the least tolerant of the uncertainty of an undifferentiated fever in a moderately unwell person and are more likey to ‘shoot first and ask questions later’.
I agree that not enough is being done about antibiotic over prescribing. I tried to present some evidence based guidelines in my practice but was shouted at by one of the other doctors who also supervises medical students. I get patients coming to me with obvious viruses who wonder why I don’t prescribe antibiotics ‘like the other doctor does’. There needs to be a big campaign with advertising and a refresher for doctors.
While there is undoubtedly room for improvement in doctors’ antibiotic prescribing , it is easy for ivory-tower professors to pontificate about this when they are removed from the bedside and direct patient responsibility. Also we never hear about problems when antibiotics are NOTprescribed when they should be.
All the attention is focussed on doctors but Vets and farmers also carry responsibilities here. Vets prescribe antibiotics and steroids for most cases because their “patients” can’t tell them what’s wrong.
Vancomycin -resistant enterococci arose because of farming practices where pigs were routinely fed vancomycin to fatten them up ( prevented the dreaded pig enterocolitis)