natural treatment for the disease aplastic anemia

hello. i'm norman swan. welcome to this program on antibioticresistance and infection control. antimicrobial resistanceis a public-health threat of enormous importance, and the serious and real risk is by 2030we'll be back in a pre-antibiotic era. if you think that's just scaremongering,watch on. let me introduce our panel to you. john bell is vice president of theinternational pharmaceutical federation, and a past presidentof pharmaceutical society of australia,

and the australian collegeof pharmacy practice. - welcome, john. glad you could come.- thank you. marilyn cruickshankis a registered nurse, who works in safety and quality. - welcome.- thank you. marilyn's currently leading the nationalhealthcare associated infection program with the australian commissionon safety and quality in health care. margaret duguidis a pharmaceutical advisor at the australian commission also.

margaret is involved in leadingand coordinating improvements in the safe use of medicines.welcome, margaret. thank you. margaret also works,you'll hear more about this later, on antimicrobial stewardship, and coeditedthe commission's publication - antimicrobial stewardshipin australian hospitals. gary franks is a general practitionerin illawong. -welcome, gary.- thank you.

gary is a consultantat the national prescribing service, and was a gp member of the expert group guiding the antibiotic therapeuticguidelines, versions 13 and 14. tom gottlieb is a specialist inmicrobiology and infectious diseases. - welcome, tom.- thank you. tom's currently president of the australasian societyfor infectious diseases, the president-elect of theaustralian society for antimicrobials, and is on the executive

of the australian groupon antimicrobial resistance. so welcome to you all.an august and authoritative panel. looking forward to what you have to say. i mean, tom, if you look at the graph here, there's... we've had a remarkable effect from antibiotics. they've been an astounding medical technology.

tom: they're the true miracle drugs, and no other anti... no other drugs have had such a profound effect on diseases in the 20th century. and you can see on that graph that in the 1940s and so on when these drugs were introduced, they reduced morbidity and mortality. but our risk is that

we'll go back to that era, as you've already mentioned, when we lose a lot of these antibiotics. norman: what's that blip at the end of the graph there? tom: the blip at the end is hiv, and the mortality associated with hiv. but luckily, a lot of companies have gone into hiv-drug production,

and that blip has gone down again with better antiretroviral medications. but the sad thing is those companies are no longerproducing antibiotics. norman: and that's the key here. no sooner is an antibiotic produced... i mean, how quick is itthat you get resistance appearing after a new antibiotic coming out? usually you can see it worldwidewithin about a decade.

i mean, resistance occurs very quicklyafter antibiotics are used, but when you're on a flat curveof an exponential curve, you don't really see it fromepidemiological point of view. it's only after a whilethat you start seeing it, and by then it's often too late. so what is the extent to which... what's the number needed to treatto get resistance? do we know that? for example, you've got a patientcoming in with a uti, you give them an antibiotic.

of 100 patients being treated with a utiwith the antibiotic, how many of them do we know will develop resistance as a resultof the antibiotic prescription? you can't... the point is that the... all bacteria potentially possessthe mechanism for resistance. in any population of bacteria, there'salready a percentage of bacteria that... - you inherently select for resistance.- you select for resistance. that resistance is already thereto some extent, but it hasn't been producedto any large number.

as we use antibiotics, we allow thoseresistant organisms to come to the fore. so the extent to which we're talkingabout are population-based problem, or one in our individual patients? i mean, that's what i'm tryingto get at. should your hand be quiveringover the prescription pad, that five days from now,seven days from now, this person's got a 50% chance of having the growthof a resistant population of bacteria? no. for the specific infectionyou're treating,

you can be confidentthat your antibiotics are going to work. but that person's gut florawill be changed within a number of days, and what you'll see is resistant flora,often of a different species, colonising that patient's gut. some of those organismswill have already resistance factors, which can spread to other bacteria. so how does the resistance bacteria...you got phages, you got the viruses that infect bacteria that can carry resistancebetween different species of bacteria.

how else? well, a lot of bacteria have plasmids, and these plasmidscollect resistance factors, and congregate them. these plasmids can movefrom mother to daughter, but they can also move horizontally toother species of organisms very quickly. bacteria spread resistancevery promiscuously. norman: so here's the scary graph. this is the extent to which

new antibiotics are being produced over time. i mean, this is the truly frightening... this is the frightening scenario here. tom: yes. we had a lot of new antibiotics in the '50s and '60s, but when you look at that graph, really, there've been two new classes of antibiotics in...

..at the end of the 20th century. and both of those classes are very narrow in their capacity, and resistance to both of these have already become well established. norman: what we're looking there is that red box is the front line against resistance. tom: these are the new antibiotics.

they're often extremely expensive, and they're not gonna last us long-term. the issue is that if you're not producing new antibiotics, you've got to preserve your old ones. you've got to find means of controlling the spread of antimicrobial resistance. some of that isthrough controlling antimicrobial use. but also, once you've alreadygot resistance, controlling the spread,

and that could be in hospitals withbetter infection control, for example, or better programsabout antimicrobial use. tell me the story of greece. greece is in the news at the moment, but it's got a bad storywith antibiotic resistance. tom: yes. this is an example where a particular resistance has occurred to our last-line antibiotics.

these are called carbapenem antibiotics. they're beta-lactam antibiotics that cover the broadest spectrum of bacteria. you can see that within a decade in greek hospitals, you've gone from 0% resistance in klebsiella, which is a very common gut organism,

to 80% in greek hospitals. that's a clear indictment of antimicrobial prescribing, but also of hospital infection control. 'cause once this organism appears in your hospital, if you can't contain it, it'll spread elsewhere. and that's exactly what's happened.

so this could applyto a general practice or a hospital. you've done studies of tourniquets. (chuckles) yes, we've lookedat tourniquets in our hospitals, just to make a pointto our administration about how hospitals need to be cleaned better. but the example of the tourniquets was that these tourniquetswere sitting in the wards, being used by a lot of the rmos, and going from patientto patient to patient.

and when you actually tested them, 20% of our tourniquetshad either mrsa or vre already sitting on that tourniquet. and that's justenvironmental colonisation. but the point is that the tourniquetitself is not to blame, it's the cleaning of the environment that allows these organismsto remain there and potentially spread. and you've got another example hereof another resistance, because you could saywith the greek story,

'what does that matter?i mean, it's greece. it's not gonna happen here.' norman: but people travel.- exactly. i think the point with the greek one was this was greek hospitals, and failures there. but here's an example of a very similar organism. here actually, it's a particular enzyme

that again destroys all penicillin-like, or beta-lactam antibiotics, and a whole lot of others as well. this resistance emerged in the community in new delhi, in india and pakistan, and rapidly spread to england, and within two years, from 2009 to 2011, has spread worldwide. norman: it's come to australia as well.

tom: it has come to australia. norman: poor practices somewhere else... poor practices somewhere else, and here this organism survivesin water, in seepage and sewage. so this is a community problem. but the problem really is that a lot ofpeople... they're never gonna get sick, sick with this organism. but when they do developthe urinary-tract infection, or sepsis,

and that person presentsto your hospital, you wouldn't realiseyou've got this resistance until you test that patientand get results 48 hours later. so are resistant organismsmore virulent, or it's more that you miss the factthat they're resistant? some resistant organismscan also have other virulence factors, like certain staphs. but in this situation, this organism'snot more virulent in itself, it's just that we don't anticipatethat we've got this.

we treat the patientwith the wrong antibiotics, or we may have no antibioticsleft in this situation. and, margaret, there's stats showingthat people die more frequently with resistant organisms. - they're more likely to die.margaret: yes, yes. there are studies that have shown,they're more likely to... ..twice as likely to die from aninfection with a resistant organism. tell me the e. coli story now,and that spread. tom: the e. coli?

norman: the third-generationcephalosporins. oh. well, these are even more common. these are called espls e. coli. this graph shows a change in five years in europe, both in e. coli and klebsiella. you can tell by the colours that green is less than 5% resistance, but red or orange

is 20 to 50% resistance, and you can see how rapidly... these are bloodstream infections in europe, and you can see how rapidly resistance has emerged. it's an index of both those things - use and infection control. but the point there is

that often the scandinavian countries, the countries to the north, have got much lower rates of resistance. yet when you look at statistics on mortality or morbidity with these infections, those patients in scandinavia are not dying anymore by not usingantibiotics to the same extent. norman: so those are lowantibiotic-prevalence countries

- with low resistance.tom: exactly. norman: with no correspondingincrease in mortality 'cause they're dyingbecause of lack of antibiotics. tom: exactly. so our antibiotic usecan often be out of proportion to need. and what about the australian situation? well, australia in some situations has been lucky. we've had much better control of agricultural use of antibiotics.

that doesn't protect us. but in certain situations, we're starting to see changes. this graph shows the rise of community mrsa, which is a nasty, potentially very virulent organism that we're seeing particularly in rural and indigenous areas. and the point to make here is

you can see the trend from 2000 to 2008 in some studies in australia. but if you were to look in 1990, that graph would be zero. you wouldn't get community mrsa anywhere in australia pretty well. there were some exceptions. now there's an inexorable rise upwards, and we don't know where it will end.

will it be 50%? certainly in the united states now, 70% of patientspresenting to emergency departments with staph infectionshave community mrsa. which means, gary, that...(clears throat) ..you know, you can't be complacentabout your coughs or tourniquets in a general practice anymore. gary: absolutely not. in fact, beyond that is the needfor us to be very diligent

on using narrow-spectrum antibioticsfor skin and soft-tissue infections, which are often causedby staphylococcus of course, and not the use of cephalosporins,which is often the case. so do we know the extentto which community mrsa is caused by poor prescribingin general practice? we know that it has evolved throughantibiotic... poor antibiotic use, and certain areas we can actuallydocument how it's been used - it's been related to cephalosporin use. but once that clone is established,clones of bacteria spread unrelated.

so, the antibiotics still maintaina pressure on use, but once it's escaped, there areother dynamics in place as well. so you could say in greece, becausethey can't afford carbapenem anymore, does that mean you're gonna seethat graph reversing? that graph may tone down a bitand go away if they can controltheir antibiotic use, but sadly, a lot of those resistancefactors will remain in those organisms, or in a subset of those organisms. at the minuteyou reintroduce antibiotics of a class,

or a similar class... norman: they'll surge back.- they'll surge back. i thought it was expensive foran organism to carry that resistance, that their natural non-resistant statewas their most energy conserving. it's probably a bit of a myth.it depends on some organisms. in certain tb strainsit may be the case, but in most of our bacteria, in fact, acquiring antibiotic resistance has hadvery little cost to their virulence. to what extent, john, do pharmacists usetherapeutic guidelines?

well, it's a mandatory textin community pharmacy, norman. i guess we don't use the book though,as much as we should. one of the reasons, i guess,is that we're most often not privy to the diagnosis, the type of infection,the type of condition the patient has. we can assume, most often, if someonecomes in coughing and spluttering, that's a respiratory tract infection. um... otherwise if they walk inuncomfortably, maybe we can presume it's a uti. but there are hints, of course, in theprescription that we're presented with.

in hospitals, there's, i think, enormous collaborationbetween pharmacy and medicine - the doctors and the pharmacists there. not as much on issues like thisin the community. norman: is there any?- there's some, but very little i think. it would be rarefor a general practitioner... i should ask gary this as well. ..general practitioner to referto his or her local pharmacist for adviceas to which antibiotic to use.

the question that's come inis from jill fletcher, the manager of berri hospital,general services, who has the recent south australiancleaning guidelines, and wants to know what placecleaning standards have in assisting without smarting bacteria in hospitalwith regard to antibiotic resistance. - marilyn, that's a question for you.- hm... look, cleaning's very, very importantbecause, as tom has said previously, that, you know, antibiotics causeresistance in different organisms, and that's in a particular patient.

but that patient then can transferthat multi-resistant organism to the surroundings. so if hospital surfaces and surroundingsaren't cleaned adequately, then other patients can eitherbecome infected with those multi-resistant organismsby touching those surfaces, or healthcare workers can transfer themfrom one patient to another around the... around the area. so, another problem is too thatyou can't tell by looking at a surface whether there aremulti-resistant organisms on it.

so we really need to have,you know, well-trained staff who can do the cleaning. we need to have... which, i presume, is not often the case. well, no. it often isn't,because often there's... you get contract cleaners inwho think they can do it. yes, and we have a large turnover, so we need to have well-trained cleanerswho stay. and does it matterwhat they use to clean with?

do they ever get resistanceto disinfectants? well, that's an interesting...that's an interesting question. but usually cleaning with detergents... norman: you're not going to answer it? well...(laughter) well, usually cleaning with detergentsand cleaning thoroughly, and then disinfecting with bleachor some other disinfectant is adequate. norman: right.john: can i ask, norman... marilyn, in the community setting,in the home,

we see promotion of lots ofantibacterial disinfectant cloths, and wipes and solutions and so on. these are not really not necessary,are they? they're not necessary. no. detergent and soap is the best productto be cleaning with. so the other use of chemical,the antibacterials and so forth, could actually exacerbate the problem. absolutely. that can also add tothe problem of antimicrobial resistance. margaret, do we know the extentof inappropriate prescribing?

well, we certainly knowthat in hospitals, probably around 50% of prescribingcould be inappropriate. norman: 50%?- hm. up to 50%. certainly the studies have shown that. is that omission, commission?what's the story here? well, this is mainlyif we look at it against guidelines. if we look at prescribingagainst guidelines, it's pretty poor. so... not necessary, wrong antibiotic,wrong duration. we'll come to all that in a minute.

tom, clostridium difficile. they say, in britain,there's 250,000 premature deaths due to clostridium difficilein hospitals a year. i mean, that's an enormous number. yeah. clostridium difficile is anorganism that really colonises surfaces, and it's extremely difficultto get rid of. in the uk, they had an outbreakof a very toxic strain, which we've been very lucky thatwe haven't had in australia to date to any large extent.

norman: i thought we had somein western australia. we had some actually in sydneyand in melbourne in the last two years, but they haven't really got outto any degree. i think what happened in the ukis that they had, at that time, poor infection control, and it got into the nursing homes,into the really vulnerable. but england's got their act together. to some extent, they've improvedtheir prescribing guidelines, their infection control,and ahead of us i think.

so we're an accident still waitingto happen as far as that goes. what's the role of surveillance,margaret? margaret: surveillance in terms of...? we've got the national antimicrobialutilisation surveillance program. well, the national antibiotic usagesurveillance program collects data from about 50% of principal referral hospitalsin australia. so it doesn't involve country hospitals? if you live in south australia,they collect data,

and also in queensland they collect datafrom the... from most hospitals. norman: so you're lookingat common infections, and comparing it to the antibiotic use? no, there is... depends on what's usedat the hospital. they may use that data to compareagainst their susceptibility data. but the... generally... that data, at this point in time,certainly national data, is not related to resistance data. we don't have a comparison.

gary, give me the antibiotic creed, 'cause this really will framethe rest of our discussion. it's a profound statement.it'll be on the screen. it's probably one that most gps have either not seen, or cannot remember seeing, and it's an acronym - mind me. (reads) norman: let's unpack that a little bit.

so, microbiology guides therapy. so, does that mean swabs, bloodcultures, etc. in general practice? obviously, in general practice, it'smore limited than in a hospital setting but there's a lot of roomfor micro urines to be tested, swabs of wounds, throat swabs appropriate on occasions, sputum cultures can be useful so it's limited but comparedto the hospital, obviously less so but it can guide our therapyand make a directed therapy

a few days later. tom, what is the rolefor empirical therapy? i'm assuming when we're talking aboutempirical therapy is that you're giving treatmentwithout knowing what the diagnosis is but on a hunchyou know that somebody's sick and you suspect a bacterial infection,is that what we're talking about here? yes, there's always a role for it. the beauty of antibioticsis that they save lives. if you've got patients with sepsis,

there's no time to waitfor the diagnosis, you want to treat appropriately but still, it's got to collatewith what the likely diagnosis is. if you're dealingwith meningococcal sepsis, it's different to someone with pneumonia and there are very good guidelines inthe therapeutic guidelines for example which still give you a good directionto empiric therapy. but it's driven by the idea thatyou don't know what the pathogen is and the problem withantimicrobial resistance is again,

10, 20 years ago, you could predict thatyou could give certain antibiotics and get away with it. what we're facing in the near future is patients, young people coming inwith pyelonephritis and you might be getting it wrong20% of the time. that's a worry. so empirical therapydoesn't get you out of jail in terms of doing the microbial test? no, you still want, in that emergencysetting, you want a blood culture but if it's not an emergency setting,

where on the other hand, you still arepretty convinced you need antibiotics, well, for example, taking someonewith a staphylococcal infection, you really want to knowif it's an mrsa or not. you really want to takethat pus specimen and send it off. you don't want to put it in a bin. let's go... so, but if you're a gpand you've got somebody who's septic with funny spots and you thinkit's meningococcal septicaemia, you wouldn't hang around? no, that antibiotic should have hitfive minutes ago.

yeah, so there are exceptionsto this rule? absolutely. i think what we want to sayabout antimicrobials, we want to preserve them so we can usethem for the patients that need them. we've got a question from shepparton, a general practitioner wanting to knowwhat are the one or two things a gp should do to reduce the spreadof antibiotic resistance. gary? i think that comesin that antimicrobial creed and if i can refer back to that, indication should be evidence-based.

we have good evidence in therapeutic guidelines that can be on all our desktops, minimised and referred to daily throughout the day. and really, wisdom is the correctapplication of knowledge. therapeutic guidelinesgives us this knowledge. it's up to the gps to wisely apply that. we can use narrow spectrum antibiotics,

tonsillitis - bacterial tonsillitis - often broad spectrum antibiotics, i witnessed being prescribed for this like amoxicillin when phenoxymethylpenicillin bd is the drug of choice, a narrow spectrum antibiotic, dosage appropriateto the site and type of infection. i often see wound infections

being treated with cephalosporins when flucloxacillin isthe standard guideline recommended when patients are not allergicto penicillin. i mean,i would imagine that for most gps, the first thing in their mindwhen they prescribe is actually resistanceeither consciously or unconsciously and presumably that's the reason whythere's such vast prescribing of amoxiccillin, clavulanic acid. but what you're saying isthat's the wrong thing to do.

in certain infections,that's the wrong thing to do. we should be guiding our prescribingon evidence to try and help... and then you kind of think, 'well, let's just blastthis bloody infection to smithereens and i'm going to give, you know,the do40, you know, hit them between the eyes with it'cause i wanna get rid of this, i want to level the landscape here.' well, we have a right to prescribe,we also have a responsibility - and there are risks and...norman: talk to me about dosage.

is there a lowest possible dose? when we can, the lowest possible dosefor the shortest duration of time is appropriate for certain infections. now, that's not appropriatefor the patient who's septic. but for a urinary tract infectionfor a symptomatic woman where we have some evidence that clinically they may haveurinary tract infection, again, i anecdotally observeda prescription of cephalosporin for a week and a repeat

when the guidelines say five days bdis enough. tom, what happens when you givetoo high a dose for too long or too high a dose, that's one issue,or too long? what happens? the too high a dosedoesn't worry me that much because you're really killingthe bacteria and the only problem with a high dose is that you might havemore intolerance or more side effects but it's the duration of therapythat's a concern because the more you use antimicrobials,

the more resistance you will see.it's darwinian. and we really have an onus on usto reduce the duration of therapy. a lot of things that have beenalways said mythologically that you must use10, 14 days aren't wrong, you can use five days. and, tom and gary, i mean,that's something that pharmacists have,i guess, reinforced for decades. you must finishthe course of antibiotics and the repeat ifthe doctor's ordered a repeat

and, i mean, you've suggested maybea shorter course for uti, maybe three days i think is appropriatefor trimethoprim and yet, seven-day courseis almost always prescribed and certainly,we pharmacists have had it inculcated that we must reinforce that message. so you're telling usthat's not quite right. well, that's communicationto the patient and to the pharmacist but also, we need to be carefulin our antibiotic prescribing where we're usingelectronic prescribing method

that we don't just click on the defaultwhich has a repeat. we need to remove thatand be very careful because patients often don't use itthen they save it for another time. i think it's a beauty of evidence that,you know, things change over time and if the evidence comes out that youdon't need to use those long durations, we should be ready to adapt. we know that meningococcal meningitisneeds three days of therapy. often, people get 14 days. and what about prophylactic therapy?

you know, in surgical situations, peoplewatching this who are gp surgeons and, you know, we've got guidelineson prophylactic antibiotics... absolutely. the prophylaxis should befor the duration of that surgery which often requires one dose. if it's prolonged surgery,it may require two dose. there is very little prophylaxisthat requires treatment to go on for more than 24 hoursyet we often see that in hospitals. that's no longer prophylaxis,that's therapy. and sometimes 50% of prescribingin a hospital can be prophylaxis.

so the longer you go, the more likelyyou are to get resistance. what aboutwhen you're treating some conditions... where you're treating children with acneor people with acne with long-term tetracyclines or... itwouldn't be children in this case but... or, say, somebody with, who seemsto have a chronic infected prostatitis and you're putting him on, say,six weeks of antibiotics. is that indicated or is that just... well, those are two different things. i think... it's often a balance,i must admit.

i personally worry aboutthose prolonged courses of tetracyclines 'cause there is going to bean ecological effect without a doubt. but i think one of the issueswe've really got to here is that we can be patient advocatesor we can be society advocates. we've got to balance the two. and i think too oftenpeople are patient advocates and will give very prolonged courses when often when they ask about it, they're not really surethat they're justified

so i think we really haveto question ourselves. norman: and ensure monotherapy but most people use monotherapy,aren't they, these days? in general practice,i think that's probably the case, yes. but not to multiply the drugsin the hospital situation. john: norman, we often get,we see in community practice... ..an amoxicillinor amoxicillin and clavulanic acid with roxithromycinfor a respiratory tract infection. gary, can i ask you, in nursing homes,

our experiences there, a very highpercentage of women particularly are on cranberry extract tablets for the preventionof urinary tract infections. have you got a comment on that?is that reasonable therapy? i personally find it difficultin a nursing home. i think that usuallythe patient's on so many medications, the nursing staffare struggling to give cranberry, i think we can do better than that. they're probably crushing it upin cranberry juice,

distributor horrors there, john. well, there are dose administrationlots of nursing homes are using so from a complianceor adherence point of view, i guess it's not that bad but you're right, i mean,most nursing home residents are taking multiple medications so another onejust adds to that drug load. there've been a couple of studiesrecently. one suggested thatthere was a benefit of the tablet form

and a subsequent study suggestedthere was no benefit so i think the evidenceis still out there. so, what about route of administration,tom? is, you know, the temptationthat you've got an elderly person with a community acquired pneumonia, you know, just a quick iv and then oral. is there any evidence that ivis more effective than oral, im? there are occasionswhere intravenous therapy clearly gets to the site of action fasterin bigger doses

but i think there's also good evidence,if you take pneumonia, that if you can look atthe patient's presentation and apply whatever score you useto assess their pneumonia, that there's a groupthat's predicted to do well and can be treatedwith oral antibiotics at home so yes, you may do marginally betterwith intravenous therapy but probably not. but then there's also patientswho clearly need hospital admission and they benefit fromintravenous therapy.

so again, it's applyingour clinical know-how to assess that patient. there's also the issue, tom, though,of changing over from iv to oral when you can. absolutely, and the other thing to sayin the same... norman: but does that have any impacton resistance development? well, again, dependingwhich context we're talking about, generally speaking, i don't think so. the point to make is thatintravenous therapy has the risks

of complications like line sepsis and there are a numberof oral antibiotics that get the same systemic levelsas iv therapy. so when you have to use oral therapy, metronidazole orally is as good as iv -it's just one example, many others. i've got a questioncoming from toowoomba from one of our web viewersin toowoomba, gary, asking, 'what's the best way of dealingwith somebody who is demanding antibioticsbut you don't think they need them?'

obviously, a sensible discussionwith that patient. i go about it witha risk versus benefit analysis and explain that even in their body, this idea of gut flora resistanceis emerging with the prescribing of an antibiotic, let alone the concerns of side effectsand allergy development. and so, it's really up to the gpto explain depending on the infection,the severity of the infection, the type of patient,there may be circumstances,

a diabetic patient,one may be persuaded more. you've got to be carefulin making a generalised statement but i think it's a simple explanation... i find that a simple explanationto patients of the risk versus the benefit and the ability to contact me iftheir infection is changing or worsening is the best way to go about it. john, do we still have antibiotic creamson the market? we do, and i was going to asktom and gary about

whether there's any relevance. i mean, we talked about acne earlier and whether maybe,you mentioned yourself, norman, long-term tetracycline use whether it'd be more appropriateperhaps to use an ointment or a creamspecifically tailored. there's rifamycin and clindamycin creamsfor acne but there's also the otherantibiotic creams and ointments too which are still used, still prescribed.

so if you've got a staph skin infection, is there any indicationfor topical antibiotics? no, i don't believe so. there is an indicationto sometimes decolonise patients if you're trying to reducetheir carriage for... norman: that's a nasal...- nasal bactroban or mupirocins, the proper term. so it's not really antibiotics if... well, it is an antibiotic but it'sa topical one and that's sometimes used

but as a general rule, we don't likeusing topical antibiotics very much. we have a particular scenarioin australia now that anyone who gets cataract surgerygets days of quinolone topical drops. it's a frightening scenario. why are they getting it? i've no idea. right, is there any evidence thatchloramphenicol drops do anything after eye surgery? oh, this is quinolone ciprofloxacindrops that people are starting to use. i think that's a worry but yes,these things can be used for 24 hours

but to go on for days,i'm not sure what it's achieving. gary: chloromycetineven in eye infections is not without its potentialallergic developments and so we need to be careful as gpsto make sure of the diagnosis of a bacterial conjunctivitis... norman: can you get aplastic anaemiafrom eye drops? from chloramphenicol? (silence) norman: ok, we'll take that one out...

just to scare the bejesus out of people. chloramphenicol eye drops are nowavailable without prescription too directly from the pharmacistand of course they're now much more widely used. the sulfacetamide which was morecommonly recommended by pharmacists is rarely now recommendedbecause of the much more accessible... i must admit as a gp,i'm concerned about that. i've noticed that more latelyand if we're getting guidelines that tell usthat bacterial conjunctivitis

is this diagnosis clinically, is the pharmacist making a diagnosisof a bacterial conjunctivitis? how do you differentiate between viral,allergic, other forms of conjunctivitis? look, i share your concern, gary. i think pharmacists need to bemuch more concerned about assessing a particular eye problem and maybe the simple tear solutions or if it's an allergic conjunctivitis, which is probably more commonthan bacterial or even viral,

then a more appropriate productshould be recommended. mm-hm. 'cause in fact that's partof the problem in the developing world is you can buy antibioticsover the counter. tom: exactly. part of the problem toois that a lot them are counterfeit and, you know, you're not gettingthe appropriate dose anyway. norman: or something different. you may get gentamiticinwhen you thought it was amoxiccillin. let's go to a case in our case studies.

steve's a fit 45-year-old. he presentsto you, gary, with a sore throat, nasal discharge. he's been feeling a bit sickfor three days. he's got a cough with some sputum. when listening to his chest, it's clear,his temperature is 37.6. this case is presenting so far as aviral upper respiratory tract infection. it may be lowerbut it still sounds viral. however, there is the needfor an obligatory history and, i believe, thorough examination.

if you're gonna convince a patient,i believe this is a viral infection, you need to thoroughly examine them so they are confident thatyou haven't just brushed this aside. this is such a common presentationin general practice that it is difficult sometimesto spend that time doing that but it's a discipline we need to do, so we do need to examine the patientthoroughly. having said that,this so far looks like a viral infection and i then go into a spill about,as i was saying before,

risk versus benefit. why i think it's viralon my examination, what can be done to alleviatethe symptoms... so he's a bit anal retentiveand he's kept this morning's sputum and he opens this paper hankieand it's green. does that change your view? no, i then launch intoanother practice spiel that explains that, really,evidence is now shown that when your white cells are tryingto help you defend this infection,

there are release of chemicals thatbreak down that sputum and turn it green so it does not necessarily meanbacterial infection like we perhaps used to think. and when you look at his throat, there are some white fleckson his tonsils. that's not how you diagnose tonsillitis. tonsillitis should have a fever,enlarged cervical lymphadenopathy, pus on the tonsils,red inflamed tonsils. you either have a bacterial tonsillitisor you have a viral infection.

it's unusual that you see bothin my experience. you may have a viral tonsillitis with itbut you've got to look at the big story. right, so you reassure steve and you, that he's likely to havea viral infection and you say to steve to goto the pharmacist for some over-the-counter medications.what do you recommend? he wants something,he has to get back to work. he's really pressuring youfor something there. first of all, on my desktop,i print out a...

the nps put out a nice symptomaticmanagement pad and i like that. i can tick what i... patients, as you know,love to go outside of the surgery with a piece of paper in their handsand they take it to the pharmacist. plus, they forget what you tell themso by having this instruction talking about steam inhalation, nasalsprays, perhaps cough suppressants, perhaps analgesics,i believe, is an aid. but we also have a needif there is concern or we've had a patientwho's quite anxious

about the need of an antibioticto offer the ability for review and i think most gps do that these daysespecially with children. look, i mean, it's interesting because of all the categoriesin community pharmacy, the cough and cold categorywould be one of, if not the largest, - but interestingly enough...- they don't work. i was gonna say it's the categoryabout which there is least satisfaction and you've, i guess, highlightedthe main reason for that. i think... (laughs) it's a simple one -they don't work.

well, i think some of the products do,some do but there is little evidence about the benefit of lots ofthe products that we have, i must admit. i guess in this case, i knowgary's taken a very thorough history but one of the thingsi would ask steve is, is he a smoker and maybe that is contributingto some of the symptoms that he has. i'd be thinking, he seems to havethree areas of concern. one is his nose,which is running apparently, he's sniffling, he's sneezing,

maybe he's got a bit of a cough,he's got a sore throat. gary mentions steam inhalation. i think that the saline nasal spraysare very good. if it's a post-nasal dripthat's causing his cough, then we can address that situation. there are decongestants which may helpif the nose is congested. there's... manuka honey, which probablydoesn't do any harm either. well, depends whether you spread iton toast or just your bread. but there's a capsaicin sprayand an ipratropium spray

for non-allergic rhinitis. i think for cough mixtures, well, that's an areawhere there's not a lot of evidence but something like bromhexinewith pseudoephedrine, so the mucolytic with the decongestant, is something where certainly anecdotallywe've had good response. the other thing is for the sore throat. well, there's throat sprays,there's gargles and there's lozenges and they're soothing

and if you can help relievethose symptoms, i think you've got to give your patientrealistic expectations in respect tothese symptomatic treatments. gary, there have been studies,randomised trials, in children with otitis media that where there's probablya fair degree of over-prescribing of antibiotics in otitis media,properly diagnosed otitis media. and there's been a trial showingthat delayed prescriptions - you're giving a parent a prescriptionsaying if it's not resolved in two days,

fill in the prescription - showing some benefits with that. is there any argument in somebodyin steve's situation to give him a script and say, 'only fill it inif your symptoms persist beyond two, three, four, five days.'do we know? certainly, there are some circumstances when one may be tempted to do that. i think in steve's situation, assumingthat he has access to medical care

or the ability to come back to yourself under circumstanceswhere he can be re-examined, that i would tend to not do that. patients tend to either incompletelyfinish the dose if they improve or they sometimes reserve... is that a bad thing - if you're better,not finishing the dose? i mean... well, if they've developeda secondary complication that you've given them advice on,it's not appropriate and often they would reusethat antibiotic, i find,

next time down the track. a child with an otitis medianeeds a little more attention and there'll be circumstancesif it's coming up... but the whole idea of delayedprescribing is in play, if you like. the question is, is it in playin a broader group of people than for which there is evidence? i think so and i think the child is onearea where there's some good evidence and also probably correct application. i don't think the adult notes so much

unless there's exceptionalcircumstances. so, steve recovers but he comes backto see you two months later. he's had a persistent coughfor two weeks, worsened in the last two days,bit short of breath, bit of pain on breathingand he's got a temperature of 38. obviously,a much different clinical scenario that i would take just as seriouslyas the first presentation but i'm concerned that he may bedeveloping a pneumonic consolidation. so, again, a thorough history,detailed examination,

chest x-ray to confirm that diagnosis and probablysome laboratory investigations and then dependingon the circumstances... norman: so what laboratoryinvestigations - blood cultures? i wouldn't do a blood culture. where i practise in the city,i wouldn't do a blood culture but i certainly would be doingwhite cell count and mycoplasma toojust in case it turns out to be that. if the history suggests an influenzaleading up to that,

perhaps some nasal swab for pcr,for influenza. if there's history that it's legionella,serology accordingly. so, depends on the historyand the examination. and if it's a saturday morning and you can't get an x-raytill monday morning? would you empirically treat it? i would, i can get an x-ray but i wouldempirically treat him with amoxicillin. i would... norman: amoxicillin would bethe drug of choice?

yes and, again, therapeutic guidelines,there's a change there. it used to be that 500mg tdswas appropriate, it has actually gone up to 1g tds. and if there's concernthat's an atypical or mycoplasma, if it's a weekendlike you're suggesting, i may... what would make you think of thatif you haven't got a chest x-ray showing lobar pneumonia? well, if it's clinically one sidewith pleuritic chest pain, it's probably a bacterial pneumonia.

if the presentation's not as severe and bilateral change is perhapsnot as toxic, i may be considering it's mycoplasma.it's a difficult situation clinically. and if he went to see another gptwo months ago, and he got amoxicillin clavulanic acid for his upper respiratorytract infection, would that change your prescribingdecision here, two months later? look, it makes it tough,i appreciate that, but again, i need to explain and educateand communicate that patient

why i think the risk of side effectswith that antibiotic are strong and again, by having evidencethat i can demonstrate to him of why i'm prescribing whati'm prescribing, i find, is adequate. can i make a comment there tooto help with that? augmentin's got a much lower doseof amoxicillin than your higher dose of amoxicillin and the reason the doses have gone up is because strains of pneumococci which is after all the most importantbacterium to cover in pneumonia

are becoming more resistant, so we actually need higher dosesof amoxicillin to treat them. so in fact your ordinary augmentinprobably isn't as good a therapy as higher dose amoxicillin. norman: really? what about side effectsof that higher dose? tom: no, actually, the side effectsof augmentin are a lot worse than the amoxicillin on its owneven at higher dose. - really?tom: mmm. so you wouldn't be worriedthat he's got resistance

if he's had a history of antibioticsin the last two months? i wouldn't be worried enough that i wouldn't advanceon what i was describing. norman: how long would youput him on the amoxicillin for? seven days. what would you doif he came to the pharmacy, john? well, we'd reinforcethe doctor's directions. i think one of the thingswe would like... but what if it wasn't gary andit was a 14-day course he'd been given?

that's a challenging question, norman. norman: it's what i'm here to do.- apparently. the... i guess it really comes backto the communication between the community pharmacistand the general practitioner. i mean, in your pharmacy, do you askwhat the antibiotic's for routinely? not routinely, we don't, no. what we do ask, though, is 'what has thedoctor told you about your condition? what has the doctor told youabout the medicine? how long has the doctor indicatedyou should take this?

what dose has he or she told you?' now, some of that is on the prescription but we like the patient to be ableto understand that, we would provide themwith consumer medicines information. and what if it contravenesthe therapeutic guidelines? look, i guess in most cases, pharmacists are not going to go againstwhat the doctor indicates. in our pharmacy, we have sucha good relationship with the local gps, we would be able to call themand discuss the issue.

if it was someone from out of town,the gp, then, look, i have to be honest and sayby and large we would generally dispenseas prescribed. so i guess i'm admittingto a shortcoming in our practice. we should be more diligentin communicating with the doctors. now, margaret, you're going to cometo antibiotic stewardship in a moment which is about hospital situation. should there be more antibioticstewardship in the community? i mean, i really think...

norman: it's only gonna bethe pharmacist who does it. that's right. i really think thatwe do need to be thinking about that. i mean, we've really beenconcentrating on antimicrobial stewardship in hospitals but there obviously are opportunitiesout there in the community for antimicrobial stewardship as well. you got a sheet herethat you give out to people from the pharmaceutical society. that's right. the pharmaceutical societyproduces this leaflet.

it's one of around about 80 - we call them factsheetson a variety of topics and this one on antibiotics specifically talks aboutantimicrobial resistance as well. so together withthe consumer medicine information, that antibiotic factsheet,the nps which we've mentioned already has a 'the common coldneeds common sense' brochure which is relevant forrespiratory tract infections and i think this kind of informationis really important

to increase community awareness of what is obviouslya significant problem. i've got a question coming from marisain far north queensland asking, 'how would you manage cystitisin a post-menopausal woman?' i would take a urine collection,i would... if she's referring to recurrentcystitis, that's another question. we'll come to recurrent cystitisin a moment. i would usually prescribetrimethoprim for three days after a urine collection with a phonecall in two and a half to three days.

recurrent cystitis in any woman? recurrent cystitisneeds a different approach. there are methodsof trying to assist that - oestrogen creams can be effective. the use of... i'm not againstthe use of cranberry but we are talking about probably... and what about pre-menopausal womenwith recurrent cystitis? often, i would use... i'd give... if it's recurrent,i would look for a cause of course

and do a urinary tract ultrasound looking for any structural abnormality. also, advice regarding intercourseis important and there is sometimes a needwith recurrent utis to give a post-coitalone-dose trimethoprim and that is very effective. right, hospitals, julie asks - this isjulie thompson, a pharmacist in sydney - 'hospitals seem to be makingstrong gains towards judicious use of antimicrobials.

what lobbying is occurring for pbslimits on supply quantities for antimicrobials to become relevantto modern thinking?' i mean, trimethoprimwould be a good example. you get seven tablets in a packet.margaret, you have...? i don't know of any lobbyingthat's occurring at all... norman: any changes there?- no. let's go to our next case study who is diana who's 64. suffers from chronicobstructive pulmonary disease

and has recurrent symptoms, productivecough for three months of the year. her coughs recently worsenedwith coloured sputum. shortness of breath after exertion and she still smokes. gary? gary: yeah, there'sa number of issues here, isn't there? but considering the topicwe're discussing, i would be obviously wanting, because it's an infective exacerbationof copd, to be getting an infection under controlquick smart

to prevent further complications. in this case, i would again useamoxicillin 500 tds for a week as per the guidelines. i can understand whywe as gps have pressure, we have pharmaceutical pressureto use moxiclav, we have 15 to 20% beta-lactamaseproduced in h influenzaes if that's a particular bug here, so we do have this pressure,we want this patient to improve but we have got to stickwith the evidence

and obviously in this patient,there's a number of other... and how long would you waitto see an improvement before you started wonderingwhether the amoxicillin was resistant? i'd like to review in about three days. - three days?- yeah. norman: as quickly as that?- sputum cultures here can be useful. but unfortunatelythere's such colonisation that they're not always reliable if that's causing the organism too.

let's quickly go throughsome questions here. bruce, general practitioner, asks, at james cook university,during his mph, it was said that a mixed antibioticssuch as a moxiclav or co-trimoxazoleis preferable to monotherapy to pick up the outridersand decrease resistance. what are your thoughts, tom? i think you should always gofor the narrowest. i think that antibiotic creedis correct

and there's multiple organisms but you don't always have to coverall of them and, again, this situation, for example, we're particularly interestedin treating pneumococcal infection and if you don't coverhaemophilus or moraxella in the first one or two daysuntil you get your susceptibilities, the patient's not gonna sufferto any great degree. i think we should stick tonarrow spectrum wherever possible. norman: but amoxicillin'snot that narrow.

i mean, all clavulanic acid adds isa bit of anti beta-lactamase, isn't it? well, it has much broadergram-negative coverage, it covers staphylococci,it is a broader antibiotic. amoxicillin is much narrowercompared to that. gabrielle from greater southernhealth service wants to know, are there general messageswe can give about criteria for changing from iv antibiotics to oralin rural hospitals, margaret? yes, there are criteria. the... and i guess probably the bestplace to look for those would be

in the antimicrobial stewardshipfor australian hospitals book. there's certainly good informationin there and also in the therapeutic guidelines there's information about switching,yes. greg, a pharmacist asks,of new south wales, what proportional resistanceis due to poor hygiene, do we...? it's really spread thatwe're talking about with poor hygiene - rather than resistance, isn't it?tom: yes, i believe so. so the pressure comes from antibiotics,poor hygiene allows it to go nuts.

yeah, the infection to spread,that's right, yeah. bella in queensland asks, 'should it be mandatory for gps to prescribeto the therapeutic guidelines?' if it's the evidence, it's the evidence. (chuckles) it's a dual one, isn't it? we certainly,because we have this right to prescribe, the responsibilityto prescribe appropriately, we may find as this problem continues

that we findwe're under regulatory processes to have authority prescribing, here we are in an era where that'strying to be improved with streamlining. i don't know the answerto that question. it probably would be much wiser if gpshad to use therapeutic guidelines in their prescribing. it's a general, knowledgeable book but we face in general practice quite particular circumstances sometimes

where we feel we have to be giventhat autonomy to make a clinical decision. marilyn,what are the everyday strategies we should be using for prevention, youknow, for infection control in general? in general?well, i think we can't go past starting with good hand hygienepractices. so, good hand hygiene, you know,before you eat or before you prepare food, after going to the toilet,

at home, remembering to do things likeafter changing baby's nappies, before preparing children's food. also too, things like rememberingto teach children good hand hygiene practices as well. there's also other issuessuch as good cough etiquette. so for example,remembering to cover your face or to use tissues and dispose of tissuesappropriately when they've been used. so just, you know, really good basiceveryday hand hygiene and good hygiene thatwe're actually taught as children

that sometimes i thinkwe forget about doing. and the balance between spread via touchversus droplets? - so you've coughed into your...marilyn: hand? - ..paper hankie.-and then if you... if you don't clean your handsafterwards, then of course you can transfer them. so there's good, sort of,other ways of coughing such as coughing under your armrather than into your hands. - but also to...norman: isn't that gonna make you vomit?

- sorry.- no. (laughs) no, but coughing away so thatyou don't cough in your hand especially when you're outand you can't clean your hands. john: the elbow's...norman: that's right. the guys use the green sleevebut obviously it's the axilla... no, this is coughing. and also too, i think that, you know,during flu season, you know, not to stand in front ofpeople if they're coughing and sneezing and to stand away from them.

and if you're managing a facility, - it's punctilious cleaning?marilyn: absolutely. so, again, you know,good hygiene practices so making sure that the staffin the facility use good hand hygiene, that they knowwhen they should be using it, that you have alcoholic rub appropriately placed at point of care so that healthcare workers don't haveto walk away from the patients to be able to clean their hands.

so there are lots of waysthat we can try to encourage healthcare workers to cleantheir hands at appropriate times. and there are various resourcesthat we've got on the rural health education foundationwebsite such as there's ten modules for basic principles of infection control management, there are infection control guidelines from the commission and also the aussie implementation guide

and toolkit which will all beon our website. what's antibiotic stewardship? margaret: antibiotic stewardship is an effort that's made by healthcare institutions such as hospitals to optimise the use of antibiotics, so it's really about the appropriate selection of antibiotics,

it's the appropriate dose of antibiotics, it's the appropriate duration of antibiotics and this is really to improve patient outcomes, ensure cost-effective therapy and to reduce any adverse outcomes and that obviously includesside effects from the medicines

but also the development of resistance. so it's a concerted effort. right, give me how... people watching this programare often running rural hospitals, often small facilities, few beds,with a small ed but they don't want to get resistancerunning in their hospital. and from what we've heard tonight,they could very quickly. margaret: mmm. so what happens with goodantibiotics stewardship in practice?

with good antibiotic stewardshipin practice, we use guidelines to guide prescribing and we have a range of strategies around restricting antibiotic usage and requiring approval for usage. we have peopleauditing people's prescribing or just reviewing people's prescribing and providing feedback when thatprescribing's not appropriate and that involves obviouslysome consultation

with infectious diseases physicians particularly aroundthe approval systems and requiring approval frominfectious diseases to prescribe, how to be monitoring therapy and actually seeing what is usedin a hospital and acting on that, providing feedback to the prescribers when we've monitored the therapy so that they can actually see, are they prescribing wellor not prescribing well?

so, measurement, feedbackand for certain antibiotics you might identify control mechanism which isyou're not allowed to prescribe it unless you answer a few questions. that's right. and also what we havein the mind me is about having the susceptibilitytesting done for the anti... and what's the evidence, tom,that antimicrobial stewardship makes a difference to resistance? there is enough data coming outthat it does make a difference

and you can reverse the trends. you can't quite eradicate them but you can control things and it's been shown internationally. i think one of the great benefits of the program, the antimicrobial stewardship, is taking the issue out of individual doctors' hands

to publicise good prescribing but it's said this is actually an issue for the whole hospital that the administration has to take on, it's a quality issue and somebody in the hospital has to drive it and support it. i think it's very important, otherwiseyou're just putting out small bushfires but never succeeding.

so, margaret, if you've inspired peopleto take up antibiotic stewardship in their local hospital,wherever they live in australia, and the one they have some control over, what should they do?where can they go to find out how? the commission has a publication on antimicrobial stewardshipin hospitals in australia and a copy has been sentto all hospitals in australia so they should actually have one there. might be sittingon the general manager's desk.

norman: but we'll havea link to it on... we have a link on our website as well so you can download it from the website. look, thank you all very much indeed.it's been fascinating. what are your take-home messagesfor those watching, tom? yeah, my take-home messagei think would be that we should go from antibiotics as something that you use just in caseyou could have an infection to somethingthat you have to justify to use

and not use unlessyou can actually justify to yourself you got an infection. i might just ask two quick questions.i know we're running over but there's two really good questionsthat have come in. frank, a canberra gp, has experienceda patient very unwell, it's an elderly woman withsuspected urosepsis or diverticulitis who received triple therapyon an empirical basis. is this practice overusedand does it promote resistance? people use ampicillin and gentamicinflagyl sometimes

in gastrointestinal infections. norman: and is that indicated? it's ok for 24 hours... it brings a different issue. gentamicinis something that we want to use for 24, 48 hours onlybecause of its toxicity. so by that time, we want to reviewif it's really appropriate. again, it depends on the circumstance. i think that's a difficult question'cause i'm not quite sure... quickly for gary, sandra asks -of new south wales -

what's the recommended treatmentfor boils? the ideal treatmentis surgical incision, drainage, assuming that there's no surroundingcellulitis lymphangitis or lymphadenopathyin the child or the adult... norman: so no antibiotics?- no antibiotics. and nathalie,a pharmacist from victoria, asks, 'what role do probiotics playin antibiotic use?' i can't think of many situationswhere probiotics have been shown to be of great benefit.i'm trying to think of any...

norman: preventing antibiotic diarrhoea? there's a little bit of evidencebut not much. not much. and they don't preventclostridium difficile? no, there isn't good data for it. gary, what are your take-home messages? antibiotics is the only medicinethat we prescribe that affects other people as well asthe person who we prescribe it for and we need to get back to fundamentalsof qualities of medicine -

appropriate prescribing,efficacious prescribing and the only way to prescribean antibiotic efficaciously is to try and restrict and restrainour prescribing and we need to remember safety,and risk versus benefits. and mine carries on from gary's in that. we really need to act now if we'reto preserve the miracle of antibiotics for our grandchildren and beyond. norman: marilyn? well, you can't tell by looking at hands

whether or not you've gotmulti-resistant organisms on them or not so clean them anyway. norman: paranoid.(all chuckle) i guess, norman, my message would befor community practitioners whether they're doctorsand/or pharmacists to collaborate and community nurses as well. and that applies to particularlyrural hospitals where there wouldn't be a pharmaciston-site but it's often a community pharmacistin the area

and they can utilisethat pharmacist's expertise in antibiotics stewardship. i must ask the last question here 'cause there's really good questionscoming in at the last minute here. any comments about this fashionto add antimicrobials to handwash solutions and soaps? this comes from kathy, a generalpractitioner, i'm not sure where. john: i think it's counter-productive,isn't it? margaret: yeah, absolutely.

norman: it's like chlorhexidinepresumably or... you don't need it for ordinaryday-to-day handwashing, soap is good enough. norman: is it?- yes. but in a hospital settingwhere we're trying to prevent the spread of staphfrom patient to patient where we're transferring it,adding alcoholic... so when you get to the bathroom andyou wash your hands with soap and water, you remove enough of the bacteriato make a difference?

you're not going around spreading things but in a hospital setting,it's a slightly different scenario especially as a healthcare worker. right, i hope you've enjoyed the program on antibiotic-resistantinfection control. thank you to the australian government department of health and ageingfor making the program possible and thanks to our panel members forcontributing their time and expertise. thanks also to youfor watching and participating.

if you'd like to obtain moreinformation about the issues raised, there are a number of resourcesavailable on the rural healtheducation foundation's website - rhef.com.au. don't forget to completeand send in your evaluation forms to register for cpd points.i'm norman swan, i'll see you next time. closed captions by csi funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�