‘Everyone’s concern’: GPs’ role in antimicrobial stewardship

The World Health Organization (WHO) does not hold back in its warnings for World Antimicrobial Resistance Awareness Week (18–24 November).
 
For the initiative, which draws attention to the dangers of drug-resistant infections and the importance of safe antimicrobial use, the WHO says decades of medical progress are at risk, along with the health of people, plants and ecosystems.
 
‘Antibiotics that once reliably cured common infections are rapidly losing effectiveness,’ it warns.  
 
‘Antimicrobial resistance is already responsible for more than a million deaths each year, with the toll expected to climb in the coming decades.’
 
With rising rates of antimicrobial resistance in hospitals and the community in Australia, and thousands of associated deaths each year, the issue is also one of fundamental importance to Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care.
 
A researcher on antimicrobial stewardship at Bond University, and co-author of a review of successful, evidence-based strategies for the Australian Journal of General Practice (AJGP), he understands the difference GPs can make.
 
‘Antimicrobial stewardship needs to be everyone’s concern,’ Professor Morgan told newsGP.
 
‘Clinical decision-making in general practice could have a significant impact on reducing low-value antimicrobial use.
 
‘GPs provide a lot of healthcare and so we are responsible for the majority of antimicrobial use.’
 
Professor Morgan can recall conversations during his GP training 30 years ago about strategies to reduce antibiotic use for conditions that are often self-limiting, including sore throats, otitis media, sticky eyes, sinus congestion, and acute bronchitis.
 
‘Many of the strategies and much of the science around antimicrobial stewardship does not seem to be very different now,’ he said.
 
‘Back then we were encouraged not to prescribe unless the presentation was severe or there were patient-vulnerability factors.
 
‘We were encouraged to use ‘delayed prescribing’ as a strategy to give some, albeit brief, time for self-limiting conditions to start getting better without antibiotics.’
 
He says ‘a long tradition’ of blame-shifting should not become a distraction.
 
‘Many times, I’ve heard the blame for antimicrobial resistance attributed to vets, agriculture and international travellers,’ he said.  
 
‘These other potential contributors to antimicrobial resistance do not remove the need for better antimicrobial stewardship in general practice.’
 
Professor Morgan is also concerned about emerging risks, which include expanded pharmacy prescribing, with topical and oral antibiotic prescribing by pharmacists ‘an increasing component of our health landscape’.
 
While he says the COVID-19 pandemic promoted awareness of measures to reduce the spread of infections, including the importance of hand and respiratory hygiene and social isolation when symptomatic, he notes the growing impact of vaccine fatigue and hesitancy.
 
‘We should be doing everything possible to increase immunisation rates for vaccine-preventable infections to reduce direct harms from infections and subsequent antimicrobial use,’ he said.
 
One cautious source of optimism is that antibiotic use in the community has fallen in Australia, but Professor Morgan also notes that is ‘from a high base compared to other countries’.
 
The evidence, too, has evolved, a factor he hopes could help GPs.
 
‘The science has become clearer about the individual harms from using antibiotics including the lasting impact on the individual’s biome,’ he said.
 
‘Research has also demonstrated the marginal benefits of using antibiotics in most common acute respiratory infections.
 
‘The balance of harms and benefits opens the way for shared decision-making.’  
 
A summary of evidence-based primary care strategies for antibiotic stewardship and a comparison of their impact is available on the AJGP website.
 
A summary guide on antibiotic prescribing is also available on the Therapeutic Guidelines website.
 
First Do No Harm, the RACGP’s guide to choosing wisely in general practice, includes a new chapter on otitis media, with a GP resource and a patient resource.  
 
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