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.


Poll

Pharmacists should be allowed a wider scope of practice
  • Strongly disagree (52%, 188 Votes)
  • Strongly agree (21%, 76 Votes)
  • Disagree (19%, 69 Votes)
  • Agree (7%, 24 Votes)
  • Neutral (2%, 8 Votes)

Total Voters: 365

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7 thoughts on “Queensland decision threat to antimicrobial stewardship

  1. Prof J Andrews says:

    Happy for them to enlarge scope of evidence-based practice if they rid their shops of much of the “rubbish” which they endorse by having it on their shelves….. The public should get a clear visual signal as to whether any product has evidence behind it, or simply marketing/profit motive

  2. Anonymous says:

    Surely it is time for a Firm response from AMA, RACGPs ,Infectious Disease Physicians etc to counter this retrograde poor decision by a Health Minister another minister for Pharmacy Guild

  3. Anonymous says:

    Politicians know what’s best.. for them.

  4. Anonymous says:

    If pharmacists are allowed to dispense antibiotics without a doctor’s script, thereby playing both prescribing and dispensing roles, why aren’t doctors allowed to dispense antibiotics from the medical clinic? Isn’t this proposal fair if not better for the public?

  5. Anonymous says:

    Do we really need the huge financial cost of ANY Dispensing Community Pharmacies to the Health system ?

    Clearly GP Software is far superior to any level of competence and vigilance I have ever seen in community pharmacies to detect and warn the prescriber about drug interactions and individual patient’s contraindications.
    One local pharmacy happily added potentially lethal Ciproxin from a specialists hand written script to Azilect ,which was their only other medication.
    I find Community Pharmacies often appear to be dangerous and misleading settings for the vulnerable public.
    It’s ridiculous to allow the public into these profit driven “Candy-Stores” where they are exposed to endless unproven,unscientific products often added on to their prescription item at the “recommendation “ of the pharmacist,
    Or worse still harmed by pharmacy assistants like the diabetic who got expensive magnesium for his tingling feet,while his bsls were over 20 !

  6. Anonymous says:

    It’s so sickening listening to all the arguments from both groups about each other’s turf… we need people who ultimately are thinking about what’s best for the patient and not their damn profession

  7. Anonymous says:

    I agree with the expansion of the scope of practice for pharmacists. I’m sure pharmacists could be further utilised to mitigate the blowing costs of medicare. If pharmacists are trained as prescribers in a 6-12 month post degree qualification with restrictions on practice settings (i.e. pharmacy vs general practice vs hospital etc.), this can avert additional waiting times in clinics and in rural areas.

    I don’t agree with antibiotic prescribing in pharmacy settings, as we currently have antibiotic resistance at crisis levels. I don’t think this will help tackle the issue, it will most likely impact it further. In saying that, doctors need to really address this issue, as it has happened at their helm. They need to act as prescribers not to say yes to everything, due to patient pressure.

    Ive seen on a number of occasions from both GPs and pharmacists recommending chlorsig, when it is clearly not indicated or appropriate. Both settings don’t have slit lamp bio-microscopy and both GPs and pharmacists arent trained in ophthalmology like eye care health professionals. Its ridiculous to see GPs and pharmacists acting like ophthalmologists or optometrists when they clearly dont have the diagnostic equipment to do so.

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