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NEW measures are needed to curb antibiotic prescribing rates, say experts, after researchers reported that GPs were prescribing the drugs for acute respiratory infections (ARIs) at four to nine times the recommended rate.
In research published in the MJA, it was estimated that 5.97 million ARI cases in general practice were managed annually with at least one antibiotic, far exceeding the 0.65–1.36 million prescriptions recommended by the Therapeutic Guidelines.
The authors compared general practice activity data over 5 years, from 2010 to 2015 – sourced from the Bettering the Evaluation and Care of Health (BEACH) program – with the estimated prescribing rates recommended by Therapeutic Guidelines.
“Had GPs adhered to widely consulted antibiotic prescribing guidelines, the rate of prescription would have been 11–23% of the current rate,” the authors wrote.
Co-author Professor Paul Glasziou, of Bond University’s Centre for Research in Evidence-Based Practice, said the antibiotic prescribing rate in general practice had dropped in the decade to 2003, but the rates had since increased again.
“There are lots of reasons why it’s high: diagnostic uncertainty, consumer expectations and also doctors’ sometimes incorrect expectations that patients expect antibiotics,” said Professor Glasziou, who is also a former GP.
Professor Glasziou said Sweden’s antibiotic prescribing rates were similar to Australia’s 20 years ago, but an active antimicrobial stewardship program in Sweden had seen rates decline to a point where they were now less than half the rate here.
“That’s important,” Professor Glasziou told MJA InSight. “It shows that you could safely stay within the guidelines and drop the prescribing rate quite a lot.”
To do so, he said a range of measures would be needed, including individualised audit-and-feedback initiatives and shared decision making tools, which were already available through the Australian Commission on Safety and Quality in Health Care.
“We also need to provide doctors with ways of identifying the seriously ill cases,” he said, pointing to improvements in point-of-care testing, such as C-reactive protein or procalcitonin testing.
Professor Glasziou said that these measures needed to be properly resourced over the long term to be effective.
“The cost is actually fairly modest compared with the cost of us doing nothing.”
Professor Glasziou also welcomed the recent move by Chief Medical Officer, Professor Brendan Murphy, to write to more than 5000 of the highest antibiotic-prescribing GPs in Australia to draw attention to their prescribing rates. Professor Glasziou said a similar initiative in the United Kingdom in 2015 had resulted in a 3.3% decline in antibiotic prescribing in those practices the following 6 months.
Royal Australian College of General Practitioners president Dr Bastian Seidel said the MJA research showed antibiotics were still being overprescribed in general practice, but he noted that the data included delayed or “wait-and-see” prescriptions that may never have been dispensed. He said dispensing data would show a clearer picture of how general practice was managing antibiotic usage.
Dr Seidel agreed that a range of measures was needed to support GPs to reduce antibiotic prescribing.
However, he said, successfully incorporating these measures into routine practice required time. “If you are working in a very busy practice and you only have 6 minutes with your patients, there is a chance that prescribers are tempted to prescribe early,” Dr Seidel said.
“I want to be able to spend more time with my patient to explain to them the benefits and the risks of antibiotics, and that time needs to be financially rewarded.”
Referring to the successful reduction of antibiotic prescribing in Sweden, Dr Seidel noted that GPs in Sweden spent the longest time with their patients, with an average consultation of 24 minutes, as opposed to Australia’s average of 14 minutes, according to BEACH data.
Dr Lynn Weekes, CEO of NPS MedicineWise, said the MJA study showed the large gap between theoretical best practice in antibiotic prescribing and actual practice.
She said NPS MedicineWise had been implementing educational programs on antimicrobial resistance and antimicrobial stewardship for several years.
“Our preliminary evaluation indicates that, although we have a way to go, GPs are responding to the antimicrobial resistance situation and the education. We have seen a downward trend in antibiotic prescribing rates for respiratory tract infections in the past few years. This will need to be confirmed,” she said.
However, she added, education alone was not enough. “We need to recognise there are limits to what can be achieved rapidly by education alone – without system changes, such as regulation and restrictions.”
Professor Lindsay Grayson, director of infectious diseases at Austin Health and member of the Therapeutic Guidelines antibiotic expert writing group, said the increasing availability and accuracy of point-of-care testing would give GPs confidence as to when antibiotics would be helpful and when they were unnecessary. Correctly identifying the organism responsible for an infection would also aid GPs in better targeting antibiotic treatment, he said.
“For example, we now have an incredibly accurate multiplex polymerase chain reaction test for respiratory viruses, which can be done on throat swabs,” Professor Grayson said.
“We need greater awareness of what current tests are available and we need a reassessment of which tests should have improved funding, so ordering these tests is not prohibitive.
“The test itself may be an added cost but, if it is saving a prescription for antibiotics, it should be looked on more favourably because it’s avoiding an inappropriate consequence.”
Professor Grayson said it was noted at the Antimicrobial Resistance Summit, held in Melbourne in late June 2017, that the Therapeutic Guidelines were not freely available to all GPs.
He said that among other policy drivers, there was an argument that the federal government should make the Therapeutic Guidelines freely available to all Australian doctors, including GPs.
The MJA authors also noted that paid subscriptions were “possibly a barrier” to the broadest implementation of the Therapeutic Guidelines.
Professor Glasziou said it would take many years to safely reduce antibiotic prescribing rates.
“We are not trying to blame GPs. The [guideline recommended prescribing rate] is a best case, and we have to make sure we can lower the rates without missing any serious cases. That’s not going to occur overnight.”
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The article presents the naivety of the authors. ‘Academic general practice’ has very little knowledge of the practical ‘day to day’ (I will even say ‘run of the mill’) problems of treating acute respiratory infections, particularly in the wintertime epidemic. A first problem – never mentioned – is the real risk that if the doctor spends any length of time with the patient – particularly if one examines the patient’s throat – one will one’s-self contract several of the infections in the course of the season. To seriously obviate that risk one needs effective eye protection, as well as nose/mouth protection – a face mask. A short consultation is protective, as is a minimal clinical assessment. A second problem is the diagnosis. The Guidelines present 10 different diagnoses. Most of my patient have at least two of them, by the time they attend. A third problem is the commonly inadequate and incomplete nature of recorded clinical notes – if one judges them by the quality needed for valid inclusion in a study such as this. I would suggest to Dr Seidel that his acknowledgement of this problem – although welcome – is still grossly inadequate. The $38 bulk-billed fee, which is what the patient wishes to pay for a one-time visit for this condition, must cover the running cost of the clinic, and the total cost of the doctor, which must include the equivalent of all professional costs, superannuation and sick leave – as well as the doctor’s equivalent before tax private income. A fourth factor is the adult patient is looking for a sick leave certificate, and commonly believes that – after more than 4 days of symptoms – an antibiotic is the treatment of choice. The patient information leaflets provided by the AUSTRALIAN COMMISSION in SAFETY and QUALITY in HEALTH CARE are – in my view – utterly useless. Dense, confusing, and in one argument, manifestly untrue. “What is antibiotic resistance? …This means that antibiotics may not work if you or your child needs them in the future to treat a bacterial infection. A person who has recently used antibiotics is more likely to have resistant bacteria in their body.” The statement is absolute. But the vast majority of cultures – at worst – still demonstrate an incomplete panel of resistance. There will be some antibiotics to which the bacteria are sensitive. That is why we take a throat swab. Particularly if I do not prescribe an antibiotic.
I have an argument I very commonly use with essentially healthy adult patients who had caught what I consider is an uncomplicated intercurrent viral respiratory infection. It has not yet been mentioned in these discussions. I tell them the likely clinical – symptomatic -response to an antibiotic, if the infection is bacterial, will be up to 4 days. A prescription for a codeine-paracetamol analgesic will provide a major reduction in general misery and in relevant forms of pain: throat, sinus, general somatic, substantially reduce respiratory secretion and cough. This symptomatic relief begins almost immediately and will continue for the 3 days of the script. Lesser concentrations of codeine are available – if subsequently needed – over the counter. ‘That is probably all you need’.
I am in agreement with the Dr 3 above, and I too am heartily sick of having the GP’s singled out as the principal cause of antibiotic resistance. The amazing cocktails of antibiotics that are doled out to patients in hospitals for relatively simple infections makes GP prescribing fade into insignificance! Pt education will help, and adequately remunerating GP’s for a 15-20 minute consultation would also greatly help. Researchers need to get out into the field & perhaps have their funding based on dealing with a busy consulting room with all its pressures including a $38 rebate for a 5-20 minute consult! Perhaps hospitals also need to increasing staffing, allow time for their workers to clean their hands and scrub surfaces, and perhaps build them with a solarium to allow more fresh air and sunshine which is usually the only cure for the hospital acquired super-infections. Don’t pick on the GP’s as the cause of bug resistance because we didn’t cause the problem. And also, as Dr 9 above says, …it is over 20 years since I saw a Rheumatic Fever or glomerulonephritis – but I have swabbed a great number of beta Strep throats…simple penicillin judiciously applied has made a big impact there. The big message is don’t keep prescribing multiple different antibiotics for post-infective conditions like cough! That can be resisted…as long as there is consulting time!! And influenza (as opposed to “Flu” that the population has to call a common cold) can be usually diagnosed with an adequate history & an urgent swab if necessary. Pharmacists need reining in on over selling useless or harmful remedies & potions. People do need education in basic manners & hygiene & that infections are infectious!!
Isn’t the “overprescribing” of antibiotics one of the reasons that rheumatic heart disease is rare in Australia except in places where medical services are lacking or not used? Maybe GPs consider this and the Therapeutic Guidelines don’t?
The pressure from patients is responsible for prescribing antibiotics inappropriately. If there wasn’t that pressure, doctors would save time trying to plead with them that there is no need for antibiotics for viral infections. Why do doctors give in to this pressure? I would guess it’s because the doctor has to make a living.
It can be difficult to decide whether to prescribe antibiotics on not when faced with the clinical situation of a very ill patient with acute respiratory infection. Retrospective decision making is easy. An increase in “wait and see” policy in order to reduce antibiotic prescribing may result in an increased incidence of morbidity or even mortality due to delayed antibiotic prescription. Guidelines would be useful so that the responsibility with regard to “morbidity-mortality associated with delayed antibiotic prescribing” can be shared with “guidelines authors” if litigation arises.
I can’t help feeling that this article is preaching to the choir. In my local area, if someone comes to my ED with URTI-like symptoms and tell me their GP gave them antibiotics, I can usually guess within three or four tries the name of the GP. All hold the FRACGP. Education of GPs alone will not solve the problem, which has been known and well-publicised for 20+ years (since I was a student). Those who wish to practice in an evidence-informed way are mostly already doing so. Those who don’t have had enough education, they simply choose a different path and don’t seem to care that they are not in sync with accepted practice nor that they are harming their patients. I’m not sure what, if anything, can be done to protect people from those who choose not to do the best by their patients. As an aside, yes, I am aware that hospitalists have their own antimicrobial stewardship battles.
Point-of-care white cell counting is a means of reducing unnecessary antibiotic use. When I was working in a remote aboriginal community there was a direction to administer a third generation cephalosporin to any child under 2 years with a temperature above 38C if no specific cause could be found. After following this direction it was not uncommon for the fever to abate in 12 hours with no recurrence, and when the white cell count was received (a day or so later) it was not elevated. Point-of-care testing was a very useful diagnostic tool in such cases. The technology has been validated,1 and the only problem was that in the event of malfunction, there would be a long wait while the equipment was sent away for repair (a problem mainly arising from the remoteness I suppose). I find it surprising that it is not used routinely, for example when assessing whether a respiratory infection is bacterial or viral.
1 Int J Lab Hematol 2009 Dec; 31(6):657-664
So the BEACH program had some uses after all!
It lost funding because the bureaucracy did not want the GP s to have a reliable source of data
not under its control.
Nemini
I think we also need to look at what happens when pyrexic patients are admitted to, or attend ED at, hospital.
I’d be surprised if many of the antibiotics dished out in those situations have much do to with cultures/sensitivities, or evidence based guidelines.
Let’s also have a look at what the orthopaedic surgeons are prescribing their non-infected patients!
I’m totally fed up of GP’s being singled out for scrutiny in this way. It happens far too often.
Maybe we should take Professor Glasziou to a remote practice, put him in a small room with a screaming pyrexic toddler at 5.30pm on a Friday afternoon, and see how he deals with the situation when the parents are travelling 100km to another rural village the following day. These are the things which are always forgotten when throwing down abuse at GP’s from on high.
In regards to the poll – I think doctors need the education campaign more than patients! Doctors ultimately make prescribing decisions, not patients. Sure, decisions are made in the context of patient expectations and pressures, but doctors are the ones qualified and with the authority to make prescribing decisions.
As long as universal bulk-billing remains, we will have unscrupulous doctors practising six-minute medicine. The “average” GP consult might take 14 minutes but there are plenty of docs out there seeing upwards of fifty patients a day – sometimes as many as eighty or even a hundred. Are they seeing their patients for an average of 14 minutes? No. They are reaching for their script book almost before the patient has finished telling them their symptoms.
Thirty years ago I made a personal commitment always to prescribe ethically and as close as possible to accepted guidelines. As a result, I saw half as many patients per hour as all the other docs at my outer-suburban bulk-billing barn, and of course, I made half as much income.
Seems nothing has changed in the interim. You cannot make an unethical doctor ethical. The only way we can stop overprescribing of antibiotics is by offering financial incentives for doctors not to over-prescribe.