The third annual Antimicrobial Use and Resistance in Australia (AURA) report, released today, highlights the importance of getting everyone on board with our national antimicrobial resistance strategy.
This article is published by Croakey Professional Services as sponsored content. It is funded by The Australian Commission on Safety and Quality in Health Care.
Antibiotic prescription rates in the community have fallen for the first time in 20 years as campaigns to improve the use of antibiotics cut through, while aged care facilities have emerged as a key front in the fight against antibiotic resistance and inappropriate use, according to a new government report examining Australian antimicrobial use and resistance.
The third annual Antimicrobial Use and Resistance in Australia report, AURA 2019, reveals a mixed picture on the ongoing fight against antibiotic resistant bacteria and the drugs used to treat them, with progress in some areas and poor performance in others.
Overall, the report warns that antimicrobial resistance “shows little sign of abating” and poses an ongoing risk to patient safety, with common bacteria such as E. coli, Salmonella, Neisseria gonorrhoeae and Neisseria meningitidis growing less susceptible to major antibiotic drug classes, and some organisms down to last-resort treatments.
Residential aged care a serious challenge
The additional surveillance data from AURA 2019 highlights the aged care sector as a significant reservoir of multidrug-resistant disease and inappropriate antibiotic use, calling for antimicrobial stewardship and infection control strategies to be a priority for the new Aged Care Quality and Safety Commission.
“This is an area that we need to focus on as a matter of urgency, because of the interactions between aged care homes, hospitals and the community,” explained AURA Clinical Director Kathryn Daveson. “Increasing resistance is a real concern due to the frequency with which our elderly citizens come in and out of hospitals.”
According to the AURA Surveillance System data, 10% of all aged care residents were prescribed at least one antimicrobial at the time of the survey and, worryingly, more than half of all scripts were for people with no recorded signs or symptoms of infection. One in four residents had no documented indication of why the drug was prescribed. Dr Daveson said,
From the data provided, there are large gaps in information. More broadly, we’re finding that we don’t know when antibiotic use starts, we don’t know when it stops, and we don’t know what the antibiotics are being prescribed for.”
Rates of resistance are higher in aged care facilities than in hospitals or the community setting in Australia, underscoring the gravity of this challenge, said Professor John Turnidge, Senior Medical Advisor to the Commission’s AURA program.
There’s a huge amount of unnecessary prescribing and a lot of prescribing that extends for long periods of time – residents getting put on antibiotics for weeks, months or years,” said Professor Turnidge.
It’s extraordinarily important for us to tackle this issue because the last thing that we want for our elderly are serious infections with multi-resistant or untreatable organisms that can potentially be transferred between aged care homes and hospitals.”
Dr Daveson said it was not just the risk of infecting others; colonisation with resistant bugs also increased the risk of treatment failures, which due to age and other medical problems were more likely to have very significant outcomes, potentially including death, in an elderly patient.
“It’s an important point for not only community control, but also for the quality of care that our elderly population is receiving,” she said.
Curbing community prescribing
More than 10 million Australians had at least one antibiotic prescribed under the Pharmaceutical Benefits Scheme/Repatriation Schedule of Pharmaceutical Benefits in 2017 – some 41.5% of the population, according to AURA 2019.
In technical terms, this translates to 20-22 defined daily doses per 1,000 people per day, double the rate of the best-performing nations in Europe, and a result that puts Australia in the top 25% of countries for antibiotic overuse.
However, concerted campaigns to reduce inappropriate use of antibiotics are working, with antibiotic prescriptions on the PBS and RPBS declining in 2016 and again in 2017 for the first time since the late 1990s.
“I think it reflects a two-fold change, firstly we as consumers expecting less antibiotics and getting the message about antimicrobial resistance and that antibiotics aren’t the solution for coughs or colds,” said Dr Daveson. “The second facet is GPs better understanding antimicrobial resistance and the need to reduce prescribing, and I think we are seeing that message getting out and influencing practice over the past three years.”
The sustained efforts of NPS Medicinewise, mass media coverage of so-called superbugs and a personal correspondence drive by Australia’s Chief Medical Officer Dr Brendan Murphy to the top 25% of primary care prescribers, are each considered to have played a role in reducing unnecessary prescribing and use.
Though declining, the report found antibiotics are still being overprescribed compared with guidelines, particularly in upper respiratory tract infections where there is no evidence they are effective. According to AURA 2019 prescribing data, 92.4% of patients with recorded medications of acute bronchitis patients and 52.2% of influenza patients were given antibiotics. Professor Turnidge said,
If we had to make one major change it would be stopping prescribing for coughs, colds and sore throats. It’s easy to say, but it’s been going on for 50 years and it’s going to take concerted efforts and to turn around.”
Even where antibiotics are indicated, Dr Daveson said doctors continue to overuse broad-spectrum agents like amoxicillin-clavulanic and cefalexin, particularly in the treatment of sinus, skin and soft tissue infections, pneumonia and UTIs, where amoxicillin trimethoprim or flucloxacillin may be more appropriate.
A lot of the antibiotics we’re using in both the community and hospital sectors are broader than we need, and we can certainly choose narrower spectrum antibiotics when they are actually indicated, as well as aiming not to prescribe for conditions where antibiotics have been shown to not be of benefit,” she said.
Complexity in the hospital sector
While community prescribing saw improvements in the latest AURA surveillance period, results for the hospital sector remained stable, with inappropriate antibiotic prescribing still at 23.5%.
In 2017, total antibiotic use in hospitals, captured by AURA Surveillance, increased for the first time since 2013. A global shortage of piperacillin-tazobactam – a key agent for serious infections in the acute setting – is thought likely to account for a spike in hospital use in 2017, with clinicians forced to choose multi-drug regimens with higher defined daily doses in its absence.
Of particular concern is the use of antibiotics to treat infectious flares of chronic obstructive pulmonary disease, with a long-term trend in hospitals of inappropriate prescribing and tendency for these patients to develop resistant respiratory isolates.
In terms of resistance, CPE (carbapenemase-producing Enterobacteriaceae) is an ongoing concern in both hospital and aged care settings, as it is “resistant to one of the last-line antibiotics we have available, meropenem”, said Dr Daveson. By international standards the prevalence of CPE in Australia remains low, in large part due to prudent regulation of antibiotic use, particularly in food production, she added.
Professor Turnidge agreed. The importance of leadership and joint efforts across human health, food production, and veterinary practice cannot be under-stated.
Australia continues to have the highest prevalence of vancomycin-resistant enterococci, or VRE in the world, with strains emerging and expanding that are resistant to teicoplanin – a last line agent beyond which there are few remaining treatment options, of uncertain efficacy.
Methicillin-resistant Staphylococcus aureus (MRSA) has evolved from a predominantly hospital-acquired infection, to one now largely concentrated in the community, particularly in remote and very remote regions of Australia. Limited accessibility of microbiological testing makes “our ability to target the right bug for the right drug for the right patient at the right time more complex,” said Dr Daveson.
A particular strain of MRSA which is nonsusceptible to daptomycin, which is a reserve line antibiotic, has also taken hold in aged care homes.
Antifungal data features in AURA 2019 for the first time, and a pathogen called Candida auris is being added to Australia’s red flag alert system, known as CARAlert, after a number of global fatalities linked to the resistant fungus that recently made headlines.
Professor Turnidge said there was anecdotal evidence of about eight cases in Australia to date, and authorities will be urgently notified as new infections came to hand. Candida auris is only susceptible to reserve line drugs called echinocandins, and has been linked to deaths in immune compromised patients.
Acting on AURA 2019
Professor Turnidge said the latest AURA 2019 data presented a “mixed blessing” for Australia, providing a breadth of information to target our prevention and response strategies, and reinforcing the importance of doubling down on efforts to ensure we continue to make gains.
“I think you can call AURA both a stick and a carrot. A stick to say ‘Hey, these are the problems, we’d better do something about it’, and a carrot saying ‘Hey, these are the problems, aren’t you tempted to do something about it’,” he said. “We do have a national AMR strategy now, and we do have resources being put towards AMR. I look forward to sustained support for both.”
We need the public and community prescribers, GPs particularly, to come on board and embrace the importance of AMR and reduce unnecessary prescribing, and we also need all those involved in health care in Australia to commit to this as a priority issue.”
To find out more and to read the AURA 2019 report visit: https://www.safetyandquality.gov.au/AURA2019
*This article was written by Amy Coopes and edited by Ruth Armstrong, on behalf of Croakey Professional Services. It was sponsored by The Australian Commission on Safety and Quality in Health Care, which had final say over the content.
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