Reflections on community antimicrobial prescribing in Australia

[Music] Welcome to the Australian Prescriber Podcast, an independent, no-nonsense podcast for busy health professionals.

I'm Dhineli Perera, your host for this episode, and it's an honour to be chatting to Professor John Turnidge today about the perpetual topic of community antimicrobial use in Australia. Professor Turnidge is a senior medical advisor leading the national surveillance program for Antimicrobial Use and Resistance in Australia [AURA]. John, together with co-authors, Carolyn Hullick and Kim Stewart, have reflected on the trends observed in community antimicrobial prescribing in Australia, the impact of the pandemic and priority areas from here on. John, a really warm welcome to you.

Thank you.

So John, I'm interested to know how our rates of community antimicrobial use compare to other countries with similar healthcare systems and disease profiles. Is there still a significant difference?

Yes, there is. It's been a running sore in Australia that our rates of community use have been much higher than countries we'd like to compare ourselves [to], such as the United Kingdom, but particularly Scandinavia and the Netherlands, and even Canada. We can't get comparative data from the US, so we don't know about them and that's a country we would like to compare ourselves to, but it's high and we'd like it to be lower and reduce the amount of inappropriate use.

I wanted to touch on your appointment to the lead national surveillance program for antimicrobial resistance and antibiotic use back in 2014, which is now known as AURA. Could you tell us what AURA is and where it collates data from and what it's been able to show us so far?

I had the privilege of joining the Commission [Australian Commission on Safety and Quality in Health Care] to establish AURA. It's quite common for countries to focus on antimicrobial resistance and measure that because we can often get data from laboratories that gives us those answers. But from our point of view, we also needed to have an equal interest in the use of antimicrobials, and the points about high usage compared to other countries in the community was one of the motivations for that. So, we focused on use in all sorts of settings, tried to be as comprehensive as we could, and that includes getting data from the community on usage and appropriateness of antibiotics, and the same in the hospital setting. And more recently clarifying a third section called the aged care sector. And at the same time getting antimicrobial resistance data. We classified that as passive, that is data that we collect from laboratories that they would've done as part of routine testing, and also active where we pay for special programs to get additional information about antimicrobial resistance, such as the Australian Group on Antimicrobial Resistance [AGAR].

Okay. There's a few different arms to AURA, which is great to know. And so John, there were some positive trends noted in 2024 reported and published by the Commission describing antimicrobial use in the community in 2023. So, obviously there's a lag there. Could you broadly describe these trends for us from the report with regards to the impact that COVID-19 had?

We've been seeing a slow and steady decline from very high numbers up to 30 million prescriptions per year on the Pharmaceutical Benefits Scheme, [which] was coming down quietly over a period of 10 years to around 25 million, and at one point a little bit lower than that. And then COVID arrived and we had a very dramatic drop, 25% in that first full year of COVID from previous values. And of course there were a lot of good reasons why that would happen; people couldn't get to the doctor as easily anymore, and of course viruses weren't being transmitted in the community at the same rate. We observed very low rates of influenza when COVID was in full swing.

And that's the irony of course. We know from trending data over many years, that quite a lot of antimicrobial prescriptions in the community are for viral respiratory tract infections; we can observe that during the winter seasons in every year where rates increase by up to 50% compared to summer. And that's the challenge for us all. We haven't yet reached that critical point where the GP can with confidence, say, ‘Yes, this is a virus, and I have that data sitting in front of me’ while the patient is consulting them, and therefore make the scientific decision, ‘No, it's a virus, we don't need antibacterials for this patient.’ We're a long way from that, sadly.

You're right, it's still a road to that destination. But when you were talking about the restrictions that were imposed during COVID, so that's these restrictions on social interaction and multiple infection prevention measures that were introduced, the article suggests that the decline in antimicrobial use could reflect what you've just described, that antibacterials were prescribed for viral infections, but more respiratory. My question to you, John, is do you think it could be just overall less infections altogether, not just respiratory? So, that would include gastrointestinal, urinary, skin and soft tissue infections. What are the details from the data that suggest that it's mainly the respiratory infection use of antimicrobials that has been avoided?

There are some antibacterial agents used in the community quite commonly, but which don't have a role in the treatment of respiratory infections. So, the ones that we like to give for urinary tract infection, for instance, trimethoprim and nitrofurantoin, don't have a role at all in respiratory infections, and our observations is that once COVID hit, those rates of prescribing did not change, so they continued in the background. And it's a bit harder to dissect antibiotics used for skin and soft tissue infections because there is a bit of overlap with respiratory antibiotics, but again, agents like cefalexin might be considered mainly non-respiratory, and cefalexin has in fact persisted, it's slightly lower level, but persisted close to the original levels before COVID hit.

Interesting, that's a really good point to make then. So, the ones that we know that can really only be used for those types of infections didn't change during that time?

Yes. That's right.

Excellent. So, further along this point, John, the article mentions that the largest declines were observed for amoxicillin+clavulanate and amoxicillin. Were there other antibacterials for systemic use where an increase in prescribing was observed during that same period of COVID?

Yes, we did see that and we don't have a good explanation.

So, which ones were they?

That's the trouble with the data is just numbers and we crunch them, and we see what's happening, but we really have to go back to the coalface to find out exactly what's going on. We can make those assumptions about respiratory antibiotics and non-respiratory antibiotics, they're easy. But dissecting further into those changes or slight increases that we've seen in classes of antibiotics like the tetracyclines made us scratch our head a little bit about what was going on. We don't have the answer yet.

Okay. I guess if it's doxycycline, then it could be potentially that being prescribed instead of amoxicillin, maybe for CAP [community-acquired pneumonia]?

Yeah it could be, or everybody's getting more acne. A whole lot of other reasons why doxycycline is important, including in sexually transmitted diseases and all of those things. So, we don't know. We don't have that direct information.

Moving on to some trends observed for residents of aged care homes. The article comments on the fact that we were surprised to see that there was an opposite trend for this population of Australians. Could you take us through what the data tells us?

We know that prescribing in aged care has been problematic for a long time, and efforts are now commenced to try and do something about it. We know that the aged care sector are picking up the messages about inappropriate antimicrobial use, and we were quite surprised to see an increasing trend in the last 2 to 3 years of use in the aged care sector. Why was it increasing? We can't imagine that there were a million more patients getting managed in aged care. We know it would've gone up, but not by much. It's really important and it just emphasises that this is a sector where we really do need to concentrate on reducing inappropriate prescribing because, in a way, a residential aged care facility is just like a hospital: lots of people in a small space, they're more mobile than those patients in hospital, bugs can get around more easily, they're elderly, they have many more infections, they need antimicrobials more, they carry more antimicrobial resistant bugs. So, increased prescribing needs to be examined in detail. The Australian Commission on Safety and Quality Health Care is liaising strongly with the new Aged Care Safety and Quality Commission to address this issue.

So, John, conversely, it appears that the rebound use of antimicrobials post-pandemic has thankfully not reached those pre-pandemic levels, which is great. What does this data look like now and do you expect this net downward trend to be sustained?

It depends on how you look at the data. If you look at the raw number of prescriptions, you will see an increasing trend, but we do also know that we've got an increasing population and certainly after the pandemic phase, we have increased our population significantly. And we therefore address the problem by looking at another statistic, which is defined daily doses per 1,000 people per day, and that figure has remained stable for the last 2 years at 16.8. So, that's some comfort that 16.8 might stay there for a while. We might've found, if you like, a new level. The disappointment is that that's almost double the Netherlands to which we like to compare ourselves. So, we've still got quite a long way to go and it suggests that [we] still have quite a lot of inappropriate prescribing in the community.

So, we don't expect it to bounce back up again. But we'd like it to be lower.

Yes, that's right. We need another mechanism, but not another COVID pandemic. We need another method and I think that's one of the things now that we want the states and territories and the federal government to collectively think about. What's the next move to reduce inappropriate prescribing in the community?

Now, John, with my antimicrobial stewardship hat on, I'm interested to hear what strategies the Commission has planned to develop infection prevention and control, and AMS programs in the community. Is there some aspects of this that you could possibly take us through today?

The Commission is there to provide guidance essentially to the prescribing community and there's a whole range of strategies. We have a lot of written documentation that's available to prescribers and particularly to those people considering setting up stewardship programs, which are now going to be equally important in the community setting and general practices and the like, knowing that we really started our stewardship experience in hospitals and now we realise that the bulk of the problems are actually out in the community. It's a little bit more difficult in the community setting because as you know, general practice are basically autonomous businesses and it requires the collective wisdom of entities such as the Royal Australian College of GPs [RACGP] and all the experts to support them to roll out programs in the community. And of course, it's a quite different one from a busy general practice in a city suburb to something that might be way out in the sticks where the practice and the priorities are different. So, there's quite a lot of work to be done, but I'm sure if it's done well, we will reap the benefits and see that figure of prescribing in the community of 16.8 go down.

Yes. As you're saying, it's really targeting the community with similar sort of programs to what's been well established in the hospital sector. So John, I'm also really interested to hear more about the re-establishment of the Medicine Insight Program. Could you tell us more about this and where can GPs sign up and find out more information?

It was developed by the National Prescribing Service, NPS MedicineWise, which was now obviously been closed down, but the Commission acquired a number of its activities, in particular the Medicine Insight Program. That program extracts data from GPs’ desktop computers, essentially, to look at prescriptions and the reasons for prescribing. We've been getting some very valuable information from that for our biennial AURA reports. But with the closure of NPS MedicineWise, and the transition to the Commission, it meant basically, starting again and re-establishing the whole program because there was a new entity that needed to get ethics committee approval from all those practices. It has provided [an] enormous amount of insight for us about appropriateness of prescribing. So, we can look at the prescription and we can look at the disease that they're treating, and we can find out what proportion of patients were labelled upper respiratory tract infection or influenza-like illness, yet were still prescribed antibacterials.

So, I think it has been re-established. Is that correct? And so now GPs can sign up to it again?

Yes, it is. It's taken a while, but it's now going and we’d just love GPs to join up. It's completely painless.

So, would the best way to find out about it and to sign up [be] just to Google MedicineInsight or just to go via the Commission website or what's the best way?

Yes. They've got all these ways of joining up. It is a really good way for them to show that they're interested in antimicrobial stewardship in their practice.

Wonderful. So, John, your article has some great links to patient resources that can be accessed by direct links in the actual text of the article. I was particularly impressed actually with the CSIRO AMR Action and Insights website. I didn't even know that CSIRO had an AMR Action website; I've definitely taken note of that myself. John, how important is patient education in this challenge overall, and how best should these resources be used?

Oh, I think it's essential. It's also the hardest thing to do, and NPS MedicineWise, when it was alive, did try a number of patient information systems, patient websites to sign up pledges about antimicrobial use, but we didn't actually see much of a shift in that. I'm aware of one country, Belgium, that spent literally millions and millions of euros educating their public through all sorts of media, television, radio, and social media, and had really good effect… for a year. And they've taught us a lesson, if we start down the patient education path, which we need to because we need to give people the courage to say no to antibiotics, then we need to build something that's not one-off, but sustainable.

Yep. Just like everything else, right? It has to be something that can be sustained, otherwise it's just a blip.

That's right.

So, finally, John, 10 years is quite an achievement for AURA. What would be your number one personal highlight?

The fact that it exists. I've been in this antibiotic space for 40 to 50 years and for a very long time was desperate to find out how we could get a national program established. It's been a bumpy ride. Many of the components that we have in our current system are not mandated, they're voluntary. Fortunately, there's a lot of interest in the volunteering and that's kept the program working. I don't think there's any interest in winding it back, but we're only doing one side of the equation here. We're waiting for the data to get used to design the interventions that we think will work to the good of our community.

Wonderful. Yeah, that's excellent. I'm so happy to hear that it's been such a success. So, that's unfortunately all the time we've got for this episode. Really many thanks again for joining us today, John.

You're welcome.

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Professor Turnidge's article, Reflections on Community Antimicrobial Use in Australia, is available on the Australian Prescriber website. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. The authors acknowledge that they are employees of the Australian Commission on Safety and Quality in Healthcare, which is funded by the Australian Gov[ernment] Department of Health and Aged Care. I'm Dhineli Perera and thanks for joining us on the Australian Prescriber Podcast.

More information on how to join the MedicineInsight Program is available at  safetyandquality.gov.au/medicineinsight