Are antibiotics courses for common infections too long?

In the fight against antibiotic resistance, shorter courses of antibiotics are now recommended for patients with common infections, but how short is long enough?

The optimal antimicrobial duration for common bacterial infections is outlined in a review paper recently published in Australian Prescriber 2019;42(1):5-9.¹

‘The key message for pharmacists is that when antibiotics are deemed necessary, there is increasing evidence that shorter antibiotic courses result in clinical outcomes that are similar to longer courses, with fewer adverse drug events,’ said Dr Janet Sluggett, National Health and Medical Research Council (NHMRC), Early Career Fellow at Monash University, and Professional Services pharmacist at CPIE Pharmacy Services in Adelaide.

‘The paper is useful for pharmacists because it summarises recommended treatment durations for respiratory, urinary and skin infections that are commonly encountered in the community setting.’ 

The Australian Prescriber paper highlights data that shows Australia has relatively high rates of antibiotic prescribing.

‘In 2015, 30% of all patients attending a general practice received an antibiotic prescription,’ the paper stated.

‘Most are for acute respiratory infections, and in quantities several-fold more than recommended by Australian guidelines.’¹

While the review paper is aimed at prescribers, particularly General Practitioners, pharmacists are ‘uniquely placed to identify opportunities to support appropriate use of antibiotics’, Dr Sluggett said.

‘Prescribers are advised to document indication and duration for use on all antibiotic prescriptions, which provides us with more information and opportunity to contribute to patient care,’ she said.

‘Confirming treatment durations, breaking packs when dispensing and counselling patients that there may be tablets remaining at the end of treatment are all valuable interventions.’

It’s also important to remember that the Cautionary Advisory Label Additional Instruction D – ‘until all taken’ – may not be appropriate for inclusion on dispensing labels when the pack size is greater than the prescribed treatment duration, said Dr Sluggett, who is also a member of the Australian Pharmaceutical Formulary and Handbook (APF24) New Drug Advisory Group.

‘Pharmacists are well placed to advise consumers on how best to take antibiotics, discuss why antibiotics are not always necessary, and provide general education regarding hand hygiene,’ she said.

‘This is also a good opportunity to reinforce the importance of appropriate medicines disposal through pharmacies.’

If pharmacists do identify problems relating to antibiotic use – such as inappropriate use, suspected adverse drug events, or signs that an infection may not be resolving – they should act.

‘Steps that I might take in these situations could include a discussion with the patient, contacting the prescriber and/or referring to evidence-based resources such as the Therapeutic Guidelines: Antibiotic,‘ Dr Sluggett suggested.

‘The other important role we play is in reassuring patients, particularly in those cases where antibiotics are not indicated, or may no longer be required.’

Useful resources for pharmacists include the PSA’s new Choosing Wisely recommendation number three (do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness) and the latest Antimicrobial Stewardship in Australian Health Care publication.

Dr Sluggett also encourages pharmacists – including those working with aged care providers and in general practice – to support antimicrobial stewardship at a broader level.

‘This could mean contributing to local guideline development, education, audit and feedback, research, local drug formularies and infection control committees,’ she suggested.

When it comes to customer education, pharmacists may find the PSA’s printable Self Care Cards on antibiotics and colds and flu useful.

‘Ensuring antibiotics are used in the best possible way requires a team approach,’ Dr Sluggett said.

‘We can advise prescribers on current guideline recommendations for treatment of infections, dosing regimens and switching from IV to oral therapy. Pharmacists can also identify people at risk and administer certain vaccinations.’

References

1. Wilson HL, Daveson K, Del Mar CB. Optimal antimicrobial duration for common bacterial infections. Aust Prescr 2019;42:5-9. At: https://www.nps.org.au/australian-prescriber/articles/optimal-antimicrobial-duration-for-common-bacterial-infections#r1