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Surgeons a key in cutting antibiotics over-use

One in every two Australians who have surgery is given an excessive amount of antibiotics to prevent post-operative infection, according to a new survey, which underscores concerns about Australia’s over-use of the drugs.

Words by Julie Milland

For most types of surgery, people only need a single dose of antibiotics to prevent infection or, at most, 24 hours of treatment.

The National Antimicrobial Prescribing Survey 2013, conducted by researchers at Melbourne Health, examined hospital antibiotic practices and revealed that the need to prevent infection was the most common reason for antibiotic treatment, but that almost half of these treatments were inappropriate. Commonly, the antibiotics were given for too long, or they acted against too many different types of bacteria and were not specific enough.

This excessive antibiotic treatment actually increases the risk of people getting unnecessary complications from antibiotics, such as antibiotic-associated diarrhoea, and encourages the survival of antibiotic resistant strains of bacteria, said Associate Professor Karin Thursky, who is the director of the new Melbourne-based National Centre for Antimicrobial Stewardship.

“[The surgeons] don’t realise the actual burden of inappropriate prescribing that they are generating at a national level,” she said.

The release of some survey findings coincides with Antibiotic Awareness Week, which runs until next Sunday (November 23), a global initiative to highlight antibiotics as a precious lifesaving resource that should be used responsibly, according to Fiona Gotterson, senior project officer at the Australian Commission on Safety and Quality in Health Care.

“[The surgeons] don’t realise the actual burden of inappropriate prescribing that they are generating at a national level.” — Karin Thursky, National Centre for Antimicrobial Stewardship

The Commission is bringing together experts from the fields of health, animal health, and agriculture to raise awareness of the problem of antibiotic resistance, while focusing its campaign mostly on hospital-based doctors, who write the prescriptions.

“The thing about looking at prescriber behaviour is to raise the awareness of prescribers to the problem and of the role they can play,” said Ms Gotterson. “I think [hospitals are] widely acknowledged as the big place to start in addressing prescriber behaviour.”

While cutting back on the use of antibiotics is one approach to reducing resistance, another is to control the spread of infection so that treatment is not needed at all. The Commission is continuing to promote the simple practice of hand-washing and the use of gloves through Hand Hygiene Australia, which in June 2014 reported an overall hand hygiene compliance rate of 81 per cent in 782 public and private hospitals.

In community health facilities where 80 per cent of prescriptions are written, the not-for-profit organisation NPS MedicineWise is educating healthcare professionals about antibiotic prescribing and informing the public about the best way to take antibiotics.

The initiatives are just part of the overall approach as Australia ramps up its efforts to combat antibiotic resistance, with the release of a national strategy expected by mid-next year.

Doomsday predictions for a world without effective antibiotics draw on examples of life before their discovery, when people could die after simple medical procedures or everyday mishaps such as a gardening injury or shaving cut.

A World Health Organisation report released in May suggests that antimicrobial resistance “threatens the achievements of modern medicine”. Antibiotics only act on bacteria and are a sub-set of antimicrobials, a term covering a variety of substances that kill micro-organisms such as viruses, bacteria and funguses.

Professor John Turnidge, the senior medical advisor working on the Commission’s surveillance of antimicrobial resistance, pointed out that over the last 15 years the issue has found it hard to compete with other public health problems.

“When you get pandemic flu and swine flu and bird flu and [ebola virus outbreaks], they all seem to take the headlines and take people’s attention away,” he said. “Whereas [antimicrobial resistance] is a smouldering outbreak, a smouldering epidemic, much harder to point to and call a crisis.”

Like most countries, Australia is a long way behind the Scandinavians and the Dutch who have been effectively tackling the over-use of antibiotics in humans for more than 25 years. But Professor Turnidge said Australia is among countries, including the UK and US, which have finally realised that “they can’t sit on their hands anymore”.

Australians are among the highest consumers of antibiotics worldwide . . . [A]round 22 million prescriptions are written every year in primary care alone. About 45 per cent of the population took at least one course of antibiotics, at least half of which were unnecessary, according to Professor John Turnidge.

In Australia, researchers use the Pharmaceutical Benefits Scheme to capture data about the number of antibiotic prescriptions written by doctors, a number that Professor Turnidge described as “terrible”. “We’re one of the worst countries in the world on a per capita basis,” he added.

Australians are among the highest consumers of antibiotics worldwide, despite the country’ s excellent health care system. Researchers are keen to understand what is driving the consumer to expect antibiotics when they visit the doctor. In Australia, around 22 million prescriptions are written every year in primary care alone. About 45 per cent of the population took at least one course of antibiotics, at least half of which were unnecessary, according to Professor Turnidge.

“We can say that because we benchmark ourselves against Scandinavian countries and the Netherlands and their usage is half of ours,” he explained. “They get the same infections, essentially, and they’re not keeling over from untreated infections.”

Australia could learn from how the benchmark countries achieved these results, he added.

“We know from the European experience that [antibiotic usage] is embedded in culture. There’s an antibiotic expectation, there’s an antibiotic prescribing pattern that’s pretty much emerged over 50 or 60 years and to turn around those cultural things takes quite a lot of effort.”

An important aspect of changing the culture of hospitals involves getting “ownership” of the problem from hospital management as well as clinicians.

Antimicrobial stewardship was written into the national safety and quality standards for hospitals in 2012 and hospitals must meet these standards to get accreditation. Fiona Gotterson said Australia should reap the benefits of this approach over the next five years.

The Commission also plans to release a Clinical Care Standard for antimicrobial stewardship during Antibiotic Awareness Week. Australia is taking a “one health” approach combining actions in the human health, animal health and agriculture sectors. The Department of Agriculture last month released a commissioned report on antimicrobial resistance and antibiotic usage in animals and agriculture, with recommendations that will also feed in to next year’s national strategy.

At this stage, there is not enough information to know exactly what proportion of antimicrobial resistance in Australia comes from the agricultural sector.

Australia’s Chief Veterinary Officer, Dr Mark Schipp, said that early indicators suggested antibiotic prescribing and use in humans was the main cause of the vast majority of antibiotic resistance, but the remainder of the resistant organisms came from the environment via either companion animals or the farm.

The Australian Veterinary Association will soon release antibiotic stewardship guidelines for companion animals where bacteria are shared among humans and animals and can persist in the environment.

“So things like . . . the dog that eats at your table or the cat that sleeps on your bed can all share the same bacteria.” 

Compared with other countries, Dr Schipp said Australia has tight regulations covering antibiotic use in food for animals. Some antibiotics used elsewhere are banned. The control of antibiotics is backed up by strong biosecurity controls over the importing of both antibiotics and food products.

“Because we’re not trading in the sense that we’re not bringing animals and meat products into Australia as other countries are, we’re not faced with the challenges that those other countries are facing.”

He also cited Australia’s strong farm biosecurity controls, with farmers being given industry advice to protect their farms and to prevent infections in animals so antibiotics are not needed. Another approach would be to increase vaccinations of animals wherever possible and so minimise the use of antibiotics.

Associate Professor Thursky, of the National Centre For Antimicrobial Stewardship, said that a lot more research is required to understand the contribution of the different sectors to antimicrobial resistance in Australia.

She said there’s general anxiety about antibiotics and food security, but no one has conclusively shown how much of an impact the sector has on the problem overall. The Centre will conduct the first research in Australia looking at the use of antibiotics in livestock and in companion animals.

► An edited version of this story was also published in The Sunday Age


Source: Centers for Disease Control and Prevention, 2013

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