Key words: antibiotic resistance, drug utilisation.
(Aust Prescr 1999;22:26-8)
There is a growing realisation that the world is scraping the bottom of the antibiotic barrel.1 In response, a number of national and international bodies have outlined strategies to combat this problem.2,3,4,5 One example is the United Kingdom's `Campaign on antibiotic treatment' (Table 1). In the light of this activity, it is timely to ask if Australia is playing its part in this global battle against antibiotic-resistant micro-organisms.
Antibiotic use in Australia has been as high as in the United Kingdom, Canada and the U.S.A., but yearly increases were observed to plateau in the mid-1990s.6 The latest figures show a modest decline (Fig. 1). Over the last 3 years, change has also been observed in the prescribing of individual drugs (Fig. 2).
Australia has put in place a number of strategies to encourage the quality use of medicines (QUM) co-ordinated by the Pharmaceutical Health And Rational use of Medicines (PHARM) committee.7 These are also now the responsibility of the National Prescribing Service (NPS) (see `NPS News 3'). Measures specifically directed at improving the use of antibiotics have included National Medicines Week, support for an electronic version of `Antibiotic Guidelines'8 and funding a number of grass-roots projects involving general practitioners and consumers.
| Table 1 U.K. campaign on antibiotic treatment |
| Four things you can do: – No prescribing of antibiotics for simple coughs and colds – No prescribing of antibiotics for viral sore throats – Limit prescribing for uncomplicated cystitis to 3 days in women who are otherwise fit – Limit prescribing for antibiotics over the telephone to exceptional cases |
One such project, run by the Inner South East Melbourne Division of General Practice, looked at antimicrobial use in respiratory tract infections. The project involved consumers (Fig. 3) as well as practitioners, and produced a significant reduction in antibiotic prescriptions as well as increased compliance with the recommendations of the `Antibiotic Guidelines'. This work has confirmed previous experience; general practitioners will change their prescribing habits if they find their prescribing deviates from evidence-based national guidelines and they can reflect upon, and discuss, such differences amongst themselves.9
Other strategies have included restrictions and warnings by the Pharmaceutical Benefits Advisory Committee (PBAC) concerning flucloxacillin and trimethoprim/sulfamethoxazole. The Health Insurance Commission has also audited doctors' prescribing habits e.g. prescriptions of amoxycillin/potassium clavulanate. Ironically, while this audit decreased use of the antibiotic, there is evidence that this administrative intervention merely shifted prescribing to other equally over-prescribed antibiotics.
Fig. 1Community prescribing of oral antibiotics(DDD - defined daily doses)
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Fig. 2Changing use of oral antimicrobial drugs in Australia – Cephalexin use has increased, mirroring the decrease in use of flucloxacillin that followed its PBS restriction for use only in serious staphylococcal infections (August 1994) and the initial recommendation of cephalexin as an alternative. Dicloxacillin was listed as a pharmaceutical benefit in February 1997, but is currently only at a low level of use. – Amoxycillin/potassium clavulanate and amoxycillin use has been slowly falling. – Cefaclor utilisation is increasing despite concerns voiced by the Adverse Drug Reactions Advisory Committee (ADRAC) over the number of reactions suggestive of serum sickness with this drug (see `Letters' page 30). – Doxycycline use has been declining, as have the tetracyclines generally. – Trimethoprim/sulfamethoxazole use has been falling steadily over this period, most probably following recommendations for caution with use in the elderly due to the increased risk of adverse reactions. – The use of trimethoprim, an alternative for trimethoprim/sulfamethoxazole in some conditions, is increasing. – Roxithromycin use is increasing. – Quinolone usage is still relatively low.
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The Joint Expert Technical Advisory Committee on Antibiotic Resistance (JETCAR) of the Departments of Primary Industry and Health is grappling with the vexed subject of antimicrobials being used as growth promoters in animals. There is also the National Antibiotic Resistance Surveillance Program that collects data from 29 laboratories around Australia.
All of these efforts, while effective, have resulted in only a modest reduction in total antibiotic use. There are a number of reasons for this.
– The structure of the health system can increase the pressure to prescribe through having to deal with a large clinical workload or to maintain income.
– QUM activities have been spread thinly, with only a small number of activities aimed at prescribers and antibiotic use.
– While one-off project funding enabled a number of interventions to be piloted, there was no commitment to scale up proven activities to the level of national programs.
– Despite continued escalation of the cost of the Pharmaceutical Benefits Scheme, only small amounts of money have been allocated to QUM activities.
– Insistence upon a market model (where the sustainability of an activity was dependent upon selling services to end-users) has resulted in some excellent initiatives foundering. The end result is that many practitioners have yet to be exposed to QUM activities.
The Government has now committed substantial resources to the NPS which, in collaboration with PHARM, has the potential to overcome some of these problems.10 In addition, general practice accreditation requirements and practice incentive payments (PIP) could provide extra incentives for Divisions of General Practice and individual practitioners to engage in this area.11
Fig. 3Antibiotic education poster for general practitioners' waiting rooms (Inner South East Melbourne Division of General Practice)
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In summary, the time is ripe for Australia to build upon the solid foundations that have been laid, join with other countries, and commit to a grass-roots, nationally co-ordinated campaign, aimed at further reducing and optimising antibiotic use. In short, think globally and act locally.
(See also Dental implications)
A C K N O W L E D G E M E N T
Peter McManus, from the Drug Utilization Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee, Department of Health and Aged Care, kindly provided antibiotic utilisation data.
References
1. Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen P, et al. Antimicrobial resistance is a major threat to public health [editorial]. Br Med J 1998;317:609-10. <URL: http://www.bmj.com/cgi/content/full/317/7159/609>
2. Standing Medical Advisory Committee Sub-Group on Antimicrobial Resistance. The path of least resistance. London: Department of Health, 1998. <URL: http://www.doh.gov.uk/smac1.htm>
3. Health Canada and the Canadian Infectious Diseases Society. Controlling antimicrobial resistance: an integrated action plan for Canadians. Can Commun Dis Rep 1997;23 (7 Suppl). <URL: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/97vol23/vol23s7 /index.html>
4. Centers for Disease Control and Prevention. The C.A.USE: Careful Antibiotic Use to Prevent Resistance 1997;1:1-6. <URL: http://www.cdc.gov/ncidod/dbmd/cause/april97.htm>
5. A51/9. Emerging and other communicable diseases: antimicrobial resistance. Report by the Director-General, World Health Organization. Fifty-first World Health Assembly, 1998. Provisional agenda item 21.3. <URL: http://www.who.int/wha-1998/listang.htm>
6. McManus P, Hammond ML, Whicker SD, Primrose JG, Mant A, Fairall SR. Antibiotic use in the Australian community, 1990-1995. Med J Aust 1997;167:124-7. <URL: http://www.mja.com.au/public/issues/aug4/mcmanus/mcmabs.html>
7. Commonwealth Department of Health, Housing and Community Services. A policy on the quality use of medicines. Canberra: Commonwealth Department of Health, Housing and Community Services, 1992.
8. Writing Group for Therapeutic Guidelines: Antibiotic. Therapeutic guidelines: antibiotic. 10th ed. Melbourne: Therapeutic Guidelines Limited, 1998. <URL: http://www.tg.com.au/>
9. De Santis G, Harvey KJ, Howard D, Mashford ML, Moulds RF. Improving the quality of antibiotic prescriptions in general practice. The role of educational intervention. Med J Aust 1994;160:502-5.
10. Dowden JS. The National Prescribing Service [editorial]. Aust Prescr 1998;21:30-1. <URL: http://www.australianprescriber.com//magazine/21/2/30/1/>
11. Royal Australian College of General Practitioners. Entry standards for general practices. Sydney: Royal Australian College of General Practitioners, 1996. <URL: http://www.gpa.com.au/Standards.asp>
Dr Harvey is a member of the Board of Directors of Therapeutic Guidelines Limited, a not-for-profit organisation in which Directors receive no remuneration.
