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20 November 2023

Keep our antibiotics effective to keep communities safe, GPs warn

The RACGP has highlighted the risks posed by increased non-medical prescribing of antimicrobials during this World Antimicrobial Awareness Week, which runs from 18–24 November.

The recent AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health highlights several dangerous bacteria as major healthcare problems because they are increasingly resistant to common antibiotics – making it more difficult to treat serious infections.

While there has been an overall drop in Australia’s antimicrobial use in recent years and AURA 2023 highlighted antimicrobial stewardship efforts by GPs, the Australian Commission on Safety and Quality in Health Care highlighted the need for judicious prescribing of antimicrobials for urinary tract infections, skin infections, and other infections.

The RACGP has previously highlighted the risk pharmacy prescribing poses, including through increased use of antibiotics for presentations with symptoms of urinary tract infection without proper diagnosis.

RACGP President Dr Nicole Higgins said introducing more non-medical prescribers of antibiotics in Australia risks undercutting improvements to Australia’s antimicrobial stewardship.

“There is a strong and growing awareness of the importance of keeping antibiotics effective for our patients,” she said.

“The WHO has declared antimicrobial resistance one of the top global public health threats facing humanity, and antimicrobial-resistant infections led to 1.27 million deaths in 2019. The misuse and overuse of antimicrobials are the main drivers of antimicrobial resistance. We need to take this seriously.

“GPs and other health professionals in general practice know we need to be prudent in our use of antimicrobials, and this report reflects that. We need antimicrobials to work when we need them to keep people, especially our most vulnerable patients, safe. The days of providing a prescription for antibiotics as a matter of course are long in the past.

“That’s what makes these pharmacy prescribing trials so alarming. Pharmacists don’t have the diagnostic skills of a GP nor the clinical setting to confirm a UTI. Sometimes antibiotics may not be required at all. Or symptoms of a UTI might actually be symptoms of a more serious health problem. There is the risk that people will then present to their GP much later and their health condition has worsened. It also means a patient may have completed a course of antibiotics to no benefit before seeing a GP.

“It’s a waste and a risk. It’s risk that it has potentially contributed to antibiotic resistance, and worsening outcome for the patient. Many general practices employ pharmacists who are well-placed to work with GPs and patients on appropriate treatments in a team setting, with access to medical practitioners, knowledge of a patient’s medical history, previous medication interactions, and their sensitivities to antimicrobial drugs. It’s simply a smarter and safer approach to antimicrobial prescribing.”

The report also noted an increasing proportion of private prescriptions for antimicrobials, meaning prescriptions that are not subsidised under the Pharmaceutical Benefits Scheme (PBS). Limited reporting and monitoring mechanisms for these results in a gap in antimicrobial use surveillance in Australia that requires attention.

RACGP WA Chair Dr Ramya Raman highlighted the safeguards put in place in Western Australia’s pharmacy prescribing trial due to the state government’s consultation with GPs, infectious disease physicians, and other health experts.

“We have serious concerns about the WA pharmacist project and advocated successfully for the antibiotic cefalexin to be removed due to the heightened risk of antibiotic resistance its inclusion posed,” she said.
“While the retail pharmacy prescribing pilots do not align with RACGP’s position, the state government took the risk of antimicrobial resistance seriously in its approach to this trial.

“Along with the exclusion of cefalexin from the trial, we have been able to include the recommendation that pharmacists use urinalysis where practical, for patients to provide their GP with a service summary, and where patients do not have a GP, to highlight the importance of having a GP and encourage and assist patients to find one.

“Nonetheless, we call on the Western Australian government to rigorously evaluate this pharmacy prescribing project. We contributed to the program to reduce public health risks, and we do not endorse the program.

“Safe prescribing relies on accurate diagnosis. Research has found clinical reasoning is not a skill people acquire independent of medical knowledge and other diagnostics skills. Instead, it is something doctors develop in iterative stages as their clinical reasoning and their knowledge of clinical sciences, biochemistry, pathophysiology, and other domains improves.

“This is essential for differential diagnosis – the identification of what a patient’s health condition is, from a range of diagnoses that it might be.”

RACGP WA will run a special evening session in Perth on the evening of Wednesday 22 November, Preventing antimicrobial resistance together, on the contemporary use of antibiotics and the role of the GP in reducing the risk of resistance, changing prescribing patterns and educating patients.

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