Proposed regulatory changes to enable podiatriast prescribing of anti-infective agents in New Zealand
“As the lead professional bodies representing Infection Specialists (Infectious Diseases physicians and Clinical Microbiologists) in New Zealand, we support the proposal to expand designated prescribing authority for podiatrists but recommend explicitly that prescribing must be guideline concordant with appropriate indications, doses and durations used, and with necessary safety monitoring in place for adverse drug reactions, interactions and organ-specific harms.”
New legislation in New Zealand under the Medicines Act 1981 will see podiatrists who complete additional training able to prescribe a specified range of medicines including anti-infectives relevant to podiatric practice.
The Ministry of Health is currently developing the list of medicines that specially trained podiatrists will be able to prescribe. ASID’s New Zealand Sub Committee led by Chair Dr Michelle Balm, and Dr Juliet Elvy, Chair of the NZ Microbiology Network, provided a joint submission.
Key points from the submission include:
The proposed list of medications is broader than in previously submitted proposals and includes some anti-infectives with significant risks for adverse reactions and which are vulnerable to antimicrobial resistance. We recommend a more narrow range of anti-infectives to be available for empiric prescribing according to published or regionally approved guidelines.
We do not support the inclusion of ciprofloxacin unless under the guidance of an Infection specialists (ID physician or Clinical microbiologist). This is due to significant risk of serious adverse drug reactions (risk of promoting heart rhythm disturbances, delirium/confusion, drug interaction with warfarin, alteration in blood glucose, tendon rupture, and rupture of arterial aneurysms). These side effects are more common in older, co-morbid patients, who are often the group seeking care from podiatrists. In addition, the antibiotic spectrum covered by ciprofloxacin is not relevant to guideline-based empiric outpatient prescribing. Caution is also required when interpreting microbiology results from foot ulcers, as Pseudomonas aeruginosa and other gram negative organisms are often colonising rather than causing infection. Safe and rational prescribing is required to protect the patient and the prescriber, and we endorse involvement of an infection specialist in decisions to prescribe ciprofloxacin.
We also recommend specific caution around prescribing clindamycin as it must be appropriately dosed and not given for long periods due to potential adverse reactions including risk of antibiotic associated diarrhoea and C. difficile infection.
Specific caution with prescribing terbinafine is also recommended and should be undertaken with consideration to drug-drug interactions and safety monitoring.
There is seldom an indication for topical antibacterials such as mupirocin for the management of skin and skin structure infection. Widespread use of this agent results in high rates of resistance. Topical antiseptics are preferred instead of topical antibacterials.
We support the proposal to expand designated prescribing authority for podiatrists but recommend explicitly that prescribing must be guideline concordant with appropriate indications, doses and durations used, and with necessary safety monitoring in place for adverse drug reactions, interactions and organ-specific harms. This is an opportunity to ensure podiatrists are entitled to order laboratory testing for safety monitoring (e.g. renal function, liver function tests, full blood count).
We strongly recommend a provision requiring endorsement from an Infection specialist prior to prescribing ciprofloxacin.
We are pleased to see that podiatrists are required to undertake specific training prior to obtaining prescriber scope.