Pharmacy prescribing will worsen antibiotic shortage: RACGP President

Filip Vukasin

19/12/2022 5:02:15 PM

The trimethoprim shortage is another reason why allowing pharmacists to prescribe antibiotics is problematic, Dr Nicole Higgins has warned.

Pharmacist reaching for antibiotics.
The RACGP has warned against creating more antibiotic prescribers at a time when there is widespread shortages.

RACGP President Dr Nicole Higgins says the ongoing trimethoprim shortage is a much-needed wake-up call that demonstrates the folly of adding more antibiotic prescribers to Australia’s healthcare system.
The warning comes in the wake of multiple states and territories trialling independent pharmacy prescribing for urinary tract infections (UTIs), for which trimethoprim is a first-line treatment.
Queensland has permanently extended its UTI prescribing pilot against the advice of health groups, including the RACGP, and launched a North Queensland pharmacy prescribing pilot, while Victoria and New South Wales have also announced their own pilot programs.
GPs and medical groups have warned that expanding pharmacist prescribing powers represents a conflict of interest and will lead to greater antimicrobial resistance, as well as risk patient safety and wellbeing.
‘The trimethoprim shortage highlights why carefully managing antibiotic prescribing is so important and must be left to the experts with proper medical training,’ Dr Higgins said.
‘Australia needs proper antibiotic stewardship and evidence shows that community pharmacists overprescribe antibiotics.
‘Where I live and work in Mackay, we have limited supplies of trimethoprim and no amoxicillin nor augmentin.’
Australia has experienced supply issues for several medications due to manufacturing and distribution challenges in the aftermath of the COVID-19 pandemic, culminating in the current antibiotics shortage.
The Therapeutic Goods Administration (TGA) published a warning about the issue on 8 November and declared a Serious Scarcity Substitution Instrument (SSSI) until 31 May 2023, which allows pharmacists to substitute amoxicillin without approval.
For Dr Higgins, the current shortage presents even more red flags for a program that has already drawn the ire of clinicians.
‘A shortage of a commonly-prescribed antibiotic is much higher stakes in terms of poor clinical outcomes,’ Dr Higgins said.
‘It can compound the issue of antimicrobial resistance as GPs are forced to prescribe broader spectrum antibiotics, making the entire problem much worse.
‘That is why the judicious use of antibiotics is more important now than ever before.
‘Australia needs proper antibiotic stewardship and evidence shows that community pharmacists overprescribe antibiotics.
‘GPs are the ones who understand that UTI treatment needs to be done with conservative options, if at all possible, to both conserve antibiotics when they are so hard to access and to prevent antimicrobial resistance.’
And with a recent World Health Organization report showing that more than 20% of E. Coli isolates, the most common pathogen in UTIs, showed resistance to antibiotics, Dr Higgins says now is not the time to test pharmacy prescribing schemes. 
‘When a patient with symptoms of a suspected UTI walks into a pharmacy they will be handed trimethoprim because when your only tool is a hammer every solution is a nail,’ she said.
‘Pharmacies also have a profit motive because they will be the ones dispensing the very antibiotic they themselves have just prescribed.’
She predicts Australia will see an explosion in antibiotic prescribing due to the schemes, at a time when clinicians are trying to combat antimicrobial resistance, one of the great public health challenges of this century.
‘GPs have the requisite know-how and experience to be able to substitute an antibiotic like trimethoprim and conserve precious supply. That is essential when we are facing shortages of medicines commonly used around Australia,’ she said.
‘In the United Kingdom and next door in New Zealand, increased trimethoprim resistance has resulted from inappropriate prescribing and use of antibiotics. The antibiotic was over-prescribed and now doesn’t work for one-in-three women due to resistant bacteria.
‘Similarly, in Canada, pharmacists prescribed seven times more antibiotics than doctors for UTIs and in Queensland, pharmacists prescribed antibiotics to 96.3% of patients with UTI-like symptoms, without taking urine samples to confirm if there actually was an infection.’
Dr Higgins says Australia should learn from these jurisdictions and abandon plans for pharmacist prescribing, rather than follow their lead.
‘Action is needed to stand up to the Pharmacy Guild and stop these pharmacy prescribing powers before it is too late,’ she said.
‘The trimethoprim shortage highlights just how important it is we get this right and act without delay.
‘Otherwise, patients across Australia will suffer the consequences and that is something no one wants.’
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Dr Greg Saville   21/12/2022 5:08:30 PM

It’s much worse than this. The antibiotic shortage has been compounded by the last legal monopoly in Australia - pharmacies can only be owned by pharmacists. This means the large supermarket chains cannot open pharmacies. This then means the purchasing power of these large companies in the international medicines market is lost. Australia is shooting itself in foot when it comes to getting cheap, good quality medicines in sufficient volume. Time for the monopoly to end!