Introduction by Croakey: Growing rates of antimicrobial resistance are a significant threat to many areas of medicine, from cancer treatment to childbirth. A recent drop in antibiotic dispensing in the community provides a glimmer of hope in continuing efforts to protect this precious medical resource.
Croakey’s Nicole MacKee reports on the findings of the latest Australian Report on Antimicrobial Use and Resistance in Human Health (AURA 2021).
This article is published by Croakey Professional Services as sponsored content. It is funded by the Australian Commission on Safety and Quality in Health Care.
Croakey Professional Services writes:
A dramatic drop in antibiotic dispensing in 2020 is a “silver lining” to the COVID-19 pandemic, says an Australian infectious diseases expert who has been working to address antimicrobial resistance for decades.
Professor John Turnidge AO, Senior Medical Advisor at the Australian Commission on Safety and Quality in Health Care (the Commission), said the pandemic had driven down antimicrobial use in primary care at a rate not seen before.
“The COVID response has had a silver lining, in that there was a reduction in dispensing of antibiotics that are of no benefit for treatment of viral infections. This pattern was also seen in a number of other countries during the pandemic,” said Turnidge, who is responsible for the development of a national surveillance system for antimicrobial resistance and use.
Turnidge’s comments came ahead of today’s launch of the Commission’s Fourth Australian Report on Antimicrobial Use and Resistance in Human Health (AURA 2021).
The report found a 40% month-on-month decline in antibiotics dispensed under the Pharmaceutical Benefits Scheme (PBS) in April 2020 (1.4 million), as the first wave of COVID-19 in Australia peaked with much of the country in lockdown. This dip followed a slight increase in March (2.3 million).
Analysis of antibiotic dispensing trends from July 2016 to October 2020, showed significant reductions in seven of the 10 most commonly dispensed antibiotics (comparing trends from July 2016 to March 2020 with trends from July 2016 to April 2020).
These were: amoxicillin (down by 49%), amoxicillin–clavulanic acid (40%), cefalexin (28%), clarithromycin (31%), doxycycline (27%), phenoxymethylpenicillin (22%) and roxithromycin (42%). All of these antibiotics are frequently used for upper respiratory tract infections, the report noted, and dispensing rates remained below pre-pandemic levels to the end of the year.
Importantly, the decline in antibiotic use was not associated with, or proportionate to, a drop in primary care visits, suggesting a true shift in the rate of prescribing, assisted by population-level adjustments around physical distancing, hand hygiene, and staying home when unwell, the report suggests. Changes to the PBS that restrict repeats for five commonly dispensed antibiotics (amoxicillin, amoxicillin–clavulanic acid, cefalexin, doxycycline and roxithromycin), introduced in April 2020, may also have contributed to the decline, AURA 2021 noted.
Dr Morgyn Warner, an infectious diseases physician and clinical microbiologist at SA Pathology in South Australia, agreed that this data would send a powerful message to clinicians and consumers alike.
Warner, who is also a member and past chair of the Commission’s Antimicrobial Stewardship Advisory Committee, said:
When you see dramatic changes like this, it does help people to see in stark terms how this happens.
It’s not that bacterial infections have gone away; viral respiratory infections have gone away.
So perhaps clinicians will think ‘maybe, I don’t need to treat these respiratory infections as they are probably viral and antibiotics won’t help’.”
Much work remains
While the pandemic-driven shifts in primary care prescribing are welcome, AURA 2021 shows many areas of antimicrobial use across Australia where improvement is needed.
The extensive report provides a 360-degree view of antimicrobial resistance in Australia, incorporating data on use and appropriateness of prescribing from hospitals and the community from sources such as the National Antimicrobial Prescribing Survey (NAPS), the PBS, the National Antimicrobial Utilisation Surveillance Program (NAUSP), and the NPS MedicineWise MedicineInsight program.
It also tracks data on rates of antimicrobial resistance in hospitals and the community from sources such as the Australian Group on Antimicrobial Resistance (AGAR), the Australian Passive AMR Surveillance (APAS), and the National Alert System for Critical Antimicrobial Resistances (CARAlert).
Dr Tony Korman, Director of Monash Infectious Diseases, said continued vigilance was critical, with the COVID-19 pandemic vividly illustrating the human and economic cost of treatment-resistant disease. He told Croakey:
Everybody’s world has been overtaken by one particular virus, while the ongoing, major issue of antimicrobial resistance is not going away.
We wouldn’t be able to practise modern medicine as we do without antibiotics. Cancer treatment, intensive care treatment for adults and babies, major surgeries, these are only possible because we are able to treat infections associated with them with antibiotics. And in some cases now, we are not able to do that because of the rise of resistant organisms.”
Ten million scripts
AURA 2021 showed that before the impact of COVID there had been a continued, gradual decline in antimicrobial use in primary care to 2019.
Still, more than 10 million people (40.3% of the total population) had at least one antimicrobial dispensed under the PBS or the Repatriation PBS in that year, and about half of all scripts were ordered with repeats, though PBS changes have since been introduced limiting this practice.
Inappropriate prescribing remains an issue, with 2019 data from practices participating in the NPS MedicineInsight program showing 81.5% of patients presenting with acute bronchitis and 80.1% with acute sinusitis left their GP with an antibiotic script, despite there being no evidence for their use in these conditions.
Warner said it was “disappointing” to see the prescribing data on these conditions, which are overwhelmingly caused by viruses, for which “we see some of the highest areas of use”.
On global comparisons, primary care antimicrobial prescribing in Australia continues to outstrip Canada and most European countries, with rates more than double those of benchmark countries such as The Netherlands, where there was also far less use of broad-spectrum preparations.
“Both in the quantity and the quality of their prescribing, they are much better,” said Korman of the Scandinavian countries.
Aged care concerns, hospital use static
There are enduring concerns in the aged care sector according to AURA 2021, with overuse and inappropriate use driven by high rates of ‘as-needed’ (PRN) orders, and prophylactic prescribing in place of non-pharmaceutical measures for conditions like skin infections, tinea and cystitis, where preventative strategies and improved hygiene had an important role.
Each of the AURA reports have shown that aged care facilities have some of the highest rates of carriage of MRSA, and urinary tract infections caused by resistant Escherichia coli are concerning,” said Warner.
This was echoed by Turnidge, who said the “single biggest conundrum” in aged care was the management of asymptomatic bacteriuria.
“Test-and-treat has become routine,” said Turnidge, adding that this was in spite of “overwhelming evidence” that it is not good practice for this condition.
“We should only treat obvious symptomatic UTIs. Longer term use of low dose antibiotics – prophylaxis – is very common in this setting, and creates the most powerful selection pressure for resistance.”
On the hospital front, tackling antimicrobial use and appropriateness is complex, and progress has been slow.
In 2019, hospitals participating in NAUSP showed a 2.8% increase in use of antimicrobials compared with the previous year, and AURA 2021 shows that on a defined daily dose (DDD) per 1,000 people basis, use in Australian hospitals was almost four times that of The Netherlands, which had the lowest rate of use in Europe.
The report also noted that overall appropriateness of prescribing across hospitals participating in NAPS was 75.8%, a figure that was essentially unchanged since 2013.
Inappropriate prescribing of several broad-spectrum antimicrobials was identified in hospitals in 2019, including cefalexin, cefazolin, azithromycin and amoxicillin–clavulanic acid, the report found. The three indications with the most inappropriate prescribing were chronic obstructive pulmonary disease (COPD), surgical prophylaxis and surgical wounds.
For COPD in particular, the AURA report called for “urgent intervention,” noting that non-compliance with clinical guidelines continued to rise.
Warner said dose duration was also a critical area for improvement in hospital prescribing, singling out surgical prophylaxis as a priority:
In most procedures, if antibiotics are indicated, you just need a single pre-operative dose so there are antibiotics in the tissue at the time of surgery, reducing the risk of infection.
Administration of antibiotics during or after surgery provided negligible, if any, benefit.”
Turnidge said stewardship was key, as demonstrated by gradual improvements in appropriateness of use over the past five years in principal referral and larger urban public hospitals where antimicrobial stewardship programs were most mature. Smaller public and private hospitals require investment of antimicrobial stewardship effort, he said.
Hospital accreditation requirements were recently strengthened by the Commission. Facilities now have to demonstrate that they review prescribing and use, as well as local resistance data, to inform programs to improve the appropriateness of antimicrobial use.
Patterns of resistance
Resistance data shows that rates of multidrug-resistant Escherichia coli – a pathogen that causes both urinary tract infections and sepsis – have continued to slowly climb, increasing from 24.2% in 2015 to 26% in 2019, a trend Korman described as “very worrying”.
Despite the introduction of PBS restrictions on their use, ciprofloxacin and ceftriaxone resistance has also risen over the past five years, according to AURA 2021.
Carbapenemase-producing Enterobacterales remain Australia’s commonly reported critical antimicrobial resistance to last-line antimicrobial treatments. CPE accounted for 81% of all reports to CARAlert in 2019, but Turnidge said the rate for these “concerning multidrug-resistant organisms” was holding steady “which is pleasing”.
“We will clearly need to keep an eye on those over the years,” he said.
For the first time, AURA 2021 includes specific resistance data from the HOTspots surveillance system in far northern Australia, showing higher or increasing rates of antimicrobial resistance compared to other parts of the country.
This includes third-generation cephalosporins (ceftriaxone and cefotaxime), which are a mainstay of hospital treatment for many common conditions, and methicillin-resistant Staphylococcus aureus (MRSA). Warner said where there were limited oral antibiotic options, “if you lose those, you end up having more hospitalisations, because intravenous antibiotics are required”.
The HOTspots surveillance data is drawn from regions with a higher proportion of Aboriginal and Torres Strait Islander peoples than the rest of Australia. Prescribing guidelines appropriately recommend lower thresholds for antibiotic use in populations considered at higher risk of bacterial infections or their complications.
However, AURA 2021 notes that a combination of inappropriate prescribing and poor housing conditions in northern Australia, especially in remote communities, are likely to be important determinants of AMR rates in this part of the country.
Data drives change
If the COVID-19 pandemic has shown anything, it is the critical role the public has to play in responding to population-level health challenges, and Korman said this was no less true in antimicrobial resistance.
I think the general public needs more information to understand what a big issue this is. We have to bring it home to people that antimicrobial medicines are a precious resource; these are life-saving medicines that we have to use wisely,” he said.
Data reported in AURA 2021 show that meaningful change is possible, with a shift in attitudes and behaviour, and underscore the broader lessons of the pandemic around informing and engaging communities in public health action, added Warner.
“There is a growing realisation of the importance of a healthy microbiome,” she said. “If people understand that taking antibiotics may possibly make them feel better by one day earlier, but may have side effects – such as rash or diarrhoea – or long-term consequences, they may be less likely to take them.”
Recognising the changes seen in 2020, affirming positive messages and reinforcing progress on antibiotic use is timely, concluded Turnidge.
“This is a real opportunity,” he said. “We need continued education programs to reinforce for prescribers and patients that you don’t need antibiotics, for flu, cold and bronchitis”.
This article was written by Nicole MacKee and edited by Dr Amy Coopes, on behalf of Croakey Professional Services.
The series was conceptualised and sponsored by the Australian Commission on Safety and Quality in Health Care, which had final say over the content.
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