ASID raises concerns about the expansion of pharmacy prescribing programs for antibiotics for urinary tract infection (UTI)
The Australasian Society for Infectious Diseases (ASID) is the peak association for professionals working in the field of infection – including human and animal health – and across clinical and laboratory medicine and microbiological research. Our members are increasingly concerned about the expansion of pharmacy prescribing programs for antibiotics for urinary tract infection (UTI) in many Australian states, most recently as outlined in the South Australian Senate Committee report. (1)
ASID supports initiatives that improve patient access to care and that allow health professionals to act at the top of their scope of practice, particularly for the provision of preventative measures such as routine vaccine administration. However, pharmacy antibiotic prescribing risks misdiagnosis and the promotion of multidrug-resistant urinary tract infections, which are a leading cause of infections due to resistant organisms globally. (2)
These programs contravene the principles outlined in Australia’s National Antimicrobial Resistance Strategy (3), having no antimicrobial stewardship (AMS) oversight or accountability for their potential contribution to overuse of antibiotics. We reject the assertion that the model of community pharmacists as prescribers and dispensers of antibiotics for UTIs is comparable to a pharmacist’s role in hospital-run AMS programs, where there is a clear governance framework under the National Safety and Quality Health Service Standards and no potential for conflict of interest by way of commercial incentives. (4)
Pharmacists undertaking additional training have the knowledge needed to safely prescribe certain medications but are not trained to recognise the clinical warning signs of complicated UTIs or early clinical deterioration. They may lack sufficient information about the patient’s medical history and do not have the ability to perform clinical examination to determine a patient’s risk of severe infection, drug resistant UTI or assess for alternative diagnoses. Confounding diagnoses such as sexually transmitted infections or non-infectious causes of symptoms (e.g., local irritation or medication adverse effects) may present with similar symptoms but require different treatment. For these patients, these programs may contribute to delays in provision of appropriate management and adverse outcomes. Testing for antibiotic resistance and consideration of alternative diagnoses is necessary and requires medical input.
Pharmacy antibiotic prescribing is a missed opportunity for preventative messaging to be conveyed to a patient to mitigate their risk of future infections, or to undertake other opportunistic preventative health interventions that are a routine part of primary care visits. It is unclear what non-antibiotic management for cystitis is offered with these programs. In-person prescription of antibiotics by pharmacists has clear disadvantages when compared to, for example, an online resource with medical input, allowing greater access and helping to reduce the load on emergency departments.
The suggestion that pharmacy UTI prescribing will increase access to treatment may not be true in many remote locations where there aren't any out-of-hours pharmacies. Uncomplicated UTIs are rarely a medical emergency and are best treated following clinical assessment to ensure correct investigation and management with appropriate follow-up. In addition, there is evidence that unnecessary antibiotic treatment leads to a greater frequency of UTI - not a reduction - along with greater antibiotic resistance. (5)
We note the overall lack of medical oversight of pharmacy UTI prescribing pilots conducted in Australia to date. Clinicians involved should include infectious diseases physicians, clinical microbiologists, urologists and general practitioner representatives to offer important technical expertise in the diagnosis and treatment of cystitis, as well as the risks of adverse effects from antibiotics including antibiotic-associated diarrhoea and antimicrobial resistance (AMR).
It is noted in the evaluation of the Queensland pilot of pharmacy prescribing for UTI (6) that follow-up was very short, with large proportions of participants having unexplained loss to follow up, and therefore lacking sufficient sensitivity to detect important safety signals. Serious adverse events are noted with four hospitalisations amongst those that were followed up in the pilot, including a missed case of appendicitis - a potential life-threatening condition when there are delays to definitive management. We also note a lack of comparator arm for this pilot evaluation with usual standard of care. Paradoxically, AMA Queensland reported that the number of patients presenting to ED with UTIs has increased since pharmacists were able to diagnose and sell antibiotics for UTIs. (7)
ASID believes that this initiative has not been adequately considered, with a significant risk of harm to patients and disregard of the potential impact on AMR - one of the greatest threats to modern medicine that we face. (8) (9)
We are not supportive of this initiative and urge governments to reconsider introducing this into mainstream care.
References
1. Final report of the Select Committee on Access to Urinary Tract Infection Treatment. https://www.ama.com.au/sites/default/files/2023-09/REPORT~1.PDF. https://www.ama.com.au/sites/default/files/2023-09/REPORT~1.PDF
2. Li et al. Global and regional burden of bacterial antimicrobial resistance in urinary tract infections in 2019. J Clin Med 2022; 11(10): 2817.
3. Australian Government. Australia’s National Antimicrobial Resistance Strategy – 2020 and Beyond. https://www.amr.gov.au/resources/australias-national-antimicrobial-resistance-strategy-2020-and-beyond.
4. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. https://www.safetyandquality.gov.au/our-work/clinical-care-standards/antimicrobial-stewardship-clinical-care-standard.
5.Cai et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis 2015; 61(11): 1655-61.
6. Nissen at al. The management of urinary tract infections by community pharmacists: A state-wide trial: Urinary Tract Infection Pilot – Queensland (Service Evaluation Report – Approved April 2023). https://eprints.qut.edu.au/239310/.
7. AMA Media Release. Pharmacy pilot fails to keep UTI patients out of EDs. Published 27 Sep 2023. https://www.ama.com.au/qld/news/UTI-pilot-fails-stop-ED-presentations.
8. WHO. Antimicrobial resistance. Published 21 Nov 2023. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.
9. Murray et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022; 399(10325): 629-55.
Media Contact: Alison Sweeney alison@asid.com.au or 0425 221 155.