Facing harsh truths: Antibiotics in modern general practice

Evan Ackermann

14/11/2017 8:31:58 AM

To mark World Antibiotic Awareness Week, prominent GP Dr Evan Ackermann writes for newsGP about the realities of antimicrobial resistance.

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Healthcare professionals understand the truth that antibiotics aren’t naturally beneficial for anyone; rather, there’s just an expectation that antibiotics will do more harm to the bacteria rather than the patient when illness arrives.
This is a truth that may not sit well with some people. Unfortunately, at a time when the world is facing a future with less effective antimicrobial agents, some harsh realities need to be faced by both clinicians and health sector managers.
Australia has mounted a coordinated multi-sector strategy to reduce the threat of antimicrobial resistance. In this response, general practice has a significant role to play to address the rise of resistant bacteria.
The main priority for this strategy is patient safety, and not simply reducing antibiotic prescriptions as some have inferred. On one hand, our patients are simply not going to tolerate inappropriate risks for themselves or their families. The other side of the argument is that antibiotics are currently over-prescribed, with almost every second person in Australia getting an antibiotic prescription every year, often in low-risk situations.
Finding time to work through issues with patients is going to be fundamental to a general practice response to antimicrobial resistance. To facilitate a safe approach, we simply must improve at detecting clinical severity and risk of clinical deterioration. No one will want to see media articles about young children dying or suffering after ‘missed diagnoses’ while being ‘turned away from the GP or hospital’.  
Reducing the use of antibiotics will be possible, but added point-of-care diagnostic tools and monitoring systems may be a necessity. Maximising vaccinations is essential, as is optimising infection control and environmental hygiene within general practice.
Targeting therapy in acute respiratory tract infections (ARTIs) is an evidence-based strategy. The ‘viral vs bacterial’ paradigm has had its day as the sole determinant for antibiotics. Not only do viral and bacterial ARTIs co-exist, both viral and bacterial infections often resolve in the context of a healthy patient and immune system. Identifying those patients with ARTIs who are likely to be at risk of developing complications is the key strategy. In the event of prognostic uncertainty, further investigation, delayed antibiotic prescriptions or monitoring systems should be preferred to antibiotic therapy.
Whoever said ‘broad spectrum antibiotics are no substitute for rational thought’ was probably thinking of the clinical variations that form part of ARTI presentations in general practice. ARTIs that are too frequent, too severe, last too long or fail to resolve raise concerns for patients, parents and GPs alike. Undiagnosed allergy, atypical infection, chronic disease and occasionally immunodeficiency can be contributors to this and improved guidance on therapeutic approaches is needed, rather than multiple antibiotic courses.
At a health sector level, rising antibiotic resistance and antimicrobial stewardship requirements have exposed the lack of infrastructure for quality and safety in general practice. A priority in any national antimicrobial stewardship response must be to gather accurate detail on GP prescribing, antimicrobial resistance and patient morbidity from infective conditions.
It is surely a clinical embarrassment that we cannot accurately measure the amount of antibiotics prescribed by GPs in Australia, nor can we purposefully analyse antibiotic prescribing activity within a general practice. Calls from the RACGP to resource quality infrastructure at a practice level should be heeded.
The mechanism for supporting quality infrastructure in GP, the Practice Incentive Payment (PIP) program, is steering toward the rocks of a pay-for-performance system, while the clinical compass is pointing strongly toward issues that really matter, ie antimicrobial stewardship.
While some antimicrobial resistance information is available for community bacteria, resistance information is likely to be skewed to more severe scale because that’s when swabs and cultures are taken. A national intervention, at a GP level, to swab and culture all infective presentations may be necessary to properly determine a microbial populace.
It is vital that information on hospital admissions or accident and emergency presentations forms part of analysis of the intervention. Patient morbidity in Australia, as measured by potentially preventable hospital admissions for acute ARTIs, may be increasing. The reasons for this are unknown, but need to be continually monitored if respiratory tract infections are targeted.
In the end, antimicrobial resistance is a major problem, and part of it is on GPs’ turf. It is going to take time to address, with a 10-year framework having been suggested by some. I hold the view that 35,000 highly trained GPs can address community issues; how the Government will support the profession in doing so remains to be seen.

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Ian Light   14/11/2017 12:04:54 PM

You will need continuous education as the pressure to "do something " or "just in case " and fear of a Tradgic outcome from sepsis creates severe dissonance .
Such precision training and practice is going to be intense .

Thomas Perkins   14/11/2017 12:08:09 PM

Good article.

David Farrar   14/11/2017 12:45:18 PM

This a well written article. GP prescribing habits certainly play a role in antibiotic resistance.
However, why does the agricultural sector continue to use antibiotics to enhance the growth of farm animals without apparent regulation? The practice should be banned.

Patrick Byrnes   14/11/2017 1:08:35 PM

Our practice has a whole of practice clinical approach to viral ARTIs and the most important component is the explanation of how the patient’s immune system will fix the problem and that is why antibiotics are not given.
I must say I still have hospital access and I really resent the folklore that resistance is due to GPs using antibiotics and the specialists in the hospital routinely throw Pip Taz at everything.
I think GPs are being scapegoated and you are perpetuating this.

John Scally   14/11/2017 3:37:17 PM

Excellent article.
The advent of more rapid diagnostic tests using swabs with PCR technology is proving helpful as well as judicious use of CRP in helping to differentiate those who need treatment with antibiotics.
A concern is how can we quarantine importing the multi resistant strains?

Alan Wardrop   14/11/2017 8:26:15 PM

Good point about the Bacterial vs. Viral paradigm having had its day , this makes point of care testing for bacteria a distraction. Risk stratification must be the way to go. We need to move public (and medical) opinion away from the "pill for every ill" idea. Self limiting illness gets better, treatment is not required , get over it! The fee for service model perpetuates this .

Arnold Dela Cruz   15/11/2017 10:36:31 AM

A public campaign should be done about this. Educating the public on treating infections and other medical conditions would help much. As mentioned, the public should move from the idea that every illness needs a pill.
Healthy lifestyle should be emphasize & attention to hygiene to be a habit .

Nazeer Abdul Rahman   15/11/2017 8:52:39 PM

Thanks for the article, my question is in relation to paediatric patients, What are the available tools that could help decision making between expectant management, typical vs atypical bacteria infection or referral to hospital.

Evan Ackermann   15/11/2017 10:41:17 PM

Thanks for the feedback – its good to get thoughtful comments. The RACGP is going to release its Antimicrobial stewardship plan shortly – it will complement the national strategy. It does address many of the concerns you raise

Arnold and Ian raise the issue of a public education campaign and I agree – the problem is (if we have to be harsh) the previous NPS campaigns haven’t worked that well. NPS will disagree – independent analysis is different. So how do we structure messages to the public and to GPs – and what should those messages be? How could it be done more effectively?

Pat, I am glad you also see what is going on in hospitals. In GP-land its minor in comparison. We cannot highlight the differences as we do not have control over the data or reporting. This is a key element in the GP strategy. I too am dismayed at the amount of GP finger-pointing that is occurring.

Clinically, I am confident we can reduce antibiotics whilst still being safe. I will always be an advocate of treating a patient first and a petri dish second. As John stated, judicious use of POCT will help – but will not be a global answer – I agree with Alan -it will get back to basic clinical skill.

Interesting times – and again thanks for comments - EA

Dr Charlene Fungai Kembo   16/11/2017 12:15:53 AM

Thank you. A well-written article indeed. The balance between "to prescribe or not to prescribe"
remains so delicate but as previous colleagues have aptly put it, there is a huge mandate to continue raising public awareness and sharpening our clinical acumen as GP's. This will certainly not be a war which is won in one day.

tasmedic   16/11/2017 12:17:00 PM

Yep, all these vacomycin and methicillin resistant bugs are due to wasteful and hasty GP's pumping these into our patients on a daily basis. Hang on a minute, I can't remember the last time I prescribed any of these as a GP. Any ideas who might have brought this on?
As for Government "support". In a legislated democracy, the hammer is legislation and the nail is the individual. So, I'll leave it up to you to work out how we'll be "supported".
Maybe we should "support" some of the hospital specialists, who are the ones handing out the second and third line antibiotics, and look at the hospital practices which are allowing the spread of resistant infections throughout secondary care, too?

Evan Ackermann   16/11/2017 1:08:15 PM

Nazeer Abdul Rahman - a really good question. On one hand we have a study where we are allegedly over-prescribing antibiotics in the first year of life, and another in Queensland to suggest we are underprescribing in later infant years. Persistent Bacterial Bronchitis is a relatively "new" diagnosis.
The antibiotic guidelines are under review and this area needs an overhaul. The use of tools in this area to assist diagnosis may well be helpful.

Karen Simmons   1/09/2018 4:09:07 PM

What is happening now is that GPS aren’t prescribing antibiotics at all. Yes u may avoid prescriptions for those that may not need them, but you will miss those that do need them. I have been asking for a blood test and swabs now, to prove antibiotics are required, so aside from the resistance issue (which by the way was an issue 30 years ago and the worst hasn’t happened as yet) if the government thinks it will save money on drugs I think they’ll find the blood work will cost more. It’s a cost exercise more than a resistance problem one, lets face the elephant in the room. 😡