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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 ***,
and the mortality associated with ***.
But luckily, a lot of companies
have gone into ***-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 *** 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-*** 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.
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