Antimicrobial stewardship – the path to least resistance

Allowing multiple prescribers will have a detrimental effect on antibiotic resistance, says Dr Ramya Raman. 

A 15-month-old baby who attends day care is brought in by her mother to see me. She is worried that her baby has had a cough for four days, has a runny nose, is feeling warm to touch, has had reduced intake of solids and is generally grumpy. In the era of the pandemic, COVID-19 certainly crosses our minds. 

Dr Ramya Raman

So, we triage this baby over a phone consult and then wear a mask and review in person in our rooms. On examination, the child is alert, and examination is mostly unremarkable except noting some erythema in the throat. 

The mum asks: ‘Does my baby need antibiotics? She has not been sleeping and it’s the fourth time she has been unwell in six months. She has been so grizzly, and her nose just keeps running and she is not sleeping well. Can you please just give us some medication? My friend’s daughter had an issue like this and she had antibiotics which just cured everything.’ 

This is not an uncommon encounter in general practice. Patients ‘demanding’ or ‘requesting’ antibiotics can lead to overprescribing. Responding to the pressure to prescribe can be managed by foreshadowing a non-antibiotic outcome and using persuasion when confronted with resistance. This is about how medical practitioners communicate and when they communicate. 

Safe prescribing relies on accurate diagnosis. In medicine, research has shown that clinical reasoning is not a separate skill acquired independently of medical knowledge and other diagnostics skills. Instead, it is a stage theory of the development of medical expertise, in which knowledge acquisition and clinical reasoning go hand in hand. 

This is a complex process where, initially, medical students take in large volumes of knowledge about basic sciences, there is knowledge accretion and validation, then integration from various domains including clinical sciences, biochemistry, pathophysiology to name a few. The next stage of learning evolves where there is encapsulation of biomedical knowledge into clinical knowledge, which arises from a range of clinical encounters. 

The process relies on extensive medical experience and training which helps to ensure medical governance for prescribing in a clinical encounter. It is commonly referred to as ‘illness scripts.’ Therefore, people whose knowledge is organised in illness scripts have an advantage over those who only have semantic networks at their disposal. 

While problem solving, a medical practitioner activates one or a few of these illness scripts. Subsequently, the illness scripts are matched to the information provided by the patient. The illness scripts not only incorporate matching information given by the patient, they also generate expectations about other signs and symptoms the patient may have. This leads us, as clinicians, to seek a history and perform a physical examination. 

In this process, expected values are substituted by real findings, whilst scripts that fail are deactivated, which leads to a list of differential diagnoses. During this process, illness scripts are adjusted based on specific features of the patient. It is evident that medical training and expertise is obtained through years of experience, is a dynamic process and reliant on reflective reasoning, yet non-medical prescribing is becoming vastly incorporated into many jurisdictions in Australia.

Allowing more non-medical prescribers in Australia will increase antimicrobial resistance (AMR) – making infections harder to treat and raising the risk of disease spreading and severe illness. The World Health Organization 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. The Queensland Urinary Tract Infection Pharmacy Pilot (UTIPP-Q) is one such example that has raised significant concerns about injudicious use of antibiotic prescribing. There is evidence that points to pharmacists over-prescribing in comparison to medical practitioners and increased availability of antibiotics will increase the emergence and spread of resistance. 

Recently, in clinical practice, we are seeing a shortage of many medications including amoxycillin, which has been attributed to ‘manufacturing issues.’ This has led to the need to prescribe second or third generation antibiotics for common bacterial conditions, particularly in children. This increases the risk of AMR. In this mix, add more non-medical prescribers and we are setting ourselves up for a public health challenge. 

The Global Antimicrobial Resistance and Use Surveillance System (GLASS) 2022, recently published common bacterial infections with increasing resistance is on the rise. This includes over 60% of Neisseria gonorrhoea isolates and more than 20% of E.coli isolates, which is the most common organism causing urinary tract infections. 

We need to consider the impact of expanding scope of practice on promoting higher use of antibiotics leading to AMR. Health policy needs to be designed with a strong commitment to adequate surveillance programs, prompt diagnostic techniques and robust research initiatives. We also must consider increased funding for general practice, which will drive better health outcomes for patients and, ultimately, reduce patient hospital admissions and re-admissions. 

As Newton’s third law states, ‘for every action there is an equal and opposite reaction’. We need to consider each of our actions particularly considering our health care policies to ensure we maintain social and economic resilience. 

ED: Dr Ramya Raman is chair of the WA faculty of the RACGP. References on request.