AFTER years of urging patients to finish their full course of antibiotics, GPs are now being encouraged to tell most patients to stop treatment when they feel better.
Two articles published in this week’s MJA explore opportunities to combat increasing levels of antibiotic resistance in community and hospital settings, with both emphasising opportunities to discontinue therapy.
In a Perspectives article, Professor Gwendolyn Gilbert, of the Marie Bashir Institute for Infectious Diseases and Biosecurity at the University of Sydney, wrote that there was no risk, but “every advantage” in stopping a course of an antibiotic once a bacterial infection had been excluded and “minimal risk” if signs and symptoms of a mild infection had resolved. (1)
“There is a common misconception that resistance will emerge if a prescribed antibiotic course is not completed”, she wrote.
For most infections, there was no solid evidence for the recommended duration of therapy, while for many syndromes associated with bacteraemia, studies showed no difference in outcome when shorter courses of antibiotics were used, Professor Gilbert said.
“In practice the optimal duration of therapy depends on clinical syndrome, the causative organism, whether source control is possible and the patient’s response to therapy.”
Professor Chris Del Mar, professor of public health at the Centre for Research in Evidence-Based Practice at Bond University, Queensland, agreed, saying that for most acute respiratory and urinary tract infections, GPs should tell patients to stop taking an antibiotic once their symptoms subsided and discard the remainder.
“The old mantra about finishing a course of antibiotics was based on an assumption that unless you eradicated the infection it could come back and you would need another course of antibiotics, but there is no evidence for this except in a few very specific illnesses such as tuberculosis”, he told MJA InSight.
Professor Del Mar said he hoped that, in time, Australia would move towards a system where GPs prescribed the exact amount of antibiotic required, specific to the individual patient and their illness.
Greater cooperation was needed between GPs at the local level to agree on which antibiotics would be prescribed for which illnesses, to reduce the risk of antibiotic resistance developing in certain locales, he said.
“The problem of antibiotic resistance is primarily generated in primary care, where three-quarters of all antibiotics are prescribed, often unnecessarily, but the consequence is greatest for the hospitals, where antibiotics are most needed for things like surgical prophylaxis”, he said.
New research also published in the MJA has identified several barriers to implementing successful antimicrobial stewardship (AMS) programs in Australian and New Zealand tertiary paediatric hospitals. (2)
The study of 14 hospitals found only two used automatic stop orders for antimicrobials — “a potential area for intervention”, according to the authors.
It identified lack of education of hospital staff, and lack of pharmacy and medical staff dedicated to AMS as the two main barriers to effective AMS in paediatric hospitals.
The authors suggested part of the problem was proving the cost-effectiveness of AMS activities in paediatrics, given outcomes used in adult hospitals such as incidence of Clostridium difficile infection were not useful in the paediatric setting.
Professor Madlen Gazarian, a consultant in paediatric clinical pharmacology and therapeutics and honorary associate professor in the School of Medical Sciences at the University of NSW, broadly agreed with the authors’ conclusions. However, she told MJA InSight that the types of education and resources needed to improve antibiotic use “are broader than what is being suggested”.
For instance, she said, any effective AMS team needed to include not just clinicians such as infectious diseases physicians, AMS paediatricians or pharmacists, but also health professionals with a mix of broader expertise in therapeutics and quality use of medicines, clinical practice improvement and implementation science.
“Crucially, clinicians need to understand why a change is needed and that any changes initiated result in improvements in outcomes relevant to clinicians and patients”, she said.
“This is where clinically meaningful data collection for use in audit and feedback comes in. Yes, such audits can be time consuming and resource intensive, but they have been demonstrated to be effective in influencing prescribing behaviour when used as part of multifaceted strategies.” (3)
Professor Gazarian said the MJA study seemed to assume that having an AMS program was “a good thing in and of itself”. However, she emphasised the need to have better data on the actual outcomes of various AMS programs and more study of the characteristics of effective programs.
1. MJA 2015; 202: 121-122
2. MJA 2015; 202: 134-138
3. Pediatrics 2012; 129: 334-342
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