Opinion
Pharmacy antibiotic prescription – an outdated and harmful intervention
Promoting convenience for antibiotics sales is poor healthcare practice, writes Dr Evan Ackermann.
There are currently nearly 1900 additional antibiotic prescribers in Queensland as a result of the UTI trial.
How does a government inquiry into pharmacy oversight and ownership result in legislative changes to remove patient protections and increase drug sales in pharmacies?
For those unaware, Queensland Health recently announced an extension to a pharmacy-based urinary tract infection (UTI) management pilot until 30 June 2022. The pilot was one of the recommendations stemming from a 2018 Parliamentary Inquiry into pharmacy.
It enables pharmacists to prescribe antibiotics to women between the ages of 18–65 whom they diagnose as having an uncomplicated UTI; eligibility and ‘diagnosis’ is via a multi-question protocol.
The Queensland Government, pharmacists (The Pharmaceutical Society) and pharmacy business (The Pharmacy Guild) praised the initiative for its convenience for women and the role substitution for pharmacists.
With others, the pilot is controversial.
Legitimate community concerns were raised, least of which were long-term questions regarding the relationship between the Pharmacy Guild and all levels of government via political donations – ie, was health policy being dictated by financial lobbying from a pharmacy business group rather than a compelling clinical need?
These concerns were compounded when the medical press revealed the evaluation of the trial was based on perfunctory standards rather than typical academic assessments. To many, the trial is seen as government acceptance of pharmacy marketing that promotes pharmacies as convenient and easily accessible healthcare providers.
In the UK where there is similar pharmacist UTI prescribing, Boots pharmacy chain introduced a ‘Cystitis Test and Treat Service’ in 37 stores and stocked cystitis tests to nearly 300 stores across the UK. It has seen the rapid commercialisation in the diagnostic kits, e-technology tools for automated antibiotic prescriptions, complementary therapies and associated products.
UTI diagnosis and prescribing is the ticket of entry into these systematic sales.
Globally, the UTI treatment market is estimated to be worth more than US$10.3 billion (AU$14.31 b) annually and pharmacy groups want to be a bigger part of it.
Meanwhile, clinical concerns were raised by various health bodies regarding:
- antimicrobial stewardship
- diagnostic error
- the fragmentation of care
- pharmacy and pharmacist conflict of financial interest
- losing the safety standard of separation of prescribing and dispensing roles
- the further breakdown of collaboration between primary care groups – ie GPs and pharmacists.
These concerns have been dismissed by the usual Pharmacy Guild responses of
‘turf-war’ or ‘it’s happening elsewhere therefore it’s okay in Australia’, rather than any genuine response to the arguments.
To date, demand for the pharmacy trial service has been very limited. As of December 2021, 1895 pharmacists had completed the mandatory training, only 6300 women had accessed the
service over the 18 month trial period.
That’s just over three patients per pharmacist or one patient every six months. No evidence of a compelling need here, and there’s never been compelling evidence that such a need exists.
Now, with little clinical evaluation
publicly available, the decision has been made to continue the trial until June this year. The lead investigative pharmacist Professor Lisa Nissen is
quoted as saying ‘the six-month extension is to allow time for it to go through the government and legislative process to create a permanent model’.
That is, pharmacist UTI prescribing appears to be a
fait accompli – regardless of the results of this ‘trial’, nor even the outcry from elements within their own profession.
One need look no further than Aryan Shahabi-Sirjani, Chair of the Antimicrobial Stewardship Pharmacist Network,
who last year called for the trial to cease over fears it could risk accelerating antibiotic resistance in the community.
GP Dr Evan Ackermann has serious reservations about pharmacy prescribing of antibiotics.
Conflicts-of-interest aside, this trial has also created another 1900 antibiotic prescribers via a three-hour training module. Exam completion may equate to knowledge but does not represent competency or experience.
And since diagnosis and eligibility is via a simple question checklist, it won’t take long to know what answers guarantee an antibiotic – despite current Australian Therapeutic Guidelines stating that most women under the age of 65 treated symptomatically (without antibiotic therapy) for acute uncomplicated cystitis become symptom free within one week.
This is a very nuanced approach supporting the improved knowledge on
natural history of uncomplicated UTIs, with judicious antibiotic prescribing in low-risk patients because of the very low risk of complications.
In contrast, the pharmacy model
promotes convenience,
immediacy, and
rapid access to antibiotics without a prescription because of the ‘urgency’ of the problem.
‘The quicker an UTI [sic] can be diagnosed and treated, or referred to another healthcare provider if necessary, the less likely the patient is to experience further complications that may result in hospitalisation,’ the Guild’s Queensland Branch President Chris Owen said in a release celebrating the program’s extension.
For uncomplicated urinary tract infections – this is a patently false statement. It’s the complicated UTIs that are the problem. Clearly, pharmacy has promoted a clinical intervention which is the opposite of national guidance.
I have not seen one pharmacy or government representative address this contradiction.
Pharmacies may be convenient and accessible, but pharmacists aren’t. They are busy too, with usual workload involving prescription dispensing. From a health management perspective, we also have no idea of the backgrounds, workloads or competency of the pharmacists who are making these clinical decisions.
What we do know, is that with non-prescription medications counselling is not often provided or is of
poor quality. There are also high rates
overtreatment and overselling of medication, with pharmacists ignoring
eligibility criteria and not complying with
legislation or
clinical protocols, nor having poor appropriate
medical referral practices.
The retail environ of pharmacy is not a location where judicious use of antimicrobials is made. History shows that Australian pharmacy sales of vaginal antifungals and
chloromycetin eye drops increased dramatically when the prescriptions were made pharmacist-only.
No number of academic studies describing pharmacy prescribing appropriateness in controlled study environs will outstrip the known actions of community pharmacy in the real world.
Moreover, the usual consumer safeguards for Schedule 4 drugs have been
legislated away. Specifically, the usual protections of dual clinical oversight with prescriber/dispenser separation, and absence of financial conflicts of interest (ie a prescriber cannot gain financially from a prescribed medicine) are absent.
The initiative does not conform with current evidence-based practice or complement the Australian health system. Nor does transferring clinical decision making to a retail environ support our national health antimicrobial stewardship priorities or the women it supposedly serves.
If the promotion of pharmacy antibiotic sales and services under the guise of convenience is prioritised over good healthcare, then antimicrobial stewardship as a national priority is dead.
GPs will be stuck between a rock and a hard place. They will be forced to collaborate with a business-oriented pharmacy model of which they do not approve. They will be the clinical back-up service, managing the overdiagnosis, misdiagnosis, and treatment failures.
The outcry from medical groups is justified.
Whilst governments have a mandate to govern as they see fit, it is important that consumers and national health priorities are not sacrificed for business benefit. Drug and antibiotic sales under the guise of convenience is poor health policy with little societal or professional benefit, other than pharmacy business.
More importantly, we should be supporting the wisdom of a national antimicrobial stewardship scheme and implementing systems of care that support judicious and evidence-based antibiotic use.
Pharmacist antibiotic prescribing is not one of them.
Hopefully wiser heads in government, medicine and pharmacy will reject pharmacy-based antibiotic prescribing.
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