GRIP activations at a local level
Since the last GRIP meeting, members have been working to further disseminate GRIP messages at a local level. Members were asked to give an update on the current status of antibiotic resistance in their country and the initiatives they have been working on in the last year.
Both public and media interest in antibiotic resistance in Germany has increased. In an effort to change GP prescribing behaviour, a trial analysing the effect of educating GPs on appropriate antibiotic use and prescription rates was set up. The CHANGE-2 trial uses an algorithm to help diagnose URTIs and recommend when to refer patients for further investigation if there is uncertainty. Tests like the rapid strep test and the C-reactive protein test are common tools used in Germany to identify serious infections. Although the validity of the tests has been questioned, scientists argue that they can provide reassurance if the result is normal.
The results of CHANGE-2 will be available by mid/late 2015 and, following the success of the CHANGE-2 intervention trial, the second phase of Germany’s antibiotic resistance strategy – DART – is expected to get underway in 2015.
Awareness of antibiotic resistance in Australia is a growing concern for GRIP. Data from the NPS MedicineWise Research conducted in September 2014 and released in November during Antibiotic Awareness Week shows that 17% of patients expect an antibiotic to be prescribed when treating a URTI. However, doctors believe that 50% of patients expect to receive an antibiotic prescription. These shocking statistics are particularly worrying considering that GPs are often challenged by their patients and, when pushed for time and to avoid conflict, they prescribe antibiotics, even when they feel they are unnecessary. It has been noted that although Australian GPs are aware of the problem of antibiotic resistance and acknowledge the issue to be serious, most feel the responsibility is not theirs.
The release of a national initiative report by the Australian Commission on Safety and Quality in Health Care on Antimicrobial Resistance in 2013 hopes to tackle these issues through governance and surveillance, as well as communication, which includes education, stakeholder engagement and partnerships.
The UK’s awareness of antibiotic resistance is significantly on the rise; the reward of a £10m prize (the Longitudinal Prize) to be granted towards the production of a diagnostic test that assesses whether an infection is bacterial or viral, indicates the increasing interest in tackling the issue. With reports suggesting that failure to tackle drug-resistant infections will result in 10 million deaths a year, costing up to $100 trillion by 2050, the fight is still very much present. Survey data from the European Antibiotic Awareness Day in November 2014 suggests that more work is required to highlight antibiotics in general. Statistics show that 50% of those questioned believe antibiotics weaken your immune system, 4 in 10 believe antibiotics could be used to treat viral infections, and some believe antibiotics can be used as an anti-inflammatory or be used to treat asthma, hayfever or headaches (17%, 4%, 4% and 4%, respectively). Changing prescribing behaviour of GPs is also a key issue; the variation in prescribing habits across the UK can be up to four times from one practice to another in the same area – perhaps attributed to those in higher socioeconomic areas being more demanding and expectant to receive antibiotics.
However, there have been many successes of the CMO’s UK Action Plan on the fight against AMR, such as launching an ‘antibiotic guardian’ campaign and leading the development of a new WHO resolution on AMR. Moreover, with two NICE guidelines on antibiotic stewardship in the pipeline, as well as publication of The Review on Antimicrobial Resistance’s first paper, released at a launch event hosted by Jim O’Neill, the UK’s fight against AMR is well underway.
In 2014, South Africa made the most of opportunities to raise awareness of antibiotic resistance, with presentations by Professor Sabiha Essack at the Geneva Health Forum, the FIP World Congress and the Conference of the Independent Community Pharmacy Association on the role of the pentagonal 5P framework for antibiotic stewardship. The South African Department of Health also released a framework document outlining their AMR strategy, which includes prevention strategies focusing on IPC and vaccination programmes, interventions that are underpinned by education of HCPs and sustained multi-pronged communication and information campaigns.
This looks set to continue with plans for a 2015 Honours Research Project, which will determine the appropriateness and adaptability of interventions/tools aimed at minimising antibiotic use in the treatment of self-limiting URTIs. Looking in a South African context within the private sector, the project will:
- Assess the knowledge, attitudes and practices of community pharmacists with regard to the use of antibiotics in the treatment of URTIs
- Determine the appropriateness and adaptability of the GRIP toolkit via a questionnaire survey of pharmacists and patients, and
- Recommend modifications and adaptations to the toolkit to suit the South African context in the treatment of URTIs
Future publications in 2015, such as Prescriber Practices for Common Community-Acquired Infections in South Africa, hope to further promote awareness of AMR in South Africa.
Increasing awareness and knowledge of antibiotics is still very much the focal point in Russia’s fight against AMR. Their main aim is to reduce unnecessary use of systemic antimicrobials in outpatients with RTIs, which involves improving the knowledge of physicians and medical students, decreasing the frequency of self-treatment with systemic antimicrobials, and reducing dispensing of systemic antimicrobials without prescription, among others. A key target group, recommended by Professor Kozlov is medical students, as they seem to have a keen interest in the topic. Results from a survey undertaken among Smolensk students show that, although 63.3% are aware of the fact that antibiotics are often used inappropriately, over half (55.7%) of students had taken antibiotics without a prescription. However, promisingly, 70% of students asked were interested in understanding more about AMR. Other target groups include GPs and ENT specialists, pharmacists, patients and parents of children with a RTI and Smolensk residents.
To present the campaign in a unified style, a website has been set up to cover the problems of AMR in Russia and inappropriate antibiotic use. With the campaign in full swing, Russia anticipates an increase in awareness of antibiotic resistance, further prompting a call to action in the fight against AMR.
From 2003 to 2013, the rate of antibiotic consumption in Ireland was shown to increase from 20.34 to 23.66 DDD (defined daily dose), prompting an audit in 2014 of the Personal Antibiotic Prescribing and Irish Antimicrobial Prescribing guidelines. Results from the initial data collection showed that 10% of sore throat patients received an inappropriately prescribed antibiotic. Following an intervention and a re-audit, results indicated a reduction in inappropriate prescribing from 10% to 3.7% and the use of appropriate antibiotics increased from 80% to 100%, highlighting the fact that awareness of best practice guidelines can reduce antibiotic overuse.
With this in mind, one area of the ‘Play Your Part’ initiative aims to tackle the problem of GPs overestimating the value patients place on antibiotics during consultations, and consists of a forum, website and a resource pack. The resource pack has already been distributed to 2,530 GPs, with over 300 GPs also receiving a pack at the annual Irish College of General Practitioners winter meeting. A ‘Play Your Part’ pharmacy pack has also been handed out to 1,500 pharmacists. Focusing on an effort to tackle awareness in pharmacies, a partnership with the Irish Pharmacy Union has also been set up to reduce unnecessary antibiotic usage in Ireland. The success of the campaign is evident; ‘Play Your Part’ received a commendation for Best Education Project – General Practice/Pharmacy at the 2012 Irish Healthcare Awards.
In 2015, Ireland will focus on national guidelines and building a stronger antibiotics campaign. An emphasis will be placed on education and reinforcing guidelines for GPs and students, as for many doctors, it is easy to let things slip over time; therefore an awareness of guidelines can help maintain good practices.
Dr Pignatari reported that the campaign against AMR in Brazil is moving steadily, with a main focus on targeting patients and pharmacists in 2015. As 200 million people in Brazil speak Portuguese, it is imperative that materials are translated to communicate their messages effectively, beginning with abstracts of articles previously published in the International Journal of Pharmacy, following which they will be published in Brazilian journals. A week-long public health awareness event held in April 2015 will also be a main focus of the campaign in which the issue of URTIs will be discussed.
Many think of “resistance as a problem of the hospital not the community” highlighted Dr Sessa, who stressed that everyone is responsible. Italy’s main targets for raising awareness of AMR are GPs and pharmacists. This has included audits of small group GP practices or local health districts, and local seminars directed at pharmacists. Increasing awareness of AMR in Italy looks to be on track; plans for 2015 include preparing a study protocol aimed at collecting qualitative data regarding URTIs in pharmacy and the pharmacist-patient relationships that sit behind antibiotic use, as well as releasing the GRIP toolkit containing an introductory letter, leaflet and poster to doctors and local pharmacies.
Although antibiotic use in the Netherlands had been increasing over the last 5 years, it has decreased in the last year. Dr van der Velden, however, warns not to become too complacent as this could be attributed to a mild winter. Unnecessary antibiotic use tends to occur during the winter months and this is one area in which the Netherlands needs to focus to reduce unneeded prescriptions. Nevertheless, results from the ARTI-4 trial that looked at the effect of educational materials for GPs and patients demonstrated that GPs who received educational intervention prescribed antibiotics nearly 8% less compared with the control group. Moreover, significant results from year one of the study showed that over- and under-prescribing for RTIs decreased from 44% to 28% and 2.8% to 1.5%, respectively.
A 2014 ministerial meeting held in the Netherlands further exemplifies the country’s efforts to tackle AMR. Conclusions such as developing and implementing “national and global measures and intergovernmental standards for infection prevention” and recognising “the need for a stepwise multi-sectoral approach to enable all countries, especially developing countries to strengthen their capacities and to make progress to achieve better control of antimicrobial use and resistance at all levels”, among others, were drawn at the meeting, which they hope to action in 2015.
Four guest speakers attended the GRIP advisory board to provide case studies from different countries and highlight their local challenges and the impact antibiotic resistance has in their markets.