The Royal Australian College of General Practitioners is warning that allowing more non-medical prescribers in Australia will increase antimicrobial resistance (AMR) – making infections harder to treat and raising the risk of disease spreading, severe illness and deaths.
It’s World Antimicrobial Awareness Week, and the World Health Organisation has declared AMR one of the top 10 global public health threats facing humanity, with an estimated 1.27 million deaths due to resistant bacteria in 2019 alone. Misuse and overuse of antibiotics are the main drivers of AMR.
Meanwhile the RACGP and other medical bodies have ramped up AMR-related warnings about moves to allow retail pharmacists to prescribe antibiotics and other medications in Australia.
Recently the NSW Government announced it would allow a trial of pharmacists prescribing medications for a range of conditions, including antibiotics for urinary tract infections. This follows the Queensland Government announcing that its UTI program is now permanent, and it will push ahead with a controversial expanded scope of practice pilot, allowing pharmacists to prescribe medications including antibiotics for various conditions.
The AMR threat
RACGP President, Adjunct Professor Karen Price, says antimicrobial resistance is one of Australia’s and the world’s greatest health threats. ‘We must step up efforts to combat antimicrobial resistance,’ she said.
‘Antimicrobials, which include antibiotics, antivirals, antifungals and antiparasitics, are vital medicines for fighting disease and infection, and save countless lives every year.
‘This is why antimicrobial resistance is one of our greatest threats. The more bacteria and infectious disease that are resistant, the more we will see diseases spreading, and people suffering severe illness and deaths.
‘It is not an exaggeration to say that antimicrobial resistance, if not addressed effectively, could have a far worse impact on Australia than the COVID-19 pandemic. If we lose the key tool in our kit to fight disease, we’ll rapidly find ourselves fighting a losing battle.
‘Modern medicine as we know it could collapse, because antimicrobials are essential in so many critical medical interventions, from major surgery to cancer chemotherapy. Thankfully, we know how to fight antimicrobial resistance. We need to reduce antibiotic use, and this is a national and international priority.’
Managing the risk
‘GPs resist prescribing antibiotics to their patients unless they are absolutely necessary,’ said Adjunct Professor Price. ‘This is why the recent moves to introduce more non-medical prescribers of antibiotics in Australia is so alarming. The evidence shows that putting prescribing power in the hands of retail pharmacists leads to over-prescribing of antibiotics.
‘A 2021 study in Australia showed a dramatic rise in topical chloramphenicol prescribing after it was rescheduled to pharmacists. In Canada, pharmacists prescribed seven times more antibiotics than physicians did for urinary tract infections.
‘And in Queensland, pharmacists prescribed antibiotics to 96.3% of patients with UTI-like symptoms, without taking urine samples to confirm if they actually had the infection.
‘The introduction of pharmacist prescribers in Australia will no doubt result in a rise in antimicrobial resistance, just as it has in other countries. The United Kingdom and New Zealand have reported increased trimethoprim resistance due to inappropriate use of antibiotics.
‘Trimethoprim used to be the first line treatment pharmacists prescribed for UTIs in the UK, but it was over prescribed and now doesn’t work for one-in-three women due to resistant bacteria.’
‘One of the key problems is pharmacists don’t take urine samples when women present with symptoms that might be a UTI, whereas GPs do – this is how we confirm that there is an infection, and check whether it’s resistant to the antibiotic we may prescribe. These are important elements in antimicrobial stewardship.
‘The argument that retail pharmacists should be able to prescribe antibiotics because of the GP shortage simply does not make sense. Not only because pharmacists don’t have the necessary facilities, training and experience to diagnose patients, but because workforce shortages are affecting the pharmacy sector just as much as general practice.
‘The Pharmaceutical Society of Australia has spoken out about the labour shortages affecting pharmacies and putting strain on already exhausted pharmacists, and persistent challenges in recruiting and retaining pharmacists across all settings. As it stands, there are more GPs across Australia than pharmacists and they are better distributed across communities, including rural areas.’
Adjunct Professor Price said statistics show that in NSW there are 121.7 full time equivalent GPs per 100,000 people, compared to 88.6 pharmacists, while in Queensland the GP-patient ratio is higher, at 127.9 per 100,000, compared to 96 pharmacists.
‘State and federal governments need to find genuine long-term solutions to primary care workforce shortages that do not create bigger problems like increased antimicrobial resistance,’ she said.
‘It is deeply concerning that state and territory governments are bypassing the national safety mechanisms that are there to protect our community. This includes the Therapeutic Goods Administration, which schedules medicines and does not allow pharmacists to prescribe antibiotics.
‘State and territory governments need to put the health of all Australians ahead of politics. The RACGP is continuing to urge federal government to reform healthcare funding so that all patients can access the care they need, no matter their postcode or income. General practice must be funded and supported to improve access to care for all Australians, and ensure we have enough GPs in every community.’
The RACGP President believes general practice has a key role to play in fighting antimicrobial resistance.
‘General practice has a major role to play in maintaining antibiotics effectiveness and educating the public on their appropriate use and emerging resistance,’ she said.
‘And the RACGP, as Australia’s largest representative body for GPs, is committed to helping GPs implement new initiatives to reduce antibiotic usage, where safe to do so.
‘We do need to see more support for general practice to introduce programs to maintain antibiotics effectiveness. Antimicrobial stewardship programs have been developed for hospitals to help fight antimicrobial resistance and have shown very positive results. These programs could easily be adapted for general practice with appropriate resourcing and support.’
Adjunct Professor Price said the RACGP has a position on antimicrobial stewardship, and has outlined the role of general practice and GPs in combating AMR in Australia, in line with the priority areas in the Australian Government’s National Antimicrobial Resistance Strategy 2015-2019 Implementation Plan.