Opinion
Facing harsh truths: Antibiotics in modern general practice
To mark World Antibiotic Awareness Week, prominent GP Dr Evan Ackermann writes for newsGP about the realities of antimicrobial resistance.
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.
antibiotic-prescribing antibiotic-resistance antimicrobial-resistance World-Antibiotic-Awareness-Week
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