This CRE was funded in 2012 by an NHMRC grant APP1044904 for 5 years with $2.5. Its purpose is to provide research into the potentially reversible factors that give rise to antibiotic resistance from antibiotic prescribing for acute respiratory infections.

Chief Investigators:

Prof Chris del Mar, Bond University
Prof Paul Glasziou, Bond University
Prof John Lowe, University of the Sunshine Coast
Prof Mieke van Driel, Univeristy of Queensland
Prof Tammy Hoffmann, Bond University
Assoc Prof David Looke, Princess Alexandra Hospital
Assoc Prof Elaine Beller, Bond University

Synopsis

Antibiotic resistance is an international threat to health causing avoidable deaths and harm, and a substantial health resource waste. The Centre for Research Excellence (CRE) in Minimising Antibiotic Resistance for Acute Respiratory Infections focuses on minimising antibiotic resistance by addressing its two major contributors: antibiotic overuse, particularly in acute respiratory infections when antibiotics are most commonly prescribed; and the transfer of antibiotic resistance genes between people.

The CRE will support the design, evaluation and translation of urgently needed interventions; contribute to national and international policy; and build workforce capacity to handle current and emerging threats to national and international health as a result of antibiotic resistance. Knowledge generation methods will include: meta-analyses, randomised trials, meta-regression, modelling, population surveys and qualitative research. Research will occur in five main areas:

  1. Benefits and harms of antibiotics: updated reviews of benefits and new systematic reviews of harms will be done to correct the insufficient focus on harms which has distorted clinicians’ and patients’ benefits-harms judgement.
  2. Physical barriers: key elements of effective physical barrier interventions will be analysed in a meta-regression.
  3. Pharmaceutical packaging of antibiotics: we will research current packaging effects and community behaviours contributing to antibiotic resistance.
  4. Construction and validation of a causal model to determine relative contributions of each source of resistance and potential effect of each intervention. This will be informed by research in Areas 1-3 and epidemiological data.
  5. Development and evaluation of interventions to minimise antibiotic resistance: numerous innovative interventions, informed by research in Areas 1-4, and aimed at clinicians, patients, policy-makers and other key stakeholders, will be developed and evaluated.

Projects

This program tests whether the packaging of antibiotics aligns with guideline recommendations for duration and frequency of dose. We found they do not.

Changes in legislation are being contemplates by the PBAC – including restricting the expiry date of antibiotic prescriptions.

Current planning of targets for antibiotic use in Australia is hampered by any estimate of what is a reasonable use of antibiotics, and we have to rely and extrapolate on international comparisons.  This project is undertaken with Helena Britt and colleagues at the University of Sydney’s BEACH program. We will interpret the guidelines to estimate the model-practice prescription of antibiotics, and compare them with current levels.

It became clear that central to reducing antibiotic in primary care lies shared decision making (SDM). Australia falls behind many other western countries in adopting this method of introducing evidence to the consultation and sharing the decision making with the patient.

We have accordingly promoted SDM in the Australian literature (Hoffmann Med J Aust 2014;201:35-9), and through the NHMRC (Position Paper 2014).

We have undertaken a Cochrane review on SDM for antibiotic use in primary care consultations for acute respiratory infections (in press Coxeter 2015), that largely demonstrates they are effective.

Exploring the effect of prior beliefs of benefits and harms among the public find the benefits are over-estimated and the harms under-estimated (Hoffmann TC, Del Mar C. JAMA Int Med 2014;175:274-86).  A similar review is underway about clinicians’ beliefs.

Similar findings are found among those with ARIs, (Hansen BMC Fam Pract 2015;16:82.

Prior beliefs are also important with respect to resistance (McCullough  J Antimicrob Chemother2015doi:10.1093/jac/dkv164), and a similar review about public beliefs that are soon to be published.

One way of delivering SDM is using tools such as patient decision aids (PtDAs). We have been funded by the Australian Commission on Safety and Quality in Health care (ACSQHC) to develop a set of PtDAs in acute respiratory infections. This fits with the work of 2 PhDs students: Peter Coxeter is undertaking a trial of these PtDAs to test their acceptability with consumers.  Mina Bakhit will trial trial the PDAs to test their effect on antibiotic prescribing.

The ACSQHC has also provided funding to develop an educational module on SDM for several professional Colleges.

Widely used overseas, we have undertaken an update Cochrane review showing that delayed prescribing reduced antibiotic prescribing in primary care. It is a component of the GAPS study.

PhD student Lucy Sargent together with Amanda McCullough, John Lowe and Chris Del Mar are developing up a trial for Australia. This is preceded by qualitative work to assist the design of the intervention and gauge patients’ and GPs’ appetite for it.

We hypothesise that adverse effects of antibiotics are under-represented in the decision making process. This may be in part to inadequate quantification of their adverse effects.

Accordingly we undertook a systematic review of these effects in the most common antibiotic used, amoxicillin (+/- clavulanate) – used for any indication (Gillies M, Can Med Assoc J 2014 cmaj 140848). Another Cochrane study is under way being led by Malene Hansen on macrolides.

National Round Table