Outsmarting Bacteria: Confronting Antibiotic Resistance

Outsmarting Bacteria: Confronting Antibiotic Resistance


Hello. I’m Norman Swan. Welcome to this program on antibiotic
resistance and infection control. Antimicrobial resistance
is a public-health threat of enormous importance, and the serious and real risk is by 2030
we’ll be back in a pre-antibiotic era. If you think that’s just scaremongering,
watch on. Let me introduce our panel to you. John Bell is Vice President of the
International Pharmaceutical Federation, and a past president
of Pharmaceutical Society of Australia, and the Australian College
of Pharmacy Practice. – Welcome, John. Glad you could come.
– Thank you. Marilyn Cruickshank
is a registered nurse, who works in safety and quality. – Welcome.
– Thank you. Marilyn’s currently leading the national
healthcare associated infection program with the Australian Commission
on Safety and Quality in Health Care. Margaret Duguid
is a pharmaceutical advisor at the Australian Commission also. Margaret is involved in leading
and coordinating improvements in the safe use of medicines.
Welcome, Margaret. Thank you. Margaret also works,
you’ll hear more about this later, on Antimicrobial Stewardship, and coedited
the Commission’s publication – Antimicrobial Stewardship
in Australian Hospitals. Gary Franks is a general practitioner
in Illawong. -Welcome, Gary.
– Thank you. Gary is a consultant
at the National Prescribing Service, and was a GP member of the expert group guiding the Antibiotic Therapeutic
Guidelines, versions 13 and 14. Tom Gottlieb is a specialist in
microbiology and infectious diseases. – Welcome, Tom.
– Thank you. Tom’s currently President of the Australasian Society
for Infectious Diseases, the president-elect of the
Australian Society for Antimicrobials, and is on the executive of the Australian Group
on Antimicrobial Resistance. So welcome to you all.
An august and authoritative panel. Looking forward to what you have to say. I mean, Tom, if you look at the graph here, there’s… we’ve had a remarkable effect from antibiotics. They’ve been an astounding medical technology. TOM: They’re the true miracle drugs, and no other anti… no other drugs have had such a profound effect on diseases in the 20th century. And you can see on that graph that in the 1940s and so on when these drugs were introduced, they reduced morbidity and mortality. But our risk is that we’ll go back to that era, as you’ve already mentioned, when we lose a lot of these antibiotics. NORMAN: What’s that blip at the end of the graph there? TOM: The blip at the end is HIV, and the mortality associated with HIV. But luckily, a lot of companies have gone into HIV-drug production, and that blip has gone down again with better antiretroviral medications. But the sad thing is those companies are no longer
producing antibiotics. NORMAN: And that’s the key here. No sooner is an antibiotic produced… I mean, how quick is it
that you get resistance appearing after a new antibiotic coming out? Usually you can see it worldwide
within about a decade. I mean, resistance occurs very quickly
after antibiotics are used, but when you’re on a flat curve
of an exponential curve, you don’t really see it from
epidemiological point of view. It’s only after a while
that you start seeing it, and by then it’s often too late. So what is the extent to which… What’s the number needed to treat
to get resistance? Do we know that? For example, you’ve got a patient
coming in with a UTI, you give them an antibiotic. Of 100 patients being treated with a UTI
with the antibiotic, how many of them do we know will develop resistance as a result
of the antibiotic prescription? You can’t… The point is that the… All bacteria potentially possess
the mechanism for resistance. In any population of bacteria, there’s
already a percentage of bacteria that… – You inherently select for resistance.
– You select for resistance. That resistance is already there
to some extent, but it hasn’t been produced
to any large number. As we use antibiotics, we allow those
resistant organisms to come to the fore. So the extent to which we’re talking
about are population-based problem, or one in our individual patients? I mean, that’s what I’m trying
to get at. Should your hand be quivering
over the prescription pad, that five days from now,
seven days from now, this person’s got a 50% chance of having the growth
of a resistant population of bacteria? No. For the specific infection
you’re treating, you can be confident
that your antibiotics are going to work. But that person’s gut flora
will be changed within a number of days, and what you’ll see is resistant flora,
often of a different species, colonising that patient’s gut. Some of those organisms
will have already resistance factors, which can spread to other bacteria. So how does the resistance bacteria…
you got phages, you got the viruses that infect bacteria that can carry resistance
between different species of bacteria. How else? Well, a lot of bacteria have plasmids, and these plasmids
collect resistance factors, and congregate them. These plasmids can move
from mother to daughter, but they can also move horizontally to
other species of organisms very quickly. Bacteria spread resistance
very promiscuously. NORMAN: So here’s the scary graph. This is the extent to which new antibiotics are being produced over time. I mean, this is the truly frightening… This is the frightening scenario here. TOM: Yes. We had a lot of new antibiotics in the ’50s and ’60s, but when you look at that graph, really, there’ve been two new classes of antibiotics in… ..at the end of the 20th century. And both of those classes are very narrow in their capacity, and resistance to both of these have already become well established. NORMAN: What we’re looking there is that red box is the front line against resistance. TOM: These are the new antibiotics. They’re often extremely expensive, and they’re not gonna last us long-term. The issue is that if you’re not producing new antibiotics, you’ve got to preserve your old ones. You’ve got to find means of controlling the spread of antimicrobial resistance. Some of that is
through controlling antimicrobial use. But also, once you’ve already
got resistance, controlling the spread, and that could be in hospitals with
better infection control, for example, or better programs
about antimicrobial use. Tell me the story of Greece. Greece is in the news at the moment, but it’s got a bad story
with antibiotic resistance. TOM: Yes. This is an example where a particular resistance has occurred to our last-line antibiotics. These are called carbapenem antibiotics. They’re beta-lactam antibiotics that cover the broadest spectrum of bacteria. You can see that within a decade in Greek hospitals, you’ve gone from 0% resistance in Klebsiella, which is a very common gut organism, to 80% in Greek hospitals. That’s a clear indictment of antimicrobial prescribing, but also of hospital infection control. ‘Cause once this organism appears in your hospital, if you can’t contain it, it’ll spread elsewhere. And that’s exactly what’s happened. So this could apply
to a general practice or a hospital. You’ve done studies of tourniquets. (Chuckles) Yes, we’ve looked
at tourniquets in our hospitals, just to make a point
to our administration about how hospitals need to be cleaned better. But the example of the tourniquets was that these tourniquets
were sitting in the wards, being used by a lot of the RMOs, and going from patient
to patient to patient. And when you actually tested them, 20% of our tourniquets
had either MRSA or VRE already sitting on that tourniquet. And that’s just
environmental colonisation. But the point is that the tourniquet
itself is not to blame, it’s the cleaning of the environment that allows these organisms
to remain there and potentially spread. And you’ve got another example here
of another resistance, because you could say
with the Greek story, ‘What does that matter?
I mean, it’s Greece. It’s not gonna happen here.’ NORMAN: But people travel.
– Exactly. I think the point with the Greek one was this was Greek hospitals, and failures there. But here’s an example of a very similar organism. Here actually, it’s a particular enzyme that again destroys all penicillin-like, or beta-lactam antibiotics, and a whole lot of others as well. This resistance emerged in the community in New Delhi, in India and Pakistan, and rapidly spread to England, and within two years, from 2009 to 2011, has spread worldwide. NORMAN: It’s come to Australia as well. TOM: It has come to Australia. NORMAN: Poor practices somewhere else… Poor practices somewhere else, and here this organism survives
in water, in seepage and sewage. So this is a community problem. But the problem really is that a lot of
people… they’re never gonna get sick, sick with this organism. But when they do develop
the urinary-tract infection, or sepsis, and that person presents
to your hospital, you wouldn’t realise
you’ve got this resistance until you test that patient
and get results 48 hours later. So are resistant organisms
more virulent, or it’s more that you miss the fact
that they’re resistant? Some resistant organisms
can also have other virulence factors, like certain staphs. But in this situation, this organism’s
not more virulent in itself, it’s just that we don’t anticipate
that we’ve got this. We treat the patient
with the wrong antibiotics, or we may have no antibiotics
left in this situation. And, Margaret, there’s stats showing
that people die more frequently with resistant organisms. – They’re more likely to die.
MARGARET: Yes, yes. There are studies that have shown,
they’re more likely to… ..twice as likely to die from an
infection with a resistant organism. Tell me the E. coli story now,
and that spread. TOM: The E. coli? NORMAN: The third-generation
cephalosporins. Oh. Well, these are even more common. These are called ESPLs E. coli. This graph shows a change in five years in Europe, both in E. coli and Klebsiella. You can tell by the colours that green is less than 5% resistance, but red or orange is 20 to 50% resistance, and you can see how rapidly… These are bloodstream infections in Europe, and you can see how rapidly resistance has emerged. It’s an index of both those things – use and infection control. But the point there is that often the Scandinavian countries, the countries to the north, have got much lower rates of resistance. Yet when you look at statistics on mortality or morbidity with these infections, those patients in Scandinavia are not dying anymore by not using
antibiotics to the same extent. NORMAN: So those are low
antibiotic-prevalence countries – with low resistance.
TOM: Exactly. NORMAN: With no corresponding
increase in mortality ’cause they’re dying
because of lack of antibiotics. TOM: Exactly. So our antibiotic use
can often be out of proportion to need. And what about the Australian situation? Well, Australia in some situations has been lucky. We’ve had much better control of agricultural use of antibiotics. That doesn’t protect us. But in certain situations, we’re starting to see changes. This graph shows the rise of community MRSA, which is a nasty, potentially very virulent organism that we’re seeing particularly in rural and Indigenous areas. And the point to make here is you can see the trend from 2000 to 2008 in some studies in Australia. But if you were to look in 1990, that graph would be zero. You wouldn’t get community MRSA anywhere in Australia pretty well. There were some exceptions. Now there’s an inexorable rise upwards, and we don’t know where it will end. Will it be 50%? Certainly in the United States now, 70% of patients
presenting to emergency departments with staph infections
have community MRSA. Which means, Gary, that…
(Clears throat) ..you know, you can’t be complacent
about your coughs or tourniquets in a general practice anymore. GARY: Absolutely not. In fact, beyond that is the need
for us to be very diligent on using narrow-spectrum antibiotics
for skin and soft-tissue infections, which are often caused
by staphylococcus of course, and not the use of cephalosporins,
which is often the case. So do we know the extent
to which community MRSA is caused by poor prescribing
in general practice? We know that it has evolved through
antibiotic… poor antibiotic use, and certain areas we can actually
document how it’s been used – it’s been related to cephalosporin use. But once that clone is established,
clones of bacteria spread unrelated. So, the antibiotics still maintain
a pressure on use, but once it’s escaped, there are
other dynamics in place as well. So you could say in Greece, because
they can’t afford carbapenem anymore, does that mean you’re gonna see
that graph reversing? That graph may tone down a bit
and go away if they can control
their antibiotic use, but sadly, a lot of those resistance
factors will remain in those organisms, or in a subset of those organisms. At the minute
you reintroduce antibiotics of a class, or a similar class… NORMAN: They’ll surge back.
– They’ll surge back. I thought it was expensive for
an organism to carry that resistance, that their natural non-resistant state
was their most energy conserving. It’s probably a bit of a myth.
It depends on some organisms. In certain TB strains
it may be the case, but in most of our bacteria, in fact, acquiring antibiotic resistance has had
very little cost to their virulence. To what extent, John, do pharmacists use
therapeutic guidelines? Well, it’s a mandatory text
in community pharmacy, Norman. I guess we don’t use the book though,
as much as we should. One of the reasons, I guess,
is that we’re most often not privy to the diagnosis, the type of infection,
the type of condition the patient has. We can assume, most often, if someone
comes in coughing and spluttering, that’s a respiratory tract infection. Um… Otherwise if they walk in
uncomfortably, maybe we can presume it’s a UTI. But there are hints, of course, in the
prescription that we’re presented with. In hospitals, there’s, I think, enormous collaboration
between pharmacy and medicine – the doctors and the pharmacists there. Not as much on issues like this
in the community. NORMAN: Is there any?
– There’s some, but very little I think. It would be rare
for a general practitioner… I should ask Gary this as well. ..general practitioner to refer
to his or her local pharmacist for advice
as to which antibiotic to use. The question that’s come in
is from Jill Fletcher, the manager of Berri Hospital,
general services, who has the recent South Australian
cleaning guidelines, and wants to know what place
cleaning standards have in assisting without smarting bacteria in hospital
with regard to antibiotic resistance. – Marilyn, that’s a question for you.
– Hm… Look, cleaning’s very, very important
because, as Tom has said previously, that, you know, antibiotics cause
resistance in different organisms, and that’s in a particular patient. But that patient then can transfer
that multi-resistant organism to the surroundings. So if hospital surfaces and surroundings
aren’t cleaned adequately, then other patients can either
become infected with those multi-resistant organisms
by touching those surfaces, or healthcare workers can transfer them
from one patient to another around the… around the area. So, another problem is too that
you can’t tell by looking at a surface whether there are
multi-resistant organisms on it. So we really need to have,
you know, well-trained staff who can do the cleaning. We need to have… Which, I presume, is not often the case. Well, no. It often isn’t,
because often there’s… You get contract cleaners in
who think they can do it. Yes, and we have a large turnover, so we need to have well-trained cleaners
who stay. And does it matter
what they use to clean with? Do they ever get resistance
to disinfectants? Well, that’s an interesting…
that’s an interesting question. But usually cleaning with detergents… NORMAN: You’re not going to answer it? Well…
(Laughter) Well, usually cleaning with detergents
and cleaning thoroughly, and then disinfecting with bleach
or some other disinfectant is adequate. NORMAN: Right.
JOHN: Can I ask, Norman… Marilyn, in the community setting,
in the home, we see promotion of lots of
antibacterial disinfectant cloths, and wipes and solutions and so on. These are not really not necessary,
are they? They’re not necessary. No. Detergent and soap is the best product
to be cleaning with. So the other use of chemical,
the antibacterials and so forth, could actually exacerbate the problem. Absolutely. That can also add to
the problem of antimicrobial resistance. Margaret, do we know the extent
of inappropriate prescribing? Well, we certainly know
that in hospitals, probably around 50% of prescribing
could be inappropriate. NORMAN: 50%?
– Hm. Up to 50%. Certainly the studies have shown that. Is that omission, commission?
What’s the story here? Well, this is mainly
if we look at it against guidelines. If we look at prescribing
against guidelines, it’s pretty poor. So… not necessary, wrong antibiotic,
wrong duration. We’ll come to all that in a minute. Tom, Clostridium difficile. They say, in Britain,
there’s 250,000 premature deaths due to Clostridium difficile
in hospitals a year. I mean, that’s an enormous number. Yeah. Clostridium difficile is an
organism that really colonises surfaces, and it’s extremely difficult
to get rid of. In the UK, they had an outbreak
of a very toxic strain, which we’ve been very lucky that
we haven’t had in Australia to date to any large extent. NORMAN: I thought we had some
in Western Australia. We had some actually in Sydney
and in Melbourne in the last two years, but they haven’t really got out
to any degree. I think what happened in the UK
is that they had, at that time, poor infection control, and it got into the nursing homes,
into the really vulnerable. But England’s got their act together. To some extent, they’ve improved
their prescribing guidelines, their infection control,
and ahead of us I think. So we’re an accident still waiting
to happen as far as that goes. What’s the role of surveillance,
Margaret? MARGARET: Surveillance in terms of…? We’ve got the National Antimicrobial
Utilisation Surveillance Program. Well, the national antibiotic usage
surveillance program collects data from about 50% of principal referral hospitals
in Australia. So it doesn’t involve country hospitals? If you live in South Australia,
they collect data, and also in Queensland they collect data
from the… from most hospitals. NORMAN: So you’re looking
at common infections, and comparing it to the antibiotic use? No, there is… Depends on what’s used
at the hospital. They may use that data to compare
against their susceptibility data. But the… generally… That data, at this point in time,
certainly national data, is not related to resistance data. We don’t have a comparison. Gary, give me the antibiotic creed, ’cause this really will frame
the rest of our discussion. It’s a profound statement.
It’ll be on the screen. It’s probably one that most GPs have either not seen, or cannot remember seeing, and it’s an acronym – MIND ME. (Reads) NORMAN: Let’s unpack that a little bit. So, microbiology guides therapy. So, does that mean swabs, blood
cultures, etc. in general practice? Obviously, in general practice, it’s
more limited than in a hospital setting but there’s a lot of room
for micro urines to be tested, swabs of wounds, throat swabs appropriate on occasions, sputum cultures can be useful so it’s limited but compared
to the hospital, obviously less so but it can guide our therapy
and make a directed therapy a few days later. Tom, what is the role
for empirical therapy? I’m assuming when we’re talking about
empirical therapy is that you’re giving treatment
without knowing what the diagnosis is but on a hunch
you know that somebody’s sick and you suspect a bacterial infection,
is that what we’re talking about here? Yes, there’s always a role for it. The beauty of antibiotics
is that they save lives. If you’ve got patients with sepsis, there’s no time to wait
for the diagnosis, you want to treat appropriately but still, it’s got to collate
with what the likely diagnosis is. If you’re dealing
with meningococcal sepsis, it’s different to someone with pneumonia and there are very good guidelines in
the therapeutic guidelines for example which still give you a good direction
to empiric therapy. But it’s driven by the idea that
you don’t know what the pathogen is and the problem with
antimicrobial resistance is again, 10, 20 years ago, you could predict that
you could give certain antibiotics and get away with it. What we’re facing in the near future is patients, young people coming in
with pyelonephritis and you might be getting it wrong
20% of the time. That’s a worry. So empirical therapy
doesn’t get you out of jail in terms of doing the microbial test? No, you still want, in that emergency
setting, you want a blood culture but if it’s not an emergency setting, where on the other hand, you still are
pretty convinced you need antibiotics, well, for example, taking someone
with a staphylococcal infection, you really want to know
if it’s an MRSA or not. You really want to take
that pus specimen and send it off. You don’t want to put it in a bin. Let’s go… So, but if you’re a GP
and you’ve got somebody who’s septic with funny spots and you think
it’s meningococcal septicaemia, you wouldn’t hang around? No, that antibiotic should have hit
five minutes ago. Yeah, so there are exceptions
to this rule? Absolutely. I think what we want to say
about antimicrobials, we want to preserve them so we can use
them for the patients that need them. We’ve got a question from Shepparton, a general practitioner wanting to know
what are the one or two things a GP should do to reduce the spread
of antibiotic resistance. Gary? I think that comes
in that antimicrobial creed and if I can refer back to that, indication should be evidence-based. We have good evidence in therapeutic guidelines that can be on all our desktops, minimised and referred to daily throughout the day. And really, wisdom is the correct
application of knowledge. Therapeutic guidelines
gives us this knowledge. It’s up to the GPs to wisely apply that. We can use narrow spectrum antibiotics, tonsillitis – bacterial tonsillitis – often broad spectrum antibiotics, I witnessed being prescribed for this like amoxicillin when phenoxymethylpenicillin BD is the drug of choice, a narrow spectrum antibiotic, dosage appropriate
to the site and type of infection. I often see wound infections being treated with cephalosporins when flucloxacillin is
the standard guideline recommended when patients are not allergic
to penicillin. I mean,
I would imagine that for most GPs, the first thing in their mind
when they prescribe is actually resistance
either consciously or unconsciously and presumably that’s the reason why
there’s such vast prescribing of amoxiccillin, clavulanic acid. But what you’re saying is
that’s the wrong thing to do. In certain infections,
that’s the wrong thing to do. We should be guiding our prescribing
on evidence to try and help… And then you kind of think, ‘Well, let’s just blast
this bloody infection to smithereens and I’m going to give, you know,
the DO40, you know, hit them between the eyes with it
’cause I wanna get rid of this, I want to level the landscape here.’ Well, we have a right to prescribe,
we also have a responsibility – and there are risks and…
NORMAN: Talk to me about dosage. Is there a lowest possible dose? When we can, the lowest possible dose
for the shortest duration of time is appropriate for certain infections. Now, that’s not appropriate
for the patient who’s septic. But for a urinary tract infection
for a symptomatic woman where we have some evidence that clinically they may have
urinary tract infection, again, I anecdotally observed
a prescription of cephalosporin for a week and a repeat when the guidelines say five days BD
is enough. Tom, what happens when you give
too high a dose for too long or too high a dose, that’s one issue,
or too long? What happens? The too high a dose
doesn’t worry me that much because you’re really killing
the bacteria and the only problem with a high dose is that you might have
more intolerance or more side effects but it’s the duration of therapy
that’s a concern because the more you use antimicrobials, the more resistance you will see.
It’s Darwinian. And we really have an onus on us
to reduce the duration of therapy. A lot of things that have been
always said mythologically that you must use
10, 14 days aren’t wrong, you can use five days. And, Tom and Gary, I mean,
that’s something that pharmacists have,
I guess, reinforced for decades. You must finish
the course of antibiotics and the repeat if
the doctor’s ordered a repeat and, I mean, you’ve suggested maybe
a shorter course for UTI, maybe three days I think is appropriate
for trimethoprim and yet, seven-day course
is almost always prescribed and certainly,
we pharmacists have had it inculcated that we must reinforce that message. So you’re telling us
that’s not quite right. Well, that’s communication
to the patient and to the pharmacist but also, we need to be careful
in our antibiotic prescribing where we’re using
electronic prescribing method that we don’t just click on the default
which has a repeat. We need to remove that
and be very careful because patients often don’t use it
then they save it for another time. I think it’s a beauty of evidence that,
you know, things change over time and if the evidence comes out that you
don’t need to use those long durations, we should be ready to adapt. We know that meningococcal meningitis
needs three days of therapy. Often, people get 14 days. And what about prophylactic therapy? You know, in surgical situations, people
watching this who are GP surgeons and, you know, we’ve got guidelines
on prophylactic antibiotics… Absolutely. The prophylaxis should be
for the duration of that surgery which often requires one dose. If it’s prolonged surgery,
it may require two dose. There is very little prophylaxis
that requires treatment to go on for more than 24 hours
yet we often see that in hospitals. That’s no longer prophylaxis,
that’s therapy. And sometimes 50% of prescribing
in a hospital can be prophylaxis. So the longer you go, the more likely
you are to get resistance. What about
when you’re treating some conditions… Where you’re treating children with acne
or people with acne with long-term tetracyclines or… it
wouldn’t be children in this case but… Or, say, somebody with, who seems
to have a chronic infected prostatitis and you’re putting him on, say,
six weeks of antibiotics. Is that indicated or is that just… Well, those are two different things. I think… It’s often a balance,
I must admit. I personally worry about
those prolonged courses of tetracyclines ’cause there is going to be
an ecological effect without a doubt. But I think one of the issues
we’ve really got to here is that we can be patient advocates
or we can be society advocates. We’ve got to balance the two. And I think too often
people are patient advocates and will give very prolonged courses when often when they ask about it, they’re not really sure
that they’re justified so I think we really have
to question ourselves. NORMAN: And ensure monotherapy but most people use monotherapy,
aren’t they, these days? In general practice,
I think that’s probably the case, yes. But not to multiply the drugs
in the hospital situation. JOHN: Norman, we often get,
we see in community practice… ..an amoxicillin
or amoxicillin and clavulanic acid with roxithromycin
for a respiratory tract infection. Gary, can I ask you, in nursing homes, our experiences there, a very high
percentage of women particularly are on cranberry extract tablets for the prevention
of urinary tract infections. Have you got a comment on that?
Is that reasonable therapy? I personally find it difficult
in a nursing home. I think that usually
the patient’s on so many medications, the nursing staff
are struggling to give cranberry, I think we can do better than that. They’re probably crushing it up
in cranberry juice, distributor horrors there, John. Well, there are dose administration
lots of nursing homes are using so from a compliance
or adherence point of view, I guess it’s not that bad but you’re right, I mean,
most nursing home residents are taking multiple medications so another one
just adds to that drug load. There’ve been a couple of studies
recently. One suggested that
there was a benefit of the tablet form and a subsequent study suggested
there was no benefit so I think the evidence
is still out there. So, what about route of administration,
Tom? Is, you know, the temptation
that you’ve got an elderly person with a community acquired pneumonia, you know, just a quick IV and then oral. Is there any evidence that IV
is more effective than oral, IM? There are occasions
where intravenous therapy clearly gets to the site of action faster
in bigger doses but I think there’s also good evidence,
if you take pneumonia, that if you can look at
the patient’s presentation and apply whatever score you use
to assess their pneumonia, that there’s a group
that’s predicted to do well and can be treated
with oral antibiotics at home so yes, you may do marginally better
with intravenous therapy but probably not. But then there’s also patients
who clearly need hospital admission and they benefit from
intravenous therapy. So again, it’s applying
our clinical know-how to assess that patient. There’s also the issue, Tom, though,
of changing over from IV to oral when you can. Absolutely, and the other thing to say
in the same… NORMAN: But does that have any impact
on resistance development? Well, again, depending
which context we’re talking about, generally speaking, I don’t think so. The point to make is that
intravenous therapy has the risks of complications like line sepsis and there are a number
of oral antibiotics that get the same systemic levels
as IV therapy. So when you have to use oral therapy, metronidazole orally is as good as IV –
it’s just one example, many others. I’ve got a question
coming from Toowoomba from one of our web viewers
in Toowoomba, Gary, asking, ‘What’s the best way of dealing
with somebody who is demanding antibiotics
but you don’t think they need them?’ Obviously, a sensible discussion
with that patient. I go about it with
a risk versus benefit analysis and explain that even in their body, this idea of gut flora resistance
is emerging with the prescribing of an antibiotic, let alone the concerns of side effects
and allergy development. And so, it’s really up to the GP
to explain depending on the infection,
the severity of the infection, the type of patient,
there may be circumstances, a diabetic patient,
one may be persuaded more. You’ve got to be careful
in making a generalised statement but I think it’s a simple explanation… I find that a simple explanation
to patients of the risk versus the benefit and the ability to contact me if
their infection is changing or worsening is the best way to go about it. John, do we still have antibiotic creams
on the market? We do, and I was going to ask
Tom and Gary about whether there’s any relevance. I mean, we talked about acne earlier and whether maybe,
you mentioned yourself, Norman, long-term tetracycline use whether it’d be more appropriate
perhaps to use an ointment or a cream
specifically tailored. There’s Rifamycin and Clindamycin creams
for acne but there’s also the other
antibiotic creams and ointments too which are still used, still prescribed. So if you’ve got a staph skin infection, is there any indication
for topical antibiotics? No, I don’t believe so. There is an indication
to sometimes decolonise patients if you’re trying to reduce
their carriage for… NORMAN: That’s a nasal…
– Nasal Bactroban or mupirocins, the proper term. So it’s not really antibiotics if… Well, it is an antibiotic but it’s
a topical one and that’s sometimes used but as a general rule, we don’t like
using topical antibiotics very much. We have a particular scenario
in Australia now that anyone who gets cataract surgery
gets days of quinolone topical drops. It’s a frightening scenario. Why are they getting it? I’ve no idea. Right, is there any evidence that
chloramphenicol drops do anything after eye surgery? Oh, this is quinolone ciprofloxacin
drops that people are starting to use. I think that’s a worry but yes,
these things can be used for 24 hours but to go on for days,
I’m not sure what it’s achieving. GARY: Chloromycetin
even in eye infections is not without its potential
allergic developments and so we need to be careful as GPs
to make sure of the diagnosis of a bacterial conjunctivitis… NORMAN: Can you get aplastic anaemia
from eye drops? From chloramphenicol? (Silence) NORMAN: OK, we’ll take that one out… Just to scare the bejesus out of people. Chloramphenicol eye drops are now
available without prescription too directly from the pharmacist
and of course they’re now much more widely used. The sulfacetamide which was more
commonly recommended by pharmacists is rarely now recommended
because of the much more accessible… I must admit as a GP,
I’m concerned about that. I’ve noticed that more lately
and if we’re getting guidelines that tell us
that bacterial conjunctivitis is this diagnosis clinically, is the pharmacist making a diagnosis
of a bacterial conjunctivitis? How do you differentiate between viral,
allergic, other forms of conjunctivitis? Look, I share your concern, Gary. I think pharmacists need to be
much more concerned about assessing a particular eye problem and maybe the simple tear solutions or if it’s an allergic conjunctivitis, which is probably more common
than bacterial or even viral, then a more appropriate product
should be recommended. Mm-hm. ‘Cause in fact that’s part
of the problem in the developing world is you can buy antibiotics
over the counter. TOM: Exactly. Part of the problem too
is that a lot them are counterfeit and, you know, you’re not getting
the appropriate dose anyway. NORMAN: Or something different. You may get Gentamiticin
when you thought it was amoxiccillin. Let’s go to a case in our case studies. Steve’s a fit 45-year-old. He presents
to you, Gary, with a sore throat, nasal discharge. He’s been feeling a bit sick
for three days. He’s got a cough with some sputum. When listening to his chest, it’s clear,
his temperature is 37.6. This case is presenting so far as a
viral upper respiratory tract infection. It may be lower
but it still sounds viral. However, there is the need
for an obligatory history and, I believe, thorough examination. If you’re gonna convince a patient,
I believe this is a viral infection, you need to thoroughly examine them so they are confident that
you haven’t just brushed this aside. This is such a common presentation
in general practice that it is difficult sometimes
to spend that time doing that but it’s a discipline we need to do, so we do need to examine the patient
thoroughly. Having said that,
this so far looks like a viral infection and I then go into a spill about,
as I was saying before, risk versus benefit. Why I think it’s viral
on my examination, what can be done to alleviate
the symptoms… So he’s a bit anal retentive
and he’s kept this morning’s sputum and he opens this paper hankie
and it’s green. Does that change your view? No, I then launch into
another practice spiel that explains that, really,
evidence is now shown that when your white cells are trying
to help you defend this infection, there are release of chemicals that
break down that sputum and turn it green so it does not necessarily mean
bacterial infection like we perhaps used to think. And when you look at his throat, there are some white flecks
on his tonsils. That’s not how you diagnose tonsillitis. Tonsillitis should have a fever,
enlarged cervical lymphadenopathy, pus on the tonsils,
red inflamed tonsils. You either have a bacterial tonsillitis
or you have a viral infection. It’s unusual that you see both
in my experience. You may have a viral tonsillitis with it
but you’ve got to look at the big story. Right, so you reassure Steve and you, that he’s likely to have
a viral infection and you say to Steve to go
to the pharmacist for some over-the-counter medications.
What do you recommend? He wants something,
he has to get back to work. He’s really pressuring you
for something there. First of all, on my desktop,
I print out a… The NPS put out a nice symptomatic
management pad and I like that. I can tick what I… Patients, as you know,
love to go outside of the surgery with a piece of paper in their hands
and they take it to the pharmacist. Plus, they forget what you tell them
so by having this instruction talking about steam inhalation, nasal
sprays, perhaps cough suppressants, perhaps analgesics,
I believe, is an aid. But we also have a need
if there is concern or we’ve had a patient
who’s quite anxious about the need of an antibiotic
to offer the ability for review and I think most GPs do that these days
especially with children. Look, I mean, it’s interesting because of all the categories
in community pharmacy, the cough and cold category
would be one of, if not the largest, – but interestingly enough…
– They don’t work. I was gonna say it’s the category
about which there is least satisfaction and you’ve, I guess, highlighted
the main reason for that. I think… (Laughs) It’s a simple one –
they don’t work. Well, I think some of the products do,
some do but there is little evidence about the benefit of lots of
the products that we have, I must admit. I guess in this case, I know
Gary’s taken a very thorough history but one of the things
I would ask Steve is, is he a smoker and maybe that is contributing
to some of the symptoms that he has. I’d be thinking, he seems to have
three areas of concern. One is his nose,
which is running apparently, he’s sniffling, he’s sneezing, maybe he’s got a bit of a cough,
he’s got a sore throat. Gary mentions steam inhalation. I think that the saline nasal sprays
are very good. If it’s a post-nasal drip
that’s causing his cough, then we can address that situation. There are decongestants which may help
if the nose is congested. There’s… Manuka honey, which probably
doesn’t do any harm either. Well, depends whether you spread it
on toast or just your bread. But there’s a capsaicin spray
and an Ipratropium spray for non-allergic rhinitis. I think for cough mixtures, well, that’s an area
where there’s not a lot of evidence but something like bromhexine
with pseudoephedrine, so the mucolytic with the decongestant, is something where certainly anecdotally
we’ve had good response. The other thing is for the sore throat. Well, there’s throat sprays,
there’s gargles and there’s lozenges and they’re soothing and if you can help relieve
those symptoms, I think you’ve got to give your patient
realistic expectations in respect to
these symptomatic treatments. Gary, there have been studies,
randomised trials, in children with otitis media that where there’s probably
a fair degree of over-prescribing of antibiotics in otitis media,
properly diagnosed otitis media. And there’s been a trial showing
that delayed prescriptions – you’re giving a parent a prescription
saying if it’s not resolved in two days, fill in the prescription – showing some benefits with that. Is there any argument in somebody
in Steve’s situation to give him a script and say, ‘Only fill it in
if your symptoms persist beyond two, three, four, five days.’
Do we know? Certainly, there are some circumstances when one may be tempted to do that. I think in Steve’s situation, assuming
that he has access to medical care or the ability to come back to yourself under circumstances
where he can be re-examined, that I would tend to not do that. Patients tend to either incompletely
finish the dose if they improve or they sometimes reserve… Is that a bad thing – if you’re better,
not finishing the dose? I mean… Well, if they’ve developed
a secondary complication that you’ve given them advice on,
it’s not appropriate and often they would reuse
that antibiotic, I find, next time down the track. A child with an otitis media
needs a little more attention and there’ll be circumstances
if it’s coming up… But the whole idea of delayed
prescribing is in play, if you like. The question is, is it in play
in a broader group of people than for which there is evidence? I think so and I think the child is one
area where there’s some good evidence and also probably correct application. I don’t think the adult notes so much unless there’s exceptional
circumstances. So, Steve recovers but he comes back
to see you two months later. He’s had a persistent cough
for two weeks, worsened in the last two days,
bit short of breath, bit of pain on breathing
and he’s got a temperature of 38. Obviously,
a much different clinical scenario that I would take just as seriously
as the first presentation but I’m concerned that he may be
developing a pneumonic consolidation. So, again, a thorough history,
detailed examination, chest X-ray to confirm that diagnosis and probably
some laboratory investigations and then depending
on the circumstances… NORMAN: So what laboratory
investigations – blood cultures? I wouldn’t do a blood culture. Where I practise in the city,
I wouldn’t do a blood culture but I certainly would be doing
white cell count and mycoplasma too
just in case it turns out to be that. If the history suggests an influenza
leading up to that, perhaps some nasal swab for PCR,
for influenza. If there’s history that it’s Legionella,
serology accordingly. So, depends on the history
and the examination. And if it’s a Saturday morning and you can’t get an X-ray
till Monday morning? Would you empirically treat it? I would, I can get an X-ray but I would
empirically treat him with amoxicillin. I would… NORMAN: Amoxicillin would be
the drug of choice? Yes and, again, therapeutic guidelines,
there’s a change there. It used to be that 500mg TDS
was appropriate, it has actually gone up to 1g TDS. And if there’s concern
that’s an atypical or mycoplasma, if it’s a weekend
like you’re suggesting, I may… What would make you think of that
if you haven’t got a chest X-ray showing lobar pneumonia? Well, if it’s clinically one side
with pleuritic chest pain, it’s probably a bacterial pneumonia. If the presentation’s not as severe and bilateral change is perhaps
not as toxic, I may be considering it’s mycoplasma.
It’s a difficult situation clinically. And if he went to see another GP
two months ago, and he got amoxicillin clavulanic acid for his upper respiratory
tract infection, would that change your prescribing
decision here, two months later? Look, it makes it tough,
I appreciate that, but again, I need to explain and educate
and communicate that patient why I think the risk of side effects
with that antibiotic are strong and again, by having evidence
that I can demonstrate to him of why I’m prescribing what
I’m prescribing, I find, is adequate. Can I make a comment there too
to help with that? Augmentin’s got a much lower dose
of amoxicillin than your higher dose of amoxicillin and the reason the doses have gone up is because strains of pneumococci which is after all the most important
bacterium to cover in pneumonia are becoming more resistant, so we actually need higher doses
of amoxicillin to treat them. So in fact your ordinary Augmentin
probably isn’t as good a therapy as higher dose amoxicillin. NORMAN: Really? What about side effects
of that higher dose? TOM: No, actually, the side effects
of Augmentin are a lot worse than the amoxicillin on its own
even at higher dose. – Really?
TOM: Mmm. So you wouldn’t be worried
that he’s got resistance if he’s had a history of antibiotics
in the last two months? I wouldn’t be worried enough that I wouldn’t advance
on what I was describing. NORMAN: How long would you
put him on the amoxicillin for? Seven days. What would you do
if he came to the pharmacy, John? Well, we’d reinforce
the doctor’s directions. I think one of the things
we would like… But what if it wasn’t Gary and
it was a 14-day course he’d been given? That’s a challenging question, Norman. NORMAN: It’s what I’m here to do.
– Apparently. The… I guess it really comes back
to the communication between the community pharmacist
and the general practitioner. I mean, in your pharmacy, do you ask
what the antibiotic’s for routinely? Not routinely, we don’t, no. What we do ask, though, is ‘What has the
doctor told you about your condition? What has the doctor told you
about the medicine? How long has the doctor indicated
you should take this? What dose has he or she told you?’ Now, some of that is on the prescription but we like the patient to be able
to understand that, we would provide them
with consumer medicines information. And what if it contravenes
the therapeutic guidelines? Look, I guess in most cases, pharmacists are not going to go against
what the doctor indicates. In our pharmacy, we have such
a good relationship with the local GPs, we would be able to call them
and discuss the issue. If it was someone from out of town,
the GP, then, look, I have to be honest and say
by and large we would generally dispense
as prescribed. So I guess I’m admitting
to a shortcoming in our practice. We should be more diligent
in communicating with the doctors. Now, Margaret, you’re going to come
to antibiotic stewardship in a moment which is about hospital situation. Should there be more antibiotic
stewardship in the community? I mean, I really think… NORMAN: It’s only gonna be
the pharmacist who does it. That’s right. I really think that
we do need to be thinking about that. I mean, we’ve really been
concentrating on antimicrobial stewardship in hospitals but there obviously are opportunities
out there in the community for antimicrobial stewardship as well. You got a sheet here
that you give out to people from the Pharmaceutical Society. That’s right. The Pharmaceutical Society
produces this leaflet. It’s one of around about 80 – we call them Factsheets
on a variety of topics and this one on antibiotics specifically talks about
antimicrobial resistance as well. So together with
the Consumer Medicine Information, that antibiotic Factsheet,
the NPS which we’ve mentioned already has a ‘The Common Cold
Needs Common Sense’ brochure which is relevant for
respiratory tract infections and I think this kind of information
is really important to increase community awareness of what is obviously
a significant problem. I’ve got a question coming from Marisa
in Far North Queensland asking, ‘How would you manage cystitis
in a post-menopausal woman?’ I would take a urine collection,
I would… If she’s referring to recurrent
cystitis, that’s another question. We’ll come to recurrent cystitis
in a moment. I would usually prescribe
trimethoprim for three days after a urine collection with a phone
call in two and a half to three days. Recurrent cystitis in any woman? Recurrent cystitis
needs a different approach. There are methods
of trying to assist that – oestrogen creams can be effective. The use of… I’m not against
the use of cranberry but we are talking about probably… And what about pre-menopausal women
with recurrent cystitis? Often, I would use… I’d give… If it’s recurrent,
I would look for a cause of course and do a urinary tract ultrasound looking for any structural abnormality. Also, advice regarding intercourse
is important and there is sometimes a need
with recurrent UTIs to give a post-coital
one-dose trimethoprim and that is very effective. Right, hospitals, Julie asks – this is
Julie Thompson, a pharmacist in Sydney – ‘Hospitals seem to be making
strong gains towards judicious use of antimicrobials. What lobbying is occurring for PBS
limits on supply quantities for antimicrobials to become relevant
to modern thinking?’ I mean, trimethoprim
would be a good example. You get seven tablets in a packet.
Margaret, you have…? I don’t know of any lobbying
that’s occurring at all… NORMAN: Any changes there?
– No. Let’s go to our next case study who is Diana who’s 64. Suffers from chronic
obstructive pulmonary disease and has recurrent symptoms, productive
cough for three months of the year. Her coughs recently worsened
with coloured sputum. Shortness of breath after exertion and she still smokes. Gary? GARY: Yeah, there’s
a number of issues here, isn’t there? But considering the topic
we’re discussing, I would be obviously wanting, because it’s an infective exacerbation
of COPD, to be getting an infection under control
quick smart to prevent further complications. In this case, I would again use
amoxicillin 500 TDS for a week as per the guidelines. I can understand why
we as GPs have pressure, we have pharmaceutical pressure
to use Moxiclav, we have 15 to 20% beta-lactamase
produced in H influenzaes if that’s a particular bug here, so we do have this pressure,
we want this patient to improve but we have got to stick
with the evidence and obviously in this patient,
there’s a number of other… And how long would you wait
to see an improvement before you started wondering
whether the amoxicillin was resistant? I’d like to review in about three days. – Three days?
– Yeah. NORMAN: As quickly as that?
– Sputum cultures here can be useful. But unfortunately
there’s such colonisation that they’re not always reliable if that’s causing the organism too. Let’s quickly go through
some questions here. Bruce, general practitioner, asks, at James Cook University,
during his MPH, it was said that a mixed antibiotics
such as a Moxiclav or co-trimoxazole
is preferable to monotherapy to pick up the outriders
and decrease resistance. What are your thoughts, Tom? I think you should always go
for the narrowest. I think that antibiotic creed
is correct and there’s multiple organisms but you don’t always have to cover
all of them and, again, this situation, for example, we’re particularly interested
in treating pneumococcal infection and if you don’t cover
Haemophilus or Moraxella in the first one or two days
until you get your susceptibilities, the patient’s not gonna suffer
to any great degree. I think we should stick to
narrow spectrum wherever possible. NORMAN: But amoxicillin’s
not that narrow. I mean, all clavulanic acid adds is
a bit of anti beta-lactamase, isn’t it? Well, it has much broader
gram-negative coverage, it covers staphylococci,
it is a broader antibiotic. Amoxicillin is much narrower
compared to that. Gabrielle from Greater Southern
health service wants to know, are there general messages
we can give about criteria for changing from IV antibiotics to oral
in rural hospitals, Margaret? Yes, there are criteria. The… And I guess probably the best
place to look for those would be in the Antimicrobial Stewardship
for Australian Hospitals book. There’s certainly good information
in there and also in the therapeutic guidelines there’s information about switching,
yes. Greg, a pharmacist asks,
of New South Wales, what proportional resistance
is due to poor hygiene, do we…? It’s really spread that
we’re talking about with poor hygiene – rather than resistance, isn’t it?
TOM: Yes, I believe so. So the pressure comes from antibiotics,
poor hygiene allows it to go nuts. Yeah, the infection to spread,
that’s right, yeah. Bella in Queensland asks, ‘Should it be mandatory for GPs to prescribe
to the therapeutic guidelines?’ If it’s the evidence, it’s the evidence. (Chuckles) It’s a dual one, isn’t it? We certainly,
because we have this right to prescribe, the responsibility
to prescribe appropriately, we may find as this problem continues that we find
we’re under regulatory processes to have authority prescribing, here we are in an era where that’s
trying to be improved with streamlining. I don’t know the answer
to that question. It probably would be much wiser if GPs
had to use therapeutic guidelines in their prescribing. It’s a general, knowledgeable book but we face in general practice quite particular circumstances sometimes where we feel we have to be given
that autonomy to make a clinical decision. Marilyn,
what are the everyday strategies we should be using for prevention, you
know, for infection control in general? In general?
Well, I think we can’t go past starting with good hand hygiene
practices. So, good hand hygiene, you know,
before you eat or before you prepare food, after going to the toilet, at home, remembering to do things like
after changing baby’s nappies, before preparing children’s food. Also too, things like remembering
to teach children good hand hygiene practices as well. There’s also other issues
such as good cough etiquette. So for example,
remembering to cover your face or to use tissues and dispose of tissues
appropriately when they’ve been used. So just, you know, really good basic
everyday hand hygiene and good hygiene that
we’re actually taught as children that sometimes I think
we forget about doing. And the balance between spread via touch
versus droplets? – So you’ve coughed into your…
MARILYN: Hand? – ..paper hankie.
-And then if you… If you don’t clean your hands
afterwards, then of course you can transfer them. So there’s good, sort of,
other ways of coughing such as coughing under your arm
rather than into your hands. – But also to…
NORMAN: Isn’t that gonna make you vomit? – Sorry.
– No. (Laughs) No, but coughing away so that
you don’t cough in your hand especially when you’re out
and you can’t clean your hands. JOHN: The elbow’s…
NORMAN: That’s right. The guys use the green sleeve
but obviously it’s the axilla… No, this is coughing. And also too, I think that, you know,
during flu season, you know, not to stand in front of
people if they’re coughing and sneezing and to stand away from them. And if you’re managing a facility, – it’s punctilious cleaning?
MARILYN: Absolutely. So, again, you know,
good hygiene practices so making sure that the staff
in the facility use good hand hygiene, that they know
when they should be using it, that you have alcoholic rub appropriately placed at point of care so that healthcare workers don’t have
to walk away from the patients to be able to clean their hands. So there are lots of ways
that we can try to encourage healthcare workers to clean
their hands at appropriate times. And there are various resources
that we’ve got on the Rural Health Education Foundation
website such as there’s ten modules for basic principles of infection control management, there are Infection Control Guidelines from the commission and also the Aussie implementation guide and toolkit which will all be
on our website. What’s antibiotic stewardship? MARGARET: Antibiotic stewardship is an effort that’s made by healthcare institutions such as hospitals to optimise the use of antibiotics, so it’s really about the appropriate selection of antibiotics, it’s the appropriate dose of antibiotics, it’s the appropriate duration of antibiotics and this is really to improve patient outcomes, ensure cost-effective therapy and to reduce any adverse outcomes and that obviously includes
side effects from the medicines but also the development of resistance. So it’s a concerted effort. Right, give me how… People watching this program
are often running rural hospitals, often small facilities, few beds,
with a small ED but they don’t want to get resistance
running in their hospital. And from what we’ve heard tonight,
they could very quickly. MARGARET: Mmm. So what happens with good
antibiotics stewardship in practice? With good antibiotic stewardship
in practice, we use guidelines to guide prescribing and we have a range of strategies around restricting antibiotic usage and requiring approval for usage. We have people
auditing people’s prescribing or just reviewing people’s prescribing and providing feedback when that
prescribing’s not appropriate and that involves obviously
some consultation with infectious diseases physicians particularly around
the approval systems and requiring approval from
infectious diseases to prescribe, how to be monitoring therapy and actually seeing what is used
in a hospital and acting on that, providing feedback to the prescribers when we’ve monitored the therapy so that they can actually see, are they prescribing well
or not prescribing well? So, measurement, feedback
and for certain antibiotics you might identify control mechanism which is
you’re not allowed to prescribe it unless you answer a few questions. That’s right. And also what we have
in the MIND ME is about having the susceptibility
testing done for the anti… And what’s the evidence, Tom,
that antimicrobial stewardship makes a difference to resistance? There is enough data coming out
that it does make a difference and you can reverse the trends. You can’t quite eradicate them but you can control things and it’s been shown internationally. I think one of the great benefits of the program, the Antimicrobial Stewardship, is taking the issue out of individual doctors’ hands to publicise good prescribing but it’s said this is actually an issue for the whole hospital that the administration has to take on, it’s a quality issue and somebody in the hospital has to drive it and support it. I think it’s very important, otherwise
you’re just putting out small bushfires but never succeeding. So, Margaret, if you’ve inspired people
to take up antibiotic stewardship in their local hospital,
wherever they live in Australia, and the one they have some control over, what should they do?
Where can they go to find out how? The commission has a publication on antimicrobial stewardship
in hospitals in Australia and a copy has been sent
to all hospitals in Australia so they should actually have one there. Might be sitting
on the general manager’s desk. NORMAN: But we’ll have
a link to it on… We have a link on our website as well so you can download it from the website. Look, thank you all very much indeed.
It’s been fascinating. What are your take-home messages
for those watching, Tom? Yeah, my take-home message
I think would be that we should go from antibiotics as something that you use just in case
you could have an infection to something
that you have to justify to use and not use unless
you can actually justify to yourself you got an infection. I might just ask two quick questions.
I know we’re running over but there’s two really good questions
that have come in. Frank, a Canberra GP, has experienced
a patient very unwell, it’s an elderly woman with
suspected urosepsis or diverticulitis who received triple therapy
on an empirical basis. Is this practice overused
and does it promote resistance? People use ampicillin and gentamicin
Flagyl sometimes in gastrointestinal infections. NORMAN: And is that indicated? It’s OK for 24 hours… It brings a different issue. Gentamicin
is something that we want to use for 24, 48 hours only
because of its toxicity. So by that time, we want to review
if it’s really appropriate. Again, it depends on the circumstance. I think that’s a difficult question
’cause I’m not quite sure… Quickly for Gary, Sandra asks –
of New South Wales – what’s the recommended treatment
for boils? The ideal treatment
is surgical incision, drainage, assuming that there’s no surrounding
cellulitis lymphangitis or lymphadenopathy
in the child or the adult… NORMAN: So no antibiotics?
– No antibiotics. And Nathalie,
a pharmacist from Victoria, asks, ‘What role do probiotics play
in antibiotic use?’ I can’t think of many situations
where probiotics have been shown to be of great benefit.
I’m trying to think of any… NORMAN: Preventing antibiotic diarrhoea? There’s a little bit of evidence
but not much. Not much. And they don’t prevent
Clostridium difficile? No, there isn’t good data for it. Gary, what are your take-home messages? Antibiotics is the only medicine
that we prescribe that affects other people as well as
the person who we prescribe it for and we need to get back to fundamentals
of qualities of medicine – appropriate prescribing,
efficacious prescribing and the only way to prescribe
an antibiotic efficaciously is to try and restrict and restrain
our prescribing and we need to remember safety,
and risk versus benefits. And mine carries on from Gary’s in that. We really need to act now if we’re
to preserve the miracle of antibiotics for our grandchildren and beyond. NORMAN: Marilyn? Well, you can’t tell by looking at hands whether or not you’ve got
multi-resistant organisms on them or not so clean them anyway. NORMAN: Paranoid.
(All chuckle) I guess, Norman, my message would be
for community practitioners whether they’re doctors
and/or pharmacists to collaborate and community nurses as well. And that applies to particularly
rural hospitals where there wouldn’t be a pharmacist
on-site but it’s often a community pharmacist
in the area and they can utilise
that pharmacist’s expertise in antibiotics stewardship. I must ask the last question here ’cause there’s really good questions
coming in at the last minute here. Any comments about this fashion
to add antimicrobials to handwash solutions and soaps? This comes from Kathy, a general
practitioner, I’m not sure where. JOHN: I think it’s counter-productive,
isn’t it? MARGARET: Yeah, absolutely. NORMAN: It’s like chlorhexidine
presumably or… You don’t need it for ordinary
day-to-day handwashing, soap is good enough. NORMAN: Is it?
– Yes. But in a hospital setting
where we’re trying to prevent the spread of staph
from patient to patient where we’re transferring it,
adding alcoholic… So when you get to the bathroom and
you wash your hands with soap and water, you remove enough of the bacteria
to make a difference? You’re not going around spreading things but in a hospital setting,
it’s a slightly different scenario especially as a healthcare worker. Right, I hope you’ve enjoyed the program on antibiotic-resistant
infection control. Thank you to the Australian Government Department of Health and Ageing
for making the program possible and thanks to our panel members for
contributing their time and expertise. Thanks also to you
for watching and participating. If you’d like to obtain more
information about the issues raised, there are a number of resources
available on the Rural Health
Education Foundation’s website – rhef.com.au. Don’t forget to complete
and send in your evaluation forms to register for CPD points.
I’m Norman Swan, I’ll see you next time. Closed Captions by CSI Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�

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