In the fourth of a six-part series, we expand on the PSA Choosing Wisely recommendations, taking a closer look at the dispensing of repeat antibiotic prescriptions.

There is considerable evidence that clinical outcomes between short and long courses of antibiotics are comparable for most community-acquired infections.¹ Despite this growing body of evidence, we still commonly see prescriptions for antibiotics written with repeats; how often is this clinically appropriate? The third of PSA’s recommendations in the Choosing Wisely Campaign serves as a reminder to all pharmacists.²

Recommendation 3

Do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness.

A quick scan of the 2017 Antimicrobial Use and Resistance in Australia (AURA) report3 tells a scary tale about antibiotic resistance in Australia. For example, resistance to our last-line antibiotics for common community infections such as gonorrhoea has been reported, as well as a rapidly growing resistance to carbapenem,³ a last-line broad-spectrum antibiotic.⁴ Therefore, judicious use of antibiotics is warranted to slow the progression of resistance.

In addition to mitigating resistance, short-course antibiotics can reduce the likelihood of medication adverse effects.⁵ Isn’t this a win-win? Why, then, do our patients present with a repeat prescription of their antibiotics?

Request for a repeat antibiotic prescription: potential reasons

A patient presenting for a repeat antibiotic prescription could suggest one of three things: 1) a partial resolution of the bacterial infection, 2) no noticeable resolution of the bacterial infection from the initial antibiotic course, or 3) patient-initiated use of the antibiotic for a new infection.

In response to the first point, it is worthwhile for pharmacists to check the prescribed indication against the Therapeutic Guidelines⁶ to clarify the duration of therapy required, and the timeframe for when a referral is warranted if there is an inadequate response to therapy.

For instances where there is no noticeable resolution of the bacterial infection, it is important to double-check whether the antibiotic and/or dose/dose frequency prescribed was even appropriate in the first place for the given indication. For example, amoxicillin with clavulanic acid remains among the top three antibiotics prescribed in Australia.⁷

However, based on recommendations in the Therapeutic Guidelines, there are very few instances where it should be recommended as first-line therapy.⁶

Pharmacists should elicit from the patient their reason for requiring antibiotics. If the reason is that the patient believes they have an infection, then appropriate history taking and risk assessment are warranted.

Does the patient actually need antibiotics?

There are a number of risk assessment tools available to guide pharmacists in determining the likelihood of a bacterial infection, and whether antibiotics are warranted.

For example, the National Institute for Health and Care Excellence (NICE) in the UK have created a series of risk assessment tools for determining the necessity of antibiotics for various primary care conditions.⁸ Here are just some of many examples:

• Otitis media: nice.org.uk/guidance/ng91/resources/visual-summary-pdf-4787282702
• Sinusitis: nice.org.uk/guidance/ng79/resources/visual-summary-pdf- 4656316717
• Sore throat: nice.org.uk/guidance/ng84/resources/visual-summary-pdf-4723226606

While the choice of antibiotic, its dose, frequency, and/or duration may differ in the Australian context (and even across different regions within Australia), such risk assessment tools may be useful for pharmacists in determining whether antibiotics are indeed warranted, and if so, referral to a general practitioner for a confirmatory diagnosis.

How can pharmacists play a role in the wider adoption of the recommendation?

As custodians of the quality use of medicines, pharmacists are well positioned to become champions of antimicrobial stewardship. This means that we can ensure antibiotics are used only when warranted, and for the appropriate dose, frequency, and duration.

This also means that pharmacists have the opportunity to provide education to patients on the appropriate use of antibiotics, as well as ensure prescribers are appropriately prescribing antibiotics for patients.

Changes to current practice do not need to be significant. Every little conscious effort towards appropriate antibiotic usage counts.

Here are some ideas:

1. Re-consider using the ‘Continued until all taken’ label sig. Instead, ask about the duration and include the number of days it is to be taken. While it is important to take antibiotics regularly instead of ‘prn’, it is also important to determine the actual length of therapy – the Therapeutic Guidelines⁶ is your friend here. For example, first-line treatment for an uncomplicated UTI in non-pregnant females is 3 days.⁶ In this case, ‘continued until all taken’ would mean that the patient may be taking trimethoprim far longer than required.
2. Be on the lookout for signs of inadequate patient response to therapy and refer promptly. The sooner the patient receives appropriate therapy, the sooner their infection can be resolved.
3. Clarify with the patient their reason for requesting a repeat antibiotic prescription.

References

1. Dawson-Hahn EE, Mickan S, Onakpoya I, Roberts N, Kronman M, Butler CC, et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract [Internet]. 2017 Sep 1;34(5):511–9. doi:10.1093/fampra/cmx037. At: https://www.ncbi.nlm.nih.gov/pubmed/28486675
2. Choosing Wisely Recommendations – Pharmaceutical Society of Australia [Internet]. Pharmaceutical Society of Australia [cited 2019 Apr 24]. Available from: psa.org.au/choosing-wisely/
3. Australian Commission on Safety and Quality in Health Care. AURA 2017: Second Australian report on antimicrobial use and resistance in human health [Internet]. ACSQHC [cited 2019 Apr 24]. Available from: safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/aura-2017/
4. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2019 Wilson HL, Daveson K, Del Mar CB. Optimal antimicrobial duration for common bacterial infections. Aust Prescr [Internet]. 2019 Feb;42(1):5–9. doi:10.18773/ austprescr.2019.001. At: https://www.nps.org.au/australian-prescriber/articles/optimal-antimicrobial-duration-for-common-bacterial-infections
5. Therapeutic Guidelines. eTG complete [Internet]. Therapeutic Guidelines Limited [cited 2019 Apr 29]. Available from: http://www.tg.org.au/
6. Top 10 drugs 2017–18 [Internet]. Aust Presc [Internet]. 2018;41(6):194. doi:10.18773/austprescr.2018.067. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299179/
7. The National Institute for Health and Care Excellence. NICE [cited 2019 Apr 29]; Available from: nice.org.uk