GIVEN the history of antimicrobials and the emerging threat of antimicrobial resistance, it is difficult to understand the approach taken by the Queensland Minister for Health to allow the prescription of trimethoprim for urinary tract infections by pharmacists.
Against the express advice from the Australian Medical Association (AMA), AMA Queensland, the Australasian Society for Infectious Diseases, the Australian College of Rural and Remote Medicine and the Royal Australian College of General Practitioners, the Minister, Hon Stephen Miles, has agreed to a trial that will allow pharmacists – whose primary qualifications do not include training in the diagnosis or management of disease – to prescribe directly to patients for the treatment of urogenital symptoms.
First, some history.
The cover photograph on old, print versions of the Australian Therapeutic guidelines — antibiotic is of a blood agar plate featuring colonies of Penicillium chrysogenum and Staphylococcus aureus – a modern facsimile of Alexander Fleming’s original experiments demonstrating the antibacterial activity of penicillin.
One of Fleming’s subsequent insights was that S. aureus was capable of restricted growth in low concentrations of penicillin and effectively predicted the potential for these emerging compounds to induce antibiotic resistance and therefore risk treatment failure.
Collectively, antibiotics are typically drugs with a broad therapeutic index (with notable exceptions), which, when prescribed in an evidence-based manner, are profoundly effective in reducing morbidity and mortality consequent to infection. However, throughout the “golden” antibiotic era, all classes of microorganisms, but especially bacteria, have demonstrated their ability to acquire resistance mechanisms to compounds to which they were previously susceptible. Notable examples include penicillin and methicillin resistance in S. aureus, extended-spectrum b-lactamase (ESBL) production by Escherichia coli, penicillin-resistant Neisseria meningitidis, extended drug resistant strains of Neisseria gonorrhoeae, ceftriaxone- and ciprofloxacin-resistant strains of Salmonella typhi, multidrug- and extended drug-resistant strains of Mycobacterium tuberculosis and quinine-resistant Plasmodium falciparum.
In order to successfully treat these resistant infections, the patient and treating clinician are left with limited options, including third-line, costly or more toxic drugs that very often can only be administered in a hospital or hospital-in-the-home intravenous program; however, despite these options, these infections frequently have an increased mortality risk. Currently, 700 000 deaths per year (worldwide) are directly attributable to multiresistant organism infections, representing a major, emerging public health problem. In addition, a lack of antimicrobials could significantly restrict future capacity for many procedures, including organ transplantation, cancer chemotherapy, major surgery, and treatment of diabetic complications.
Some decades ago, “dirty hospitals” took much of the obloquy for the selection and transmission of “superbugs” as a consequence of antibiotic misuse, overuse and poor infection control practices. In response, there have been dramatic, evidence-based improvements in infection control, antibiotic management, antimicrobial stewardship and hospital regulation and administration. These have been instrumental in improving patient safety, the separation of the prescribing of medicines from dispensing, and reducing the risk transmitting multiresistant organisms.
However, many of the multiresistant pathogens listed above have been selected as a consequence of treatment in the community, whether or not the patient was treated in a high income or low income country. Antimicrobial resistance occurs wherever antimicrobials are prescribed. It is essential that antimicrobial susceptibility be preserved for our patients for as long as possible.
Antimicrobial stewardship has been part of the normal practice for infectious diseases physicians and medical microbiologists for decades. It has evolved into a true multidisciplinary process that includes pharmacists, nurses, hospital administrators, and doctors from many disciplines; and is a mandated accreditation requirement of the Australian Commission on Safety and Quality in Healthcare for all hospitals. Nationally, antimicrobial stewardship also includes the veterinary and agricultural sectors. Within hospitals, it dovetails in with infection control, vaccination strategies and hand hygiene programs to reduce the risk of patients acquiring infections, in addition to minimising the selection and transmission of multiresistant pathogens.
The stewardship process emphasises the importance of collecting appropriate cultures before commencing antibiotic therapy, not only prescribing the “correct” antibiotic but also the revision of treatment when culture results are available, the role of surgical drainage and removal of redundant devices, the use of an antibiotic with an appropriate spectrum for the appropriate duration, and audits according to nationally standardised criteria.
Antimicrobial stewardship opportunities exist in all disciplines of medicine and is a process that all doctors, to varying extents, need to support and participate in, commensurate with their practice. Such examples include the appropriate timing of pre-operative antibiotic prophylaxis, using narrower spectrum agents for non-severe lower respiratory tract infection, avoiding antibiotic use for viral upper respiratory tract infections, delayed prescribing strategies for patients with early or protean symptoms, and switching to narrower spectrum agents when cultures demonstrate susceptibility.
Many clinicians may find this daunting, and for some it could represent significant practice changes, but this needs to be balanced with the knowledge of the potential harms of antibiotics, the harm from multiresistant organism infection (including increased mortality risk for our patients), and the benefits accrued from using narrower spectrum agents. There are numerous continuing professional development programs to support clinicians in this process.
The responsibility of prescribing is conferred to medical graduates after demonstrating sufficient aptitude in the diagnosis and management of the whole patient with any particular disease.
In addition to diminishing the impact of many Queensland Health initiatives to tackle antimicrobial resistance, and being dismissive of medical training and continuing professional development requirements, the ersatz rationale for this decision by the Queensland Minister for Health risks harming our patients and the decision needs to be reversed.
Dr Paul Bartley, BMedSc, MBBS, FRACP, FRCPA, PhD, is an Infectious Diseases Specialist; Co-Chair of the Uniting Care Health Antimicrobial Stewardship Committee.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.