Choosing antibiotics wisely

---

The clinician-led Choosing Wisely Australia^® initiative has recently released a second list of tests, treatments and procedures that provide little value and may cause harm. With many of the 61 new recommendations, Australian health professionals’ colleges and societies have chosen to address the inappropriate use of antibiotics.

---

Antibiotic use, whether appropriate or inappropriate, drives selection of antibiotic-resistant bacteria. Infections with these bacteria increase morbidity and mortality, duration of hospital stay and costs. Using antibiotics only when there is a clear indication and proven benefit is key to reducing overall antibiotic use and halting the rise in antibiotic-resistant bacterial infections.
Choosing Wisely antibiotic-related recommendations
A number of the Choosing Wisely Australia recommendations relating to antibiotics are of particular relevance to hospitals and may provide a fresh angle for antimicrobial stewardship (AMS) initiatives.

• Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date – Society of Hospital Pharmacists of Australia
  

We know from results of the National Antimicrobial Prescribing Survey that almost 1 in 4 of the antibiotic prescriptions written in hospitals are assessed as inappropriate, with the largest group of these being situations where an antibiotic was not indicated.¹
Several teams may be involved in a patient’s hospital stay, which means documenting intentions for antibiotic therapy is hugely important to avoid unnecessarily prolonged therapy. Recent studies have indicated shorter courses of antibiotics may be just as effective as prolonged therapy for many conditions.^2,3 Where there is little evidence to guide duration of therapy, review dates force a fresh look at the necessity of antibiotic therapy and provide opportunity for step-down (or step-up) based on microbiological results and clinical response.

• Do not use antibiotics in asymptomatic bacteriuria – Australasian Society for Infectious Diseases
  

Bacteriuria is a common finding in the elderly and in people with urinary catheters. Bacteria are acquired at a rate of 2-7% per day of catheterisation so that bacteriuria is almost guaranteed with a long-term indwelling catheter.⁴ Since the majority of cases of asymptomatic bacteriuria do not progress to symptomatic urinary tract infection,⁵ antibiotic treatment is not indicated, except in a limited number of circumstances such as pregnancy.
Performing a urine culture on the basis of malodourous or cloudy urine in the absence of other symptoms is a waste of resources and will often lead to inappropriate use of an antibiotic⁶.
Choosing Wisely Australia has related recommendations from the Royal College of Pathologists of Australasia and the Royal Australian College of Nursing (with regard to avoiding use of urinary catheters).

• Do not take a swab or use antibiotics for management of a leg ulcer without clinical infection – Australasian Society for Infectious Diseases
  

Ulcers create a break in the skin barrier and over time will inevitably become colonised with one or several different microorganisms.⁷ Organisms in the leg ulcer environment often exist in biofilms,⁸ making them difficult to eradicate. A leg ulcer showing signs of infection, such as cellulitis, increased purulence and quantity of exudate, or increased local pain and temperature, needs to be treated with systemic antibiotics. However, there is no evidence that administration of topical or systemic antibiotics in the absence of clinical signs of infection improves ulcer healing.⁹

• Consider antibiotic de-escalation daily – Australian and New Zealand Intensive Care Society
  

Infections are common in intensive care, and may be either a cause for ICU admission and/or a complication of it. Early administration of appropriate antibiotics reduces mortality for those with sepsis,¹⁰ but they are also prescribed for patients with presumed sepsis who later prove not to have infections. If there is clinical improvement, and no microbiological evidence of ongoing infection, clinicians should consider discontinuing antibiotics at the earliest possible opportunity.
We need to act now
At the March 2016 launch of the new recommendations, Professor Michael Dooley, President of the Society of Hospital Pharmacists of Australia had a timely reminder for clinicians, “What we’re seeing on a day-by-day basis is that antibiotics aren’t as effective, bacteria that is resistant, and a result of that we’re seeing patients with life threatening infections, where in the past they were easily treated.”
With the limited number of new antibiotics being discovered, action to improve antibiotic use is a critical factor in ensuring current antibiotics will still be useful and effective in the future. These recommendations, developed by the professions themselves, reinforce the efforts of hospital AMS teams to address inappropriate antibiotic prescribing in hospitals.
The latest wave of 61 Choosing Wisely Australia recommendations are available at www.choosingwisely.org.au/recommendations.
References
1. Australian Commission on Safety and Quality in Health Care. Antimicrobial prescribing practice in Australian hospitals: results of the 2014 National Antimicrobial Prescribing Survey. Sydney, 2015.
2. Richard Pugh, Chris Grant, RP Cooke, et al. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2011;10:
3. Robert G Sawyer, Jeffrey A Claridge, Avery B Nathens, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. New England Journal of Medicine 2015;372:1996-2005.
4. Lindsay E Nicolle, Suzanne Bradley, Richard Colgan, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases 2005;40:643-54.
5. Barbara W Trautner, Richard A Hull, Rabih O Darouiche. Prevention of catheter-associated urinary tract infection. Current opinion in infectious diseases 2005;18:37.
6. Urinary Tract Infections. eTG complete Melbourne: Therapeutic Guidelines Ltd, 2015.
7. Ulcer and Wound Management. eTG complete Melbourne: Therapeutic Guidelines Ltd, 2011.
8. Garth A. James, Ellen Swogger, Randall Wolcott, et al. Biofilms in chronic wounds. Wound Repair and Regeneration 2008;16:37-44.
9. Susan O’Meara, Deyaa Al-Kurdi, Yemisi Ologun, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews John Wiley & Sons, Ltd, 2014.
10. Anand Kumar, Daniel Roberts, Kenneth E Wood, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-96.
FAST FACTS

• Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date – Society of Hospital Pharmacists of Australia.


• Do not use antibiotics in asymptomatic bacteriuria – Australasian Society for Infectious Diseases.


• Do not take a swab or use antibiotics for management of a leg ulcer without clinical infection – Australasian Society for Infectious Diseases.


• Consider antibiotic de-escalation daily – Australian and New Zealand Intensive Care Society.

Rachel Gray
Rachel Gray is the clinical lead of the Reducing Antibiotic Resistance program at NPS Medicinewise. She is an experienced hospital pharmacist, having worked in Infectious Diseases, Cardiology and General Medicine in New Zealand. She has also worked in community pharmacy in Scotland and was involved with the development of the New Zealand Formulary. Rachel has a strong interest and passion for medicines information and education.

---

“...almost 1 in 4 of the antibiotic prescriptions written in hospitals are assessed as inappropriate, with the largest group of these being situations where an antibiotic was not indicated.”
Antibiotic

---

 

Are you involved in initiatives to implement Choosing Wisely recommendations in your hospital?
Would you be interested to become a pilot site for Choosing Wisely Australia? We would love to hear from you
choosingwisely@nps.org.au
www.choosingwisely.org.au
@ChooseWiselyAU