Experts call for end to controversial pharmacy prescribing trial

Doug Hendrie

29/07/2020 4:54:19 PM

Antimicrobial experts warn prescribing the antibiotic trimethoprim could directly lead to rising rates of antimicrobial resistance.

Hand holding blister packs of capsules.
Antimicrobial resistance is on the rise.

Pharmacy prescribing of the antibiotic trimethoprim in Queensland’s controversial trial is under renewed scrutiny after infectious diseases and antimicrobial stewardship pharmacists warned it could lead to rising rates of antibiotic-resistant bacteria.
The Chair of the NSW Antimicrobial Stewardship Pharmacist Network (NASPN) – a group of 64 infectious disease pharmacists – has called for the trial to be stopped. Senior infectious diseases pharmacist Aryan Shahabi-Sirjani warns that a similar trial in New Zealand has been linked to a spike in the use of trimethoprim and a corresponding rise in bacterial resistance to the drug.
Australia’s rates of trimethoprim resistance in E. coli are substantial, and they are increasing, rising from an estimated 21–29% in 2014 to 33% resistance in 2017, according to a recent Australian Commission on Safety and Quality in Healthcare report.
Mr Shahabi-Sirjani said proposals for a similar 2010 trial in the UK had been withdrawn due to concerns about increasing resistance to antibiotics.
Queensland’s trial permits participating pharmacists who have undertaken training to diagnose urinary tract infections and prescribe trimethoprim or two other antibiotics to patients.
There is no requirement in the trial to undertake urine tests, meaning pharmacists will not be able to be certain of their diagnosis.
Around 25% of patients with urinary tract infection (UTI) symptoms do not have a bacterial infection, making antibiotic prescriptions pointless.
Mr Shahabi-Sirjani’s calls come after his network strongly opposed a 2019 proposal by the Therapeutic Goods Administration (TGA) to down-schedule trimethoprim alongside other medications from Schedule 4 to a new Schedule 3 (pharmacist-only), making them available over the counter.
‘Down-scheduling of trimethoprim from Schedule 4 to Schedule 3 will invariably lead to increased access and use, with subsequent increased rates of resistance and the threat of trimethoprim becoming ineffective. This has been demonstrated in New Zealand,’ the NASPN stated in its submission.
‘Pharmacists in Australia are not currently qualified to diagnose UTIs [which requires] utilising the
appropriate history, physical examination and investigations of the patient.
‘There is an inherent risk of pharmacists missing a differential diagnosis or complications of a UTI.
The most important complication that bears significant mortality is sepsis.’
The Society of Hospital Pharmacists of Australia (SHPA) also warned the TGA that it ‘firmly believes’ allowing trimethoprim to be dispensed over the counter by community pharmacists is unsuitable, given the impact of antimicrobial use at public health and individual patient levels.
‘Reducing the incidence of antimicrobial resistance is a national and global health priority and loosening access controls to these vital medicines can undermine actions to preserve the efficacy of antimicrobials,’ the SHPA warned in its submission.
SHPA Chief Executive Kristin Michaels told newsGP her organisation does not have a position on this specific trial, given it is taking place in a community pharmacy setting, but supports supervised prescribing in a hospital setting. 
Australia’s National Centre for Antimicrobial Stewardship also cautioned that down-scheduling trimethoprim would be ‘detrimental to antimicrobial stewardship initiatives’ in its submission
The Australian Society for Antimicrobials and the Australasian Society for Infectious Disease warned in a joint submission that pharmacists prescribing of antibiotics came with real risks.
‘One of the great benefits of the Australian healthcare system is the separation of prescribing from dispensing, thereby eliminating the risk of perverse financial incentives when prescribing,’ the submission states.
‘Avoidance of perverse financial incentives is highlighted by the World Health Organization policy on promoting rational use of medicines. We believe that there would be significant risk of creating this perverse incentive with re-scheduling of any agents.
‘We do not consider it good clinical practice in these days of rising resistance to prescribe for [uncomplicated UTI] without access to some form of testing, at a minimum a urine dipstick, but ideally a midstream urine specimen for microbiological testing.
‘Pharmacists do not have the power to order such investigations. Furthermore, pharmacists do not have access to previous culture results which may indicate that trimethoprim will be ineffective.’
The RACGP and the Australian Medical Association (AMA) have long warned of the dangers of antimicrobial resistance as a result of the trial, as well as misdiagnosis and fragmentation of care.
The trial went ahead despite lobbying of every Queensland Member of Parliament by both medical organisations.
RACGP Queensland Chair Dr Bruce Willett told newsGP the top two health risks facing the world are pandemics like the coronavirus – and antimicrobial resistance.
‘Antimicrobial resistance is in a sense very similar to this pandemic, both have the potential to kill millions,’ he said.
‘Antimicrobial resistance is the slow-motion version of COVID-19. We have seen the importance in Australia of being able to plan for the pandemic.
‘But, unfortunately, in Queensland there is a tendency to ignore the growing tsunami of antimicrobial resistance and to go the other way, rather than to improve it.’
Dr Willett said the calls by infectious disease pharmacists show the difference between retail pharmacies and hospital pharmacists.
‘Retail pharmacies are not the place to be receiving a treatment. We’ve seen evidence of why that’s a problem in the low reporting rates to the National Immunisation Register by pharmacies of vaccinations done there, with only 50% reported,’ he said.
Dr Willett said another key issue is the traditional separation of powers between doctors and pharmacists in order to avoid financial conflicts of interest.
‘From a chemist’s point of view, you could spend 15 minutes explaining why an antibiotic is not indicated [for the patient’s symptoms], in which case you receive no payment. Or you could hand over the prescription, in which case you receive $20 plus your margin on the antibiotics and a prescribing fee,’ he said.
‘What are you going to do?
‘This is why the prescriber is not the dispenser. That should be the bare minimum.’
AMA Queensland President Dr Chris Perry said doctors have grave concerns about the risk of
misdiagnosis of symptoms and the threat of patients’ conditions worsening.
‘This is a really dangerous initiative and one that doctors have vehemently opposed,’ Dr Perry
said. ‘Unfortunately, our concerns have fallen on deaf ears.’
Queensland Health did not respond to requests for comment.
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Dr Gibson Gadron Pawape   30/07/2020 7:15:37 AM

Local epidemiology of drug-resistant pattern may also be important