Australian antibiotic prescribing remains high – despite recent drop

While it has been variously referred to as a slow moving pandemic and the global warming of healthcare, the spectre of increasing antimicrobial resistance fuelled by high rates of antibiotic prescribing remains a nationwide threat.
 
In particular, a new report tracking antibiotic use in Australia over a recent five-year period has revealed a sustained pattern of high use in some of the most disadvantaged areas of major cities across the country.
 
Compiled by the Australian Commission on Safety and Quality in Health Care (ACSQHC), the report also showed the country’s prescribing rates remain comparatively high, with the 22.7 defined daily doses per 1000 people recorded in 2017–18 more than double the equivalent figures in the Netherlands (8.9) and Sweden (10.8).
 
Professor John Turnidge, the ACSQHC Senior Medical Advisor, told newsGP Australia already has ‘superbugs’ and ongoing efforts are an attempt to ‘relieve the pressure and stop them getting worse’.
 
‘There are four different types of superbugs that worry us on a regular basis now, and one [vancomycin-resistant enterococci] where we already hold what appears to be [close to] the “world record” in terms of amount,’ he said.
 
‘It’s a bug that really only troubles very sick people and it’s mostly seen in hospital. But we have very high levels when we compare ourselves to data from other countries.’
 
However, while certain parts of Australia – especially outer suburbs in Melbourne, Brisbane and Sydney – had engaged in potential overuse of antibiotics, there was still an overall 13.3% drop nationwide between 2013–14 and 2017–18.
 
Dr Rashmi Sharma, co-author of the RACGP’s Response to antimicrobial resistance in primary care, told newsGP the overall reduction in use is ‘heartening’, but warned it is not enough.
 
‘We have to remain hyper vigilant and really think twice before we prescribe antibiotics, across the board, and for all conditions in all areas of the country,’ she said.
 
‘A lot of little measures can make a big difference and that’s what we have to remember. Everyone has a role to play.’
 
Aside from individual practitioners, Dr Sharma said fragmentation of care can also have an effect on appropriate antibiotic prescribing.
 
‘For example, I can anecdotally say that I’ve had patients say to me, “Oh, yeah, I come to see you for the complex things, but when I’ve got a cough or cold I go somewhere else”,’ she said.
 
‘Or at an after-hours clinic, there can be pressure on GPs to prescribe something because you’re seeing the patient late at night and you don’t necessarily have the backups of either other people to talk to in the practice, or other services you can utilise.
 
‘In a healthcare system where you don’t necessarily have that complete continuity of care it’s often harder for clinicians to have those conversations with patients, especially if their expectation is that they should have an antibiotic or they require one.
 
‘Whereas I think if you have a pre-existing relationship with these patients you can actually take the time to have that conversation.’
 
Confoundingly, antibiotic resistance may be contributing further fragmentation of care, with resistant golden staph (Staphylococcus aureus) an example of one superbug that is changing the way medicine is conducted in Australia.
 
‘It’s changed from being a hospital problem to a community problem,’ Professor Turnidge said.
 
‘And that’s probably one that frustrates us in terms of high antibiotic use in the community, because it perpetuates the problem and it makes people need to come to hospital to get treatment rather than having to be managed by the GP or as an outpatient.’
 
However, Professor Turnidge said being able to compare local-level data will enable the healthcare sector be more active in tackling antimicrobial use in the community through more targeted strategies.
 
‘This data will be tremendously helpful for clinicians, who can use it to identify potentially inappropriate antibiotics use in their local area, which may lead to better care for patients and declines in antimicrobial resistance,’ he said.
 
‘Primary Health Networks and Local Health Districts will also be able to implement targeted interventions in areas with antimicrobial dispensing rates consistently in the top 10% each year over the five years, including local areas in outer Sydney, Brisbane and Melbourne.’
 
Three quarters of the areas with consistently high use were in the lowest quintile of socioeconomic status. Dr Sharma said more research is needed into the social determinants of health. 
 
‘If you can see that this sort of practice is going on in areas where you have lower socioeconomic circumstances, then it makes you think, “Well, the patients and the populations are obviously more vulnerable, they’re complex, and they may not be so health literate”,’ she said.
 
‘You might also find that they’re short of GPs and other health practitioners there, because it’s a more difficult area to work in and so therefore there may not be those continuity of care models due to the type of population.


Dr Rashmi Sharma believes Australia is running out of time with regard to tackling antimicrobial resistance.
 
‘It’s really complex and I think this is a good example of why you need to drill down and fix the basic things, because then flow-on effects are enormous.
 
‘Patients are part of the solution, but if they’re not health literate you can’t blame them. Really, we need to bring it right back to the prescribers.’
 
Former RACGP President Dr Liz Marles said the overall decline in use shows GPs and the public have ‘taken on board’ educational messages about appropriate antimicrobial use, adding that the latest data will allow GPs to examine patterns of antibiotic use in their local community.
 
‘Some areas are doing particularly well, such as the low rates seen in Perth North and Perth South Primary Healthcare Networks [PHNs]. It would be good to investigate why these rates are so different from those of PHNs in Sydney, Melbourne and Brisbane,’ she said.
 
‘Overuse and misuse of antibiotics poses an ongoing risk to patient safety, and we know that improving patient understanding of the potential harms can lead to a decline in prescribing and use. Shared decision-making between doctors and patients can also help address concerns around antimicrobial resistance.
 
‘In this COVID era, we are seeing the impact of not having an effective treatment for an infectious disease. Antimicrobial resistance is critical for the whole community to address.
 
‘Every GP can contribute by using guidelines to inform decision-making, and auditing to identify where we can improve.’
 
Aside from GPs, Dr Sharma said other clinicians and prescribers – such as non-GP specialists, optometrists and nurse practitioners – also need to ensure they are ‘completely responsible’ with their prescribing.
 
‘It’s not just primary care. The problem is across the health system full stop,’ she said.
 
‘We don’t want to do good on one end and then drop the ball somewhere else.
 
‘I’ve seen patients that come out of hospital with discharge summaries of antibiotics that have no instruction about how long the patient should actually take the antibiotic for or what the requirement was.
 
‘They may not be on a PBS script that we can necessarily pick up, but they’re still being used and they’re still contributing to that overall antibiotic resistance.
 
‘We’re going in the right direction, but we’ve still got a long way to go and we really have to get there quickly, because we’re running out of time.’
 
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