ANTIMICROBIAL RESISTANCE
The World Health Organisation (WHO) has identified
antibiotic resistance as one of the three greatest threats
to human health
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.
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
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)
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.
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.
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.
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
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
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
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 ?
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
CASE STUDY
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
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
CASE STUDY
What if this is Jessica’s wedding??
AN ALTERNATIVE TO ANTIBIOTICS??
Prescription for:
ADT one tablet tds
20 tablets
ADT =
Any damn thing!
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
LOCKING UP ANTIMICROBIALS
AUTHORITY SCRIPTS/VALID FOR 2
WEEKS
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
BACK TO THE FUTURE OR THE PAST?
Without effective antibiotics, routine procedures such as surgery,
organ transplantation, chemotherapy, neonatology and intensive
care will be

We had to send ET home
because we had no effective
antibiotics to treat him!
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.
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!