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No, antibiotics aren’t always needed. Here’s how GPs can avoid overprescribing

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by Mina Bakhit, Assistant Professor of Public Health and Paul Glasziou, Professor of Medicine

The growth in antibiotic resistance threatens to return the world to the pre-antibiotic era – with deaths from now-treatable infections, and some elective surgery being restricted because of the risks of infection.

Antibiotic resistance is a major problem worldwide and should be the concern of everyone, including you.

We need to develop new antibiotics that can fight the resistant bacteria or antibiotics that bacteria would not be quickly resistant to. This is like finding new weapons to help the immune system fight the bacteria.

More importantly, we need to use our current antibiotics – our existing weapons against the bacteria – more wisely.

Giving GPs the tools to say no

In 2022, more than one-third of Australians had least one antibiotic prescription, with 88 percent of antibiotics prescribed by GPs.

Many people mistakenly think antibiotics are necessary for treating any infection and that infections won’t improve unless treated with antibiotics. This misconception is found in studies involving patients with various conditions, including respiratory infections and conjunctivitis.

In reality, not all infections require antibiotics, and this belief drives patients requesting antibiotics from GPs.

Other times, GPs give antibiotics because they think patients want them, even when they might not be necessary. Although, in reality they are after symptom relief.

For GPs, there are ways to target antibiotics for only when they are clearly needed, even with short appointments with patients perceived to want antibiotics. This includes:

* Using decision guides or tests to decide if antibiotics are really necessary

* Giving patients information sheets when antibiotics aren’t needed

* Giving a “delayed prescription” – only to be used after the patient waits to see if they get better on their own.

All these strategies need some training and practice, but they can help GPs prescribe antibiotics more responsibly. GPs can also learn from each other and use tools like posters as reminders.

To help with patients’ expectations, public campaigns have been run periodically to educate people about antibiotics. These campaigns explain why using antibiotics too much can be harmful and when it’s essential to take them.

Giving doctors feedback on their prescribing

National programs and interventions can help GPs use antibiotics more wisely.

One successful way they do this is by giving GPs feedback about how they prescribe antibiotics. This works better when it’s provided by organisations that GPs trust, it happens more than once and clear goals are set for improvement.

The NPS (formerly National Prescribing Service) MedicineWise program, for example, had been giving feedback to GPs on how their antibiotic prescriptions compared to others. This reduced the number of antibiotics prescribed.

However, NPS no longer exists.

In 2017, the Australian health department did something similar by sending feedback letters, randomly using different formats, to the GPs who prescribed the most antibiotics, showing them how they were prescribing compared to others.

The most effective letter, which used pictures to show this comparison, reduced the number of antibiotics GPs prescribed by 9 percent in a year.

Clearer rules and regulations

Rules and regulations are crucial in the fight against antibiotic resistance.

Before April 2020, many GPs’ computer systems made it easy to get multiple repeat prescriptions for the same condition, which could encourage their overuse.

However, in April 2020, the Pharmaceutical Benefits Scheme (PBS) changed the rules to ensure GPs had to think more carefully about whether patients actually needed repeat antibiotics. This meant the amount of medicine prescribed better matched the days it was needed for.

Other regulations or policy targets could include:

* Ensuring all GPs have access to antibiotic prescribing guidelines, such as Therapeutic Guidelines, which is well accepted and widely available in Australia

* Ensuring GPs are only prescribing antibiotics when needed. Many of the conditions antibiotics are currently prescribed for (such as sore throat, cough and middle ear infections) are self-limiting, meaning they will get better without antibiotics

* Encouraging GP working with antibiotics manufacturers to align pack sizes to the recommended treatment duration. The recommended first-line treatments for uncomplicated urinary tract infections in non-pregnant women, for example, are either three days of trimethoprim 300 mg per night or five days of nitrofurantoin 100 mg every six hours. However, the packs contain enough for seven days. This can mean patients take it for longer or use leftovers later.

Australia lags behind Sweden

Australia has some good strategies for antibiotic prescribing, but we have not had a sustained long-term plan to ensure wise use.

Although Australian GPs have been doing well in reducing antibiotic prescribing since 2015, more could be done.

In the 1990s, Sweden’s antibiotic use was similar to Australia’s, but is now less than half. For more than two decades, Sweden has had a national strategy that reduces antibiotic use by about 7 percent annually.

It is vital Australia invests in a similar long-term national strategy – to have a centrally funded program, but with regional groups working on the implementation. This could be funded directly by the Commonwealth Department of Health and Ageing, or with earmarked funds via another body such as the Australian Centre for Disease Control.

In the meantime, individual GPs can do their part to prescribe antibiotics better, and patients can join the national effort to combat antibiotic resistance by asking their GP: “what would happen if I don’t take an antibiotic?”.

This article was first published in The Conversation.

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