eMJA     The Medical Journal of Australia

Home | Issues | eMJA shop | Classifieds | Contact | More... | Topics | Search | Login | Buy full access   

Compared with similar developed countries, Australia has a high rate of antibiotic use. This is made clear in this issue of the Journal by McManus et al.,¹ who show that retail sales of oral antibiotics in Australia in 1994 were about 25 defined daily doses (DDDs) per 1000 population/day, compared with 24 in the United States, 16 in the United Kingdom and 11 in West Germany. The reasons for these differences are less clear. Indeed, they seem paradoxical, as Australia has most of the conventional prescribing controls in place -- a strict regulatory process for evaluating new drugs, the tightly controlled Pharmaceutical Benefits Scheme (PBS), and prescription-only availability. Australia also has a strong tradition of promoting appropriate prescribing in medical schools, through publications such as Antibiotic guidelines² and through education of medical and pharmacy practitioners. The MJA has been an educational leader in this area, publishing articles and editorials on rational drug use,^3,4 antibiotic guidelines⁵ and antibiotic prescribing interventions in both hospitals^6,7 and general practice.⁸

Cynics often blame the high rate of antibiotic use on the pharmaceutical industry and its intensive promotional activities. Yet the industry is also bound by the regulatory environment, its own code of ethics, and the very powerful effects of the PBS on market forces. The PBS has ensured that drugs in Australia are among the cheapest in the Western world. But, has it ensured that we use antibiotics wisely?

Antibiotics are a valuable resource that is easily squandered. They are unique in being specifically designed to have no action on the host. This can make them attractive to both prescriber and patient, as they can be taken "just in case" the infection is bacterial. However, adverse reactions are still a risk. In addition, bacteria have the ability to mutate to or acquire resistance at rates sufficient to reduce or negate antibiotic usefulness within one to two decades.^9,10 Unnecessary prescribing adds to the selective pressure for antibiotic resistance. This leads in turn to increased costs to the community because of the need for more expensive, broader-spectrum agents, extra visits to medical practitioners, and further prescriptions or hospitalisations for antibiotic failures. Broader-spectrum agents generate further resistance, leading steadily to multidrug resistance. Eliminating unnecessary antibiotic use cannot stop resistance emerging, but can reduce its frequency and prolong the useful life of the older, cheaper antibiotics.

We have also learnt that information about adverse reactions has only a modest impact on prescribers. For example, publicity about serious adverse reactions to trimethoprim- sulfamethoxazole, flucloxacillin and amoxycillin-clavulanic acid, through means such as the Drug reactions advisory committee bulletin, letters to general practitioners and via the PBS, had minimal effects on prescribing volumes. Subsequent regulatory interventions by the Therapeutics Goods Administration and the PBS had variable results. Flucloxacillin use declined about 30% between 1994 and 1995, and adverse hepatic reactions declined by 50%. In contrast, over the same period use of amoxycillin-clavulanic acid rose by about 10%, and adverse hepatic reactions by 15%.¹¹ We have spent the past decade haranguing prescribers without the expected dividends. However, they continue to be handicapped by the lack of rapid diagnostic tests for common infections to determine need for an antibiotic before prescribing.

Thus, it may well be time to switch our attention from the supply to the demand side -- patients must be empowered with basic knowledge about infections. Last year saw the first small step, with the introduction of National Medicines Week, focusing on antibiotics. Soon after, the public began to take notice of emerging resistance and the impact of indiscriminate antibiotic use, largely through the "doomsday" and "superbug" scenarios promoted by the media with stories about drug-resistant Streptococcus pneumoniae, multidrug-resistant Mycobacterium tuberculosis, vancomycin-resistant enterococci, and, most recently, vancomycin-resistant Staphylococcus aureus. The climate is now right to educate the public about infections and when antibiotics might not help. This will reduce not only antibiotic misuse, but also the number of patient visits to medical practitioners, with major benefits for both the community and government. We need a measured approach to public education. It should be conducted at many levels, including in secondary schools, during patient visits to health professionals and through specifically targeted local and national programs similar to National Medicines Week.

On an optimistic note, as McManus et al. show, oral antibiotic use actually declined slightly between 1989 and 1994. We must capitalise on this trend by intensifying efforts to eliminate unnecessary use. Lessons can be learned from the approach to other major public health issues -- a judicious combination of regulation and education is likely to be most successful. A pro-active approach to the regulation of availability, prescribing and access to antibiotics, rather than one that is reactive to the pressures of cost and adverse reactions, will favour rational use. Education is needed for health professionals, at both undergraduate¹² and postgraduate level,^8,13 and for consumers. Everyone will benefit from a better understanding of the basics of infectious diseases and their management given that infections are the commonest of human ailments.

John Turnidge
Director, Microbiology and Infectious Diseases
Women's and Children's Hospital, Adelaide, SA

1. McManus P, Hammond L, Whicker SD, et al. MJA 1997; 167: 124-127.
2. Victorian Drug Usage Advisory Committee. Antibiotic Guidelines. 9th edition. Melbourne: Victorian Medical Postgraduate Foundation Therapeutics Committee, 1996.
3. Moulds RFW. From knowledge to action: improving drug prescribing. Med J Aust 1996; 165: 299-300.
4. Moulds RFW. Rational therapeutics: the way ahead. Med J Aust 1992; 156: 823-824.
5. McDonald P. Antibiotic guide-lines: do we know where we are? Med J Aust 1989; 150: 610-611.
6. Harvey KJ, Stewart R, Hemming M, et al. Educational antibiotic prescribing. Med J Aust 1986; 145: 28-32.
7. Landgren FT, Harvey KJ, Mashford ML, et al. Changing antibiotic prescribing by educational marketing. Med J Aust 1988; 149: 595-599.
8. DeSantis G, Harvey KJ, Howard D, et al. Improving the quality of antibiotic prescription patterns in general practice. The role of educational intervention. Med J Aust 1994; 160: 502-505.
9. Turnidge J, Nimmo G, Francis G, and the Australian Group on Antimicrobial Resistance. Evolution of resistance in Staphylococcus aureus in Australian teaching hospitals. Med J Aust 1996; 164: 68-71.
10. Collignon PJ, Bell JM, on behalf of the Australian Group on Antimicrobial Resistance (AGAR). Drug-resistant Streptococcus pneumoniae : the beginning of the end for many antibiotics? Med J Aust 1996; 164: 64-67.
11. Adverse Drug Reactions Advisory Committee. Antibiotics of continuing concern. Aust Adverse Drug React Bull 1996; 15: 6-7.
12. Snell BF on behalf of the organising committee of the ASCEPT/CHF Conference. Rational prescribing: the challenge for medical educators. Med J Aust 1992; 156: 352-354.
13. Eckert GM, Ioannides-Demos LL, McLean AJ. Measuring and modifying hospital drug use. Med J Aust 1991; 154: 587-592.