Australians are already over-using antibiotics.
According to the official statistics, Australia uses more antibiotics than 20 European countries. Some bacteria that can cause serious illness are becoming resistant to common antibiotics. And this is a cause of concern for healthcare in this country.
What do we use antibiotics for?
Antibiotics are highly effective at treating and preventing infection. Prior to antibiotics, people would die from even minor injuries that progressed to major infection. Many major medical advances, including cancer chemotherapy, organ transplantation and major surgery, would be highly risky without antibiotics.
However, antibiotics aren’t always used appropriately. Although studies consistently show that a dose or two will adequately prevent infections after surgery, but antibiotics are often continued for several days unnecessarily. Sometimes, we use the wrong type of antibiotic.
Surveys have found that 22% of antimicrobial use in hospitals is inappropriate.
Head of Antimicrobial Stewardship, Dr Kylie Horne explains that there are many reasons why antibiotics may not be prescribed appropriately.
“Many doctors worry that they may not have the right diagnosis early, so they tend to treat all possible diagnoses, including infection. Although there is a temptation to use the broadest spectrum antibiotics to make sure everything is treated, this doesn’t always serve current or future patients well, as there are increased side effects, and increasing antimicrobial resistance with increasing antibiotic use.
“In other situations, there is a degree of inertia. If the patient is improving, doctors tend to simply continue the same treatment rather than change to a more appropriate choice,” she says.
Dr Horne adds that there are treatment guidelines available that can offer doctors sound advice on which antimicrobials to use for specific conditions and when urgent treatment is required.
At Monash Health, the Antimicrobial Stewardship Service is trying to improve the quality of antimicrobial use by restricting broad spectrum antibiotics, by conducting auditing and feedback, and by refining guidelines and policy.
It has been strengthened by the recent appointment of new employees including a senior pharmacist, Sonia Koning, who has worked in several other health services in Melbourne who joins the current team.
She says a common misconception is that antimicrobial stewardship is just about telling people not to use antibiotics.
“But optimal use also means appropriately treating septic patients with antibiotics promptly, as this can be lifesaving.”
Inappropriate antibiotic use is not just a hospital problem. In general practice, the issues of diagnostic uncertainty and therapeutic inertia are often magnified, and patients may expect “a pill for every ill”.
As in humans, antibiotics are also used to prevent and treat infections in animals. The use of antibiotics for growth promotion has been phased out but in Australia, an estimated 60% of antibiotics were used in animals between 2005 to 2010.
Why is overuse a problem?
Bacteria become resistant to the effect of antibiotics through natural selection – those that survive exposure to antibiotics are the strains that have a mechanism to evade their effects.
Professor Allen Cheng, Director of Infectious Diseases says when resistance to the commonly used first-line antibiotics occurs, we often need to reach deeper into the bag to find other effective treatments.
“Some of these last-line antibiotics are those that had been superseded because they had serious side effects or couldn’t be given conveniently as tablets,” he says.
“We’ve also seen patients at Monash Health where infection was due to bacteria resistant to almost all our available antibiotics.”
New drugs for some bacteria have been developed, but many are much more expensive than older ones.
Professor Cheng says it’s not all doom and gloom, and there is a lot we can do to prevent antibiotic resistance.
For doctors in hospitals:
- Use the antibiotics we have more appropriately, guided by national and local guidelines.
- Review the choice, route and duration of antibiotics once the diagnosis is confirmed and the results of microbiological testing are available.
- Reduce cross-transmission of resistant organisms through infection prevention practices, such as cleaning and hand hygiene.
More broadly, we need to:
- Raise awareness that many infections will get better by themselves and don’t necessarily need antibiotics.
- Reduce the inappropriate use of antibiotics in animals, such as for growth promotion.
- Continue developing new antibiotics and alternatives to antibiotics and ensure the right incentives are in place to encourage a continuous pipeline of new drugs.
- Prevent infections by other means, such as clean water, sanitation, hygiene and vaccines.
Professor Cheng, also a professor in Infectious Diseases Epidemiology at Monash University, says back in the 1940s, the first true antibiotic, penicillin, was difficult to produce. One way to extend the limited supply was to “recycle” penicillin excreted in the patient’s urine.
“But today, we’re facing a world where we are potentially running out of antibiotics – not because of difficulties manufacturing them, but because they’re losing their effectiveness,” he warns.
This article is published in conjunction with the World AMR Awareness Week (WAAW), celebrated from 18 to 24 November every year.