Pharmacy prescribing trial launches

Doug Hendrie

26/06/2020 3:25:06 PM

A controversial trial allowing pharmacists to prescribe antibiotics for UTIs has gone ahead amid renewed questions on pharmacy vaccination programs.

Prescription in a pharmacy
Pharmacy prescribing of three antibiotics has launched.

Queensland’s trial of pharmacy prescribing has officially launched, with hundreds of pharmacists now able to prescribe trimethoprim, nitrofurantoin or cephalexin for uncomplicated cystitis to women without a current script from their GP.
The trial comes after sustained lobbying from the Pharmacy Guild for increased pharmacist scope of practice in areas such as prescribing and vaccinations.
The launch comes amid new findings by the National Centre for Immunisation Research and Surveillance (NCIRS) that pharmacy vaccination programs may have ‘substantial underreporting’, with only half of pharmacies that offer vaccinations supplying valid vaccination data to the Australian Immunisation Register in the 2018–19 financial year.
While 95% of pharmacy vaccinations are for the flu, the NCIRS report found that close to 500 patients received a vaccine not permitted to be pharmacist-administered in any state or territory between 2016 and 2019, including varicella, rotavirus, typhoid, pneumococcal, rabies, Japanese encephalitis, human papillomavirus, hepatitis A and B, and tetanus.
Chair of RACGP Queensland Dr Bruce Willett told newsGP the news on vaccination recording is concerning.
‘This report shows pharmacy prescribing won’t work as the Pharmacy Guild is claiming. If they can’t get the proper recording of vaccinations right, how can we trust that there will be proper administration of antibiotics?’ he said.
‘This clearly indicates the difference between what the Guild promises and what happens in real life. What occurs in the trial is likely to be very different to what happens when pharmacy prescribing is in the wild.
‘Two main challenges for world health are pandemics and antimicrobial resistance. We’ve now seen what a pandemic can do, but antimicrobial resistance is likely to be worse, though it will play out slower.
‘We remain concerned that antibiotics are becoming more available when the whole world is working to make them less available and being more careful with our husbandry of antibiotics.’
The pharmacy prescribing trial has gone ahead despite repeated protests from the RACGP, Australian Medical Association (AMA) and Australian College of Rural and Remote Medicine (ACRRM) due to concerns over patient wellbeing, antibiotic overuse and fragmentation of care.
The RACGP and the AMA separately lobbied each MP in Queensland, calling for an end to the trial. 
Under the trial, pharmacist consultations are expected to cost between $20 and $30, plus the cost of any script. Pharmacists have to refer patients to a doctor if symptoms have not resolved within 48 hours of starting the antibiotic or recur within two weeks of completion. All patients must be contacted seven days after the consultation to check if symptoms have resolved.
Questions remain over how much training pharmacists need to do before taking part in the trial, which will be run by Queensland University of Technology researchers with assistance from Pharmacy Guild researchers. 
Dr Willett called for the training module to be made public.
‘We remain concerned that the Guild are not publishing what’s occurring in the training – they’re remaining very secretive about that,’ he said.
‘That should be in the public domain.’
The trend for pharmacists to offer care traditionally restricted to medical professionals is under renewed scrutiny following the NCIRS report’s findings that only half of the vaccinations were reported in 2018–19.  
The report also found that only 100,000 flu vaccinations had been reported to the Australian Immunisation Register in 2018, though pharmacy peak bodies are on record stating the actual figure was 10 times that. In 2019, four times more flu vaccines – two million – were administered than actually reported.
Dr Willett described the Australian Immunisation Register as an ‘extraordinarily important public health measure’.
‘With it, we know who is vaccinated and where, letting us know where outbreaks are likely to occur,’ he said. ‘Failing to record these can jeopardise personal health, public health and financial wellbeing.
‘For patients, the register lets them do things like visit relatives in nursing homes by establishing they’ve been vaccinated. Childcare centres, schools and some social security payments need evidence of vaccinations.’             
Dr Willett said inadequate reporting can also lead to double-up vaccinations, or missing them altogether.
Pharmacy vaccinations have been expanding rapidly in recent years, though they still only make up a small minority of all vaccinations. Just 1.2% of all vaccinations recorded in the Australian Immunisation Register between 2016 and 2019 were pharmacist-delivered.
The report’s authors note that ‘more vaccines were reported to have been administered in 2019 by three banner groups combined than were recorded in [the Australian Immunisation Register] for all pharmacy providers in that year.’
In comments to the Australian Journal of Pharmacy, Victorian Pharmacy Guild head Anthony Tassone said his organisation supports the Australian Immunisation Register and recommends community pharmacies record the vaccinations they deliver.
‘This is not only best practice, but also strengthens the case for pharmacists practising to their full scope of practice and training in being able to deliver a wider range of vaccinations to more people in the community, including younger patients – along with having consistent and widespread access to the National Immunisation Program,’ he said.
To combat the issue, the NCIRS report recommends mandatory reporting of pharmacist vaccinations across Australia. At present, only the ACT and NSW require this measure.
In response, a Guild spokesperson has said technical issues have prevented some pharmacists from uploading vaccination data.
‘We repudiate any suggestion that pharmacists are dragging the chain on this,’ the spokesperson said.
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Dr Franziska Levin   27/06/2020 9:05:50 AM

Hopefully pharmacists will do a thorough clinical assessment including sending of an MSU, taking a full sexual health history in a sensitive and private manner, testing for STIs which can be a cause for dysuria in presumed uncomplicated UTIs. Hopefully this is then all clearly documented and forwarded to the patients’ GP to ensure continuity of care.
Will the pharmacist have access to a patient’s previous MSU result which not uncommonly show multi resistant bacteria or no bacterial infection which would explain the symptoms?
There are a number of countries with pharmacy prescribed antibiotics such as India and some of the South American countries which have high rates of multi resistant organisms . Hopefully this won’t happen in Australia and pharmacists will have the same high standards as most doctors.

Dr Antony Barry Adelman   27/06/2020 10:13:57 AM

Abdo Exam: Aust Therapeutic Guidelines. Some points of several to be made. I have heard more than once, if there is less clinical experience, the more important for following the guidelines.
"Clinical features suggestive of acute pyelonephritis include: flank pain, nausea and vomiting, fever (38°C or higher), costovertebral angle TENDERNESS."
"Acute pyelonephritis may present with or without symptoms of acute cystitis (eg acute dysuria, frequency, urgency)."
"If pyuria is absent on microscopy, the diagnosis of acute cystitis is unlikely."
Question-how without exam would one detect pyelonephritis in some cases and thus presc the correct POAB type/frequency/duration ?
Question-how without urinalysis would one reach threshold of clinical suspicion for alternate diagnosis prior to starting a POAB for presumptive cystitis ?

Dr Gobind Singh Duggal   27/06/2020 10:28:02 PM

I think it is unsafe for pharmacist to vaccinate peole with any vaccination, with any anaphylaxis, serious consequences would occure, I dont think pharmacist are equiped to deal with anaphylaxis, vaso vagal shock etc

Dr Siang Ying Siah   14/07/2021 6:15:11 PM

I have a patient few days ago been prescribed twice a different antibiotics for urinary tract infection. She went in and was given trimethoprim. It did not work so the chemist gave her nitrofurantoin. Then she came in and her dipstick and using mc&s were all clear. We as gp are trained for 6 years to prescribe appropriately and we knows what red flags to look out for. If chemist can sell antibiotics without prescription then gp clinic can trial selling emergency drug like ventolin, gtn spray, emergency antibiotics etc in the best interest of patients. We often sees patient after hours when they have no assess to after hour pharmacy. In other countries where chemist sells antibiotics without prescription, the gps sell medications too without the chemist.