Down-scheduling of oral antibiotics could improve patient access, study finds

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Immediate patient access to antibiotics through pharmacies has been recognised as a factor in addressing antibiotic misuse in the community, as antimicrobial resistance increases.

A study conducted across 90 rural and metropolitan Western Australian community pharmacies has examined the abilities of pharmacists to prescribe oral antibiotics, using a set of hypothetical case studies.¹ Respondents were asked to refer the patient to a GP; treat with oral antibiotics (from a list), or choose a different treatment regimen.

The conditions immediately treated were tonsillitis (which received a 92.5% rate of appropriate therapy choice) and otitis media (scoring lower on appropriate therapy choice at 76.6%). Acute pyelonephritis, while commonly referred to GPs, scored a 95.5% appropriate therapy choice.

Pharmacists only chose the appropriate therapy 15.1% of the time for urinary tract infections in pregnancy; however, this was another condition commonly referred to GPs.

When looking at the types of antibiotics prescribed, pharmacists showed a stronger preference for prescribing trimethoprim, amoxicillin and cephalexin and little support was suggested for prescribing antibiotics such as rifampicin and ciprofloxacin.

‘Although the study did not investigate reasons for the preference for trimethoprim, amoxicillin and cephalexin, these antibiotics are more commonly prescribed. Rifampicin and ciprofloxacin tend to be reserved for more serious infections,’ study co-author Dr Petra Czarniak told Australian Pharmacist.

This is supported by similar pharmacy prescribing habits observed in countries where drugs with established safety profiles have been rescheduled. In Scotland, for example, trimethoprim has been prescribed over-the-counter using a strict protocol providing improved patient access.²

The combination of the accessibility of pharmacists within the community and the current underutilisation of their skills and knowledge in prescribing of low-risk medications has been raised as an area in which pharmacists see opportunity to contribute to the fight against antimicrobial resistance.

‘The study adds further insight into community pharmacy and pharmacist characteristics associated with appropriateness of oral antibiotic selection and the decision to refer to doctors,’ said Dr Czarniak.

By supporting their customers through immediate patient care, it is perceived patients will be discouraged from self-diagnosis and the use of repeat antibiotics prescriptions; and will be advised to see a GP when they do not respond to initial treatment.

Dr Czarniak referenced the study’s findings in that younger pharmacists placed more importance on the autonomy of both the patients and the pharmacists themselves, saying, ‘The role of pharmacists has changed significantly over the last 20 to 30 years. The education of older pharmacists would have been much less patient centred.’

¹ Czarniak P, Sunderland B, Parsons R, Sinkala F. (2017): Survey of attitudes of Western Australian pharmacists on rescheduling selected oral antibiotics. PeerJ. 2018; 6: e4726.

² Booth JL, Mullen AB, Thomson DA, et al. Antibiotic treatment of urinary tract infection by community pharmacists: a cross sectional study. Br J Gen Pract 2013;63(609):e244–e249