Reduced risks in WA pharmacy prescribing trial

Pharmacy prescribing continues to expand nationally, with Western Australia the most recent state to announce that patients with uncomplicated UTIs can now access antibiotic treatment directly through a prescription from trained community pharmacists.
 
Although pharmacy prescribing will allow Western Australian women between the ages of 18 and 65 who suffer from UTIs more convenient access to treatment, it continues to be controversial as there are concerns about substandard patient care and the rising threat of antimicrobial resistance.
 
In Western Australia, neither RACGP nor AMA WA endorse the pharmacy prescribing trial; however, they both accepted invitations to be part of the project working party and were able to advocate for significant change that reduces the risk of harms for patients.
 
‘We’ve been able to provide some feedback on the exclusion criteria, the antibiotic choice, as well as on record keeping and mandating that the dispensing record be transmitted to My Health Record,’ RACGP WA Chair Dr Ramya Raman told newsGP.
 
‘Specifically for the antibiotic choice, the aim is to reduce antimicrobial resistance’.
 
Dr Raman worked closely with AMA WA President Dr Michael Page, along with experts in infectious diseases, throughout the process.
 
‘The fact that we saw it roll out across the country helped us to determine a position, in conjunction with the RACGP, that we weren’t going to shy away from having some proper discussions with the group as to how we could make it as safe as it possibly could be,’ Dr Page told newsGP.
 
‘And we did secure some pretty significant improvements to the originally proposed protocol.
 
‘We were the only groups that brought an infectious diseases physician and clinical microbiologist to the table to actually present some local resistance data from both public and private laboratories.’
 
The data provided by the RACGP and AMA WA showed that trimethoprim would be less than 80% effective for treating uncomplicated UTIs for the eligible patient cohort. Conversely, susceptibility to nitrofurantoin, an antibiotic that localises to the lower urinary tract and does not penetrate other body sites at therapeutic levels, was greater than 90%.
 
Based on this information and feedback, nitrofurantoin was written into the protocol as the first line antibiotic of choice. In addition to this, unlike other states, cefalexin was excluded from the trial and will not be available via pharmacy prescription due to local resistance patterns. Trimethoprim will be available as a second line option if nitrofurantoin is contraindicated.
 
Appropriate diagnosis was also at the forefront of discussions, with Dr Page saying ‘we fought very hard’ to get dipstick urinalysis written into the protocol as a mandatory standard; however, this has only been listed as a recommendation within supplementary information available to prescribing pharmacists.
 
It is expected that due to a lack of bathroom facilities available within pharmacies that urinalysis will not be routinely undertaken.
 
Dr Raman also recommended that the age limits for eligibility be reconsidered.
 
‘We were advocating for the age bracket of up to 50 years of age, primarily because women who are going into early menopause or perimenopause can have conditions that potentially mimic UTIs,’ she said.
 
‘In the realms of the setting of a pharmacy, an examination is not quite possible, so we wanted to bring the age down to 50 but unfortunately that recommendation has not gone forth.’
 
Discussions around safety issues related to pharmacy prescribing are likely to remain in focus for some time, with prescribing expanding across New South Wales and Queensland. Meanwhile, Victoria is scheduled to start a pharmacy prescribing pilot in October and a South Australian parliamentary enquiry is currently underway.
 
‘You have to make a choice as to whether you’re going to go in to help make it safer, or walk away from the table,’ Dr Page said.
 
‘I accept that sometimes walking away from the table is the thing you have to do, but in this instance we are glad we didn’t.’
 
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antimicrobial resistance patient safety pharmacy prescribing