Experts hail push to end repeats for common antibiotics

Doug Hendrie

10/10/2019 3:07:41 PM

Public health experts have welcomed a move to cut back on high-use antibiotic prescriptions by removing unnecessary repeat prescriptions.

Multiple packs of antibiotics
The PBAC has recommended the removal of repeat options for amoxicillin, amoxycillin-clavulanic acid, cephalexin and roxithromycin.

Bond University Professor of Public Health and antimicrobial resistance expert Chris Del Mar hailed the ‘very significant’ recommendation to ban repeats for four common antibiotics as a way to tackle the worrying rise of highly resistant bacteria.
The Pharmaceutical Benefits Advisory Committee (PBAC) has recommended the removal of repeat options for amoxicillin, amoxycillin-clavulanic acid, cephalexin and roxithromycin – the four antibiotics with the highest volume of repeats.
The recommendations are very likely to be accepted, with Federal Health Minister Greg Hunt understood to be supportive of the change.
Australia’s Chief Medical Officer Professor Brendan Murphy recently told the ABC the push represents the best method of tackling so-called superbugs, which he described as real threats ‘on our doorstep’.
‘[The changes] would support antimicrobial stewardship and quality use of medicines as well as assist in the reduction of antimicrobial resistance,’ the PBAC states in its reasoning.
RACGP President Dr Harry Nespolon praised the recommendations, calling antimicrobial resistance a ‘public health policy crisis’ that needs to be taken extremely seriously.
The rise of antibiotic-resistant bacteria risks a ‘return to the pre-antibiotics era of the 19th century,’ he said.
The PBAC recommendations come after Professor Del Mar called for an end to the default repeat option in electronic prescribing in a 2017 Medical Journal of Australia article.
‘Many GPs use repeats automatically, so this [move] would remove that from being able to be done. It may help set up more appropriate patterns and habits,’ he told newsGP
Professor Del Mar believes one underlying issue is the fact many clinical software tools used by GPs have repeats ticked by default for common antibiotics.
‘Many GPs aren’t aware that this is occurring – the software will tick the box without them being aware of it,’ he said.
‘It’s wonderful the PBAC is considering [ending that practice], as it’s an easy one to achieve in terms of antimicrobial resistance.
‘We know that far too many antibiotics are prescribed in general practice that don’t need to be, and that’s partly because the pack size doesn’t conform to the guidelines in many cases.
‘This is going to help GPs feel more comfortable about breaking the pack size if necessary, to make sure the right number of tablets are prescribed.’

Professor Chris Del Mar believes one underlying issue is the fact many clinical software tools used by GPs have repeats ticked by default for common antibiotics.

Professor Del Mar recommends GPs write down the exact number of tablets required for a specific infection in line with guideline recommendations.
‘For example, the guidelines suggest 15 tablets for acute otitis media, but the pack size is 21,’ he said. ‘So you write on the script “15 tablets” and the pharmacist cuts the rest off and disposes of them, so they’re not lying around the bathroom cupboard waiting to be used inappropriately.
‘We know that resistance is driven up by use. This makes sure there are less around to be used.’
Another part of the issue, Professor Del Mar said, is the fact many antibiotics manufacturers settled on an average pack size because their drug could treat multiple infections.
‘The pack size is out of alignment for the things they’re most commonly prescribed for – and that just stayed,’ he said.
If accepted by Minister Hunt, the changes would bring the Pharmaceutical Benefits Scheme (PBS) in line with the latest version of the Therapeutic Guidelines.
In a statement on their website, the Therapeutic Guidelines welcomed the recommendations as a way to ‘support antimicrobial stewardship and assist in reducing antimicrobial resistance’.
More than 30 million antibiotic prescriptions are dispensed every year through the PBS, and almost half of all Australians are given at least one course of the drugs.

Victoria’s Chief Medical Officer, Professor Andrew Wilson, told newsGP he supports the move.

‘The main implication is that people will have to come back for more clinical review, rather than more courses of antibiotics. That’s a good thing,’ he said.

‘If patients get repeats, they might go on it for four weeks before they come back and see their GP. Most of us would feel it’s reasonable clinical practice to review at the end of a course of antibiotics.’

Professor Wilson, a cardiologist, said the issue was not only inappropriate use and antibiotic resistance, but also portentially a different diagnosis.

‘If a patient isn’t getting better, that may point to another diagnosis, such as a deep seated infection or a non-infectious cause which may mimic infection. We can potentially avoid a delayed misdiagnosis,' he said. 

‘We see many patients with endocarditis, bone and joint infections and auto immune diseases who start with a fever of unknown origin and who have been on many course of antibiotics. So it’s an opportunity to rethink the whole diagnosis if a patient isn’t getting better.'
Dr Mina Bakhit, research fellow at the Bond University Institute for Evidence-Based Healthcare, said the move is important. 
He said the change will help tackle two problems with repeat prescriptions, namely that patients with repeats tend to get a second course of antibiotics and keep it at home, and the belief that they can use the repeat whenever they want.
‘This poses an issue with antibiotic resistance, and the same antibiotic is not going to be as effective the next time they use it,’ he said. 
‘With acute respiratory-tract infections, [for example], the benefit of using antibiotics would be a saving of around 12 hours over the duration of the whole infection.’
If the changes are accepted, repeats would no longer be subsidised by the PBS and patients would have to return to their GP for another script if necessary.
Australian Commission on Safety and Quality in Healthcare senior medical advisor Professor John Turnidge told The Australian the move is a significant one.
‘I’m very pleased that the PBAC has finally aligned with our national guidelines and we look forward to even greater efforts nationally to address the problem of the overuse of antibiotics,’ he said.
The RACGP has this year strongly opposed the pharmacy-prescribing trial in Queensland, which would allow pharmacists to prescribe certain antibiotics, warning of the dangers of antibiotic resistance.

antibiotics antimicrobial resistance prescriptions superbugs

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Dr Peter James Strickland   11/10/2019 12:53:35 PM

Resistance to antibiotics is NOT caused by GPs, but rather those who prescribe the 'big guns' in hospitals automatically for certain infections. Two courses of some common antibiotics are often needed for acute on chronic respiratory, renal, heart, bone etc. infections. Are these experts suggesting a patient return to their GP from home when they should be at home recovering from some of these infections?--- NOT practical, and showing lack of real care of patients out there in the community, and an ignorance of proper and considered management. The solution is to increase the size of the packages of antibiotics such as roxithromycin, as at present one pack of 5 tabs is insufficient often for bronchitis and tonsillitis, and esp. acute on chronic episodes in many patients waiting for hospital or specialist care.

Dr Cormac Fintan Carey   12/10/2019 5:03:34 PM

Again experts telling us what to do and agree that it’s hospitals that most overuse a/bs.
Even if people have repeats stashed away I suspect the percentage that is used is minimal and most scripts will be expired anyway.
Having spent this Saturday am writing countless nursing scripts and visiting RACF’s to diagnose and write countless antibiotic scripts for pneumonia’s , uti’s and cellulitis it is only going to increase the workload again of those who are actually at the coalface doing the work.
Not to mention regional areas where people are klms out of town and limited access to pharmacies.
All very well in academic theory but again hopeless suggestion in practical terms for those of us suppling the scripts.