Prescribers’ antibiotic skills got rusty during COVID

“People have just kind of forgotten”

Antibiotic use has started to creep up again after a lull during COVID-19, with some bad prescribing habits making a return too, national data indicates.

National dispensing information from the country’s community pharmacies shows three problems are emerging with antibacterial prescribing as patients return to their GP.

Prescriber education provider He Ako Hiringa, which collects and analyses the dispensing data, says all antibiotics are overused, especially in winter, and there are particular problems with urinary tract infections (UTIs), amoxicillin plus clavulanic acid, and topical antibiotics.

Lead analyst Alesha Smith says the problem appears to be with prescribers forgetting best practice for antimicrobial prescribing.

It has been five years since they were reminded in a national education campaign to reduce the global health threat posed by rising rates of antibiotic resistance, she says. Prescribers have also got out of the habit of prescribing antibacterials in the past two years.

“We have seen all antibiotics use drop over COVID because, obviously, people were less sick when we were all locked down and weren’t going to the doctor as much,” says Dr Smith, an associate professor at the University of Otago School of Pharmacy.

“People have just kind of forgotten.”

Prescribers just need a reminder about best practice to change their prescribing habits and preserve the effectiveness of antibacterials, Dr Smith says.

Nitrofurantoin is now the preferred first-line option for empiric treatment of uncomplicated urinary tract infection (UTI), according to written information from He Ako Hiringa.

It is recommended as a five-day course for women with uncomplicated lower UTI, but just under 40 per cent of all courses dispensed in the year to August were seven days long, the community dispensing data show.

Dr Smith says she thinks prescribers have “defaulted” to seven days because of the “confusing” recommendations around the various treatment options available for this indication.

Trimethoprim is still available as an alternative option but there are significant rates of E. coli resistances in some parts of New Zealand.

There are very few indications where amoxicillin plus clavulanic acid is first-line treatment, yet it is the second most dispensed antibiotic after amoxicillin, according to the data.

Amoxicillin plus clavulanic acid acts against quite a broad spectrum of bacterial infections so it is an “easy go-to” for prescribers if they are not sure of the cause, Dr Smith says.

It made up about a fifth of all 1.5 million antibiotics dispensed in the year to August, which is “inappropriately high”, she says.

Overuse was particularly high among Pacific patients, at just under 10 per cent.

Use increased by 32 per cent in winter, compared with summer, even though antibacterial infections remain at a steady level all year round.

This unwarranted seasonal variation indicates prescribers are using antibacterials to treat viral infections, which are more plentiful in the colder months, Dr Smith says.

Very few indications require topical antibiotics, according to information supplied by He Ako Hiranga.

People who need antibiotic treatment for a skin infection should get them orally.

But 19,796 scripts of fusidic acid cream or mupirocin ointment were dispensed for under-fives, 36,165 for patients aged over 65, and 88,122 for patients aged in between, data for the year to August shows.

Prescribing of fusidic acid has declined in recent years, after widespread use led to high rates of resistance.

But further reductions are possible, especially in the under-fives and those over 65, where use remains inappropriately high, Dr Smith says.

“They [topical antibiotics] were, back in the day, recommended for use, and that’s why we have them,” she says.

“But now we’re seeing such resistance that it’s actually better not to use them, and I think it’s just probably a hangover still from past prescribing habits and not realising that there’s actually quite a high rate of resistance.”

He Ako Hiranga has just launched a tool so that prescribers can compare their antibacterial prescribing habits with national patterns and reflect on their practice.

The Antibiotics tool is one of several themes on the Pharmac-funded Evaluating Prescribing to Inform Care (EpiC) dashboard available to prescribers.

Declaration of interest: The Health Media, publishers of New Zealand Doctor Rata Aotearoa, is a 50 per cent shareholder in Matui Limited, the publishers of He Ako Hiringa

acameron@nzdoctor.co.nz