2. ANTIMICROBIAL RESISTANCE
The World Health Organisation (WHO) has
identified antibiotic resistance as one of the three
greatest threats to human health
3. ANTIMICROBIAL RESISTANCE IN THE COMMUNITY
The average consumer in the community is more familiar
with the term antibiotic rather than antimicrobial.
Estimating antibiotic usage in the community is a lot harder
compared to hospital use. We can more accurately capture
antibiotic prescriptions for concession and Repat patients
but less so for general and full fee paying consumers as
most are under the co-payment threshold. We then have to
rely on estimates obtained from a representative sample of
community pharmacies.
4. ANTIBIOTIC USAGE IS IN THE COMMUNITY
The National Prescribing Service embarked on a 5 year program to
address antibiotic resistance with the roll-out of an educational
NPS visit in 2012 on this topic. This proved to be a popular
topic requested by many GPs throughout Australia including
4,500 GPs completing the clinical audit. The statistics relating to
this antibiotic program are due to be released at the end of the
year.
However other health professionals such as pharmacists and
nurses can influence antibiotic usage in the community through
education and implementation of the principles of antibiotic
stewardship.
It is unfortunate that pharmacists and nurses were not offered the
same educational visits as the GPs - due to a lack of funding.
742,000 people see a pharmacist , 300,000 see a GP a day
McCrindle 2014
5. WHO ARE THE STAKEHOLDERS IN COMMUNITY
HEALTH?
Medicare Locals, community pharmacists, nurses ( ACFs,
childcare centres, schools or community) and GPs.
Medicare Locals: Bentley/Armadale, Fremantle, Goldfields-
Midwest, Perth Central and East Metro, Perth North, Perth
South Coastal and South West WA
GPs are often concerned about pharmacists sending patients
to them with patients being told they need an antibiotic.
Yellow green phlegm does not mean bacterial - Not
evidence-based information.
Nurses: There is a growing number of nurses employed in the
primary care setting.
General Practitioners 2,454 (2011) WA 43,400 Aust (2011)
6. ANTIMICROBIAL RESISTANCE
You are twice as likely to carry resistant bacteria after a
single course of antibiotics compared to someone who has
not. The greatest risk is 30 days following antibiotic
treatment and is likely to persist for up to 12 months.
Costelloe C BMJ 2010
The longer the exposure to antibiotics, the greater the risk of
acquiring and spreading resistant bacteria.
Prof Chris Del Mar (Bond Uni) “antibiotic resistance decays
with time with no antibiotic use”. NMS May 2014
The spread of antibiotic resistance is influenced by human
migration, travel, agricultural practices and indiscriminate
use of antibiotics.
7. ANTIMICROBIAL STEWARDSHIP IN THE COMMUNITY
Australian consumers often perceive ‘antibiotic’ resistance as the
responsibility of hospitals, GPs and other prescribers – yet the greatest
proportion of Ab usage is in the community
The work of agencies such as the National Prescribing Service (NPS) and
Consumer Medicine Information (CMI) is important in educating the
community about antimicrobial resistance.
Organisations such as the NPS and Medicare Locals (MLs) are suitable
bodies to encompass the policies of antimicrobial stewardship. This
would involve assistance with education for consumers or prescribers
in primary care and the implementation of good antimicrobial practices
within the framework of the current Antibiotic Therapeutic Guidelines
2010.
8. ANTIMICROBIAL STEWARDSHIP IN THE
COMMUNITY
Which Medicare Local has an Antibiotic Stewardship
Program in place?
To be an accredited Medicare Local, there has to be in place
some antibiotic/infection control policy.
9. AMR STEWARDSHIP PROGRAM
Unfortunately not a single Medicare Local has an
Antimicrobial Stewardship Program in the community.
Programs involving diabetes, COPD, pain management, CVD
and mental health attract more funding
10. AMR – WHAT DO WE NEED?
A single regulatory body to co-ordinate use and distribution
of antimicrobials in human and animal health and
agriculture. We also need an organised approach to bridge
that divide between hospital and community use of
antimicrobials. AGAR
11. CHALLENGES FOR GPS
Under pressure to prescribe by consumers for various
reasons
There is no certainty in diagnosing infections
Is it bacterial or is it viral?
Is it bronchitis or pneumonia?
Is it bronchiolitis or whooping cough?
Fear of losing a patient to another surgery
Fear of medico-legal problems
PBS quantities? (trimethoprim) Repeats?
Need software default to no repeats
12. EDUCATIONAL PROGRAMS
Community - child care centres, schools – Caring by Not
Sharing!
Responsible media reporting
Allied health professionals – Aged Care Facilities and
Nursing Homes
GPs and prescribers – better communication with
consumers – Time!
Social media – Facebook (NPS), Twitter, Instagram
Need a series of ‘ horror movies’ on Ab resistance ?
13. CASE STUDY
Jessica, a 24 year-old female presenting with a 4 day
history of a sore throat, cough and a runny nose. She is
attending a wedding over the weekend and is concerned
that her symptoms will worsen.
Medical and social history: NKA, non-smoker, lives with
partner
Physical examination by GP: slightly red throat, tonsils not
inflamed and chest is clear, afebrile
15. THE ANTIBIOTIC CREED
M Microbiology guides therapy when possible
I Indications should be evidence-based
N Narrowest spectrum required
D Dosage appropriate to the type and site of
infection
M Minimise duration of therapy
E Ensure monotherapy in most situations
16. CASE STUDY
Reasons for not prescribing:
⇨ probably viral and will resolve within 7 days
⇨ side effects of antibiotics e.g. thrush, nausea, vomiting,
diarrhoea
50% of antibiotics prescribed in the community for URTIs are
not indicated
Antibiotic resistance – very few, delayed prescription
20. WHAT ARE PEOPLE SAYING IN THE
COMMUNITY?
Nurse (ML): The hospitals are to blame – it is all those IV antibiotics they
are using
GP (metro area): I saw two tourists within 3 weeks of each other, both with
acute UTIs resistant to the antibiotics on the PBS – had to refer both to
the hospital
GP (suburb): What is the Health Dept policy on overseas visitors with
communicable diseases? I had a patient with multi-resistant TB who
arrived on the plane, possibly infected a whole lot of passengers around
him and presented in my surgery. I sent him to the local hospital and
they discharged him back to my care stating they cannot treat him. I
rang the Health Dept and was more or less advised to send this person
back home.
Consumer: I have heard something in the news about antibiotics being not
effective anymore. I only take antibiotics prescribed by my doctor.
Consumer: I don’t take any antimicrobials, only an antibiotic sometimes
22. RE-VISITING IMPORTANT MEASURES
Prevent infections/spread of infections : hand hygiene,
cough etiquette, barriers to transmission (masks,
isolation)
lifestyle, overfed and under-nourished
Minimise use of ‘problem’ antibiotics
Immunisation : PCEMML story book on immunisation
Symptom management (NPS) – what can be done to make
the patient feel better
Consumer education – embrace technology, 65% use a
smartphone, antibiotic app
23. BACK TO THE FUTURE OR THE PAST?
Without effective antibiotics, routine procedures such as
surgery, organ transplantation, chemotherapy, neonatology
and intensive care will be
24. We had to send ET home
because we had no effective
antibiotics to treat him!
25. A BEAUTIFUL MIND
We cannot eliminate antimicrobial resistance. It is always going to
be there but we can put in place measures to delay the emergence,
thus preserving the ‘miracle’ of antimicrobials for generations to
come.
26. WHO GLOBAL HEALTH THREATS
Non-communicable diseases
Global climate change
Antibiotic Awareness Week: 2nd week November
- activities in line with similar events globally
Thank you very much for your attention!
Editor's Notes
What I hope to do today is to try and provide you with an overview of the growing problem of antibiotic resistance in the community today which was what the hospitals were facing in the 70s and 80’s.
What do you think the other two are?
Costelloe – meta-analysis of 24 studies. eg. children in pre-schools, 12% have acquired resistance
The current 2010 Therapeutic Guidelines on antibiotics - shorten the duration of most antibiotic courses to 5 to 7 days. Unless co-morbidities- immuno-compromised diabetes
Indiscriminate use can be inappropriate prescribing or use or sale of antibiotics - we know that antibiotics can be purchased OTC in many countries.
You cannot do it alone like Braveheart, you need more than a few good men to tackle AMS in the community
- With a licence to kill antimicrobial resistance
These are common concerns and challenges facing many of the GPs I see in primary care.
Pressure to prescribe – particularly when you have outbreaks of new influenza strains or the debilitating nature of some viral infections and the previous receipt of an antibiotic prescription, a need to return to work or childcare.
Shades of grey although not 50
Facebook – join up to be a resistance fighter, We are hoping that this will go ‘viral’. NPS
When given a TG of their choice, 80% ticked the Antibiotic Guidelines
From Therapeutic Guidelines Antibiotic 2010
Indications should be evidence-based - macrolides no activity against H. influenzae so do not use for patients with COPD
Antibiotic sensitivity tests are done in vitro.
The majority of GPs have jumped the fence and will now prescribe an antibiotic for her! So it is alright for the bride to have thrush and /or diarrhoea.
Placebo effect can be as high as 65% in some people
40% of Australian consumers are not aware of antibiotic resistance. A recent survey in January 2012 – 1 in 5 Australians expect an antibiotic prescription from their doctor for ear, nose, throat and chest infection. 22 million prescriptions for antibiotics written every year – one per person per year! We are one of the highest consumers of antibiotics in the developed world. Reducing antibiotic usage by 25% still puts us above the average usage for the OECD countries, 34 at present
It is much more than locking up antibiotics – restricting use such as authority prescriptions,
An expiry date on antibiotic prescriptions e.g. valid for 2 weeks only
Other measures which are often forgotten - rest rather than ‘soldier on’ and spread infection to others
When we run out of effective antibiotics we will have to go back to the pre-antibiotic era – resorting to amputations to stop the spread infections and saving lives.
I would like to finish with a ‘feel good’ movie – A Beautiful Mind. Where you have Russell Crowe playing John Nash, a brilliant mathematician who had schizophrenia - even though his condition was in the end well managed, he still experienced residual hallucinations – those people were always in the background. So it is the same with antibiotic resistance. It takes BIG reductions over LONG periods to achieve this.
