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We can beat superbugs with better stewardship of antibiotics

Antibiotic resistant bacteria are becoming a major problem. Calls to action on increasing rates of resistance have been made by the World Health Organization, the US Centers for Disease Control (CDC…

Only by prescribing antibiotics smarter instead of broader will we keep superbugs at bay. lamentables/Flickr

Antibiotic resistant bacteria are becoming a major problem. Calls to action on increasing rates of resistance have been made by the World Health Organization, the US Centers for Disease Control (CDC), and by the Australian Societies for Infectious Diseases (ASID) and the Australian Society for Antimicrobials (ASA).

And the media regularly features articles about superbugs and mega-superbugs. So why, if everyone is aware of the problem, are we still not winning the fight?

Drivers of resistance

Antibiotic resistance is caused by excessive antibiotic use. If bacteria aren’t exposed to antibiotics, there’s no impetus for them to become resistant. But much modern medicine would be impossible without antibiotics (most surgery, for instance) so they are a necessary “evil”.

More than 80% of antibiotics are prescribed in general practice, and much of this is for upper respiratory tract infections (such as colds). These are mostly caused by viruses and almost never need antibiotics.

Patients treated with antibiotics are almost three times more likely to experience a side effect (mainly nausea), for no benefit because antibiotics won’t affect the duration of their illness. And resistance can develop even after a short course of antibiotics.

Colds are mostly caused by viruses and almost never need antibiotics Image from

Hospital patients are usually sicker than patients who visit a GP. Sometimes, they’re very sick and need urgent treatment. In severe infections, the time delay until antibiotics are given is a major risk for mortality.

Since antibiotic resistance is now a fact of life in hospitals around the world, it’s understandable that doctors want to give their patients the best treatment available. This can lead to “antibiotic armageddon” where the biggest, most broad-spectrum antibiotic is felt to be the best way to proceed.

Australia has excellent prescribing guidelines that are easily available for doctors to refer to when prescribing antibiotics. In practice, though, studies in Australia and elsewhere show fairly consistently that only between half and three-quarters of antibiotic prescriptions are in keeping with such guidelines.

I performed an audit of antibiotics prescribed to in-patents of a hospital I worked at. It was based on a review of their medication charts and comparison with Australian Therapeutic Guidelines. This is what I found:

  • dosing errors – 13%;

  • choice of drug different from guidelines – 11%;

  • unnecessarily prolonged treatment – 8% and;

  • antibiotics not required at all – 8%.

The three “Es”

The solution can be simplified into three “Es” – education, expectations, and enforcement.

As medicine becomes more complex, it’s increasingly difficult to teach junior doctors everything they “must know” in order to practice. Education on good prescribing habits and the importance of rational antibiotic use are critical when doctors are in the formative stage of their careers.

Doctors' expectations are also important. Not every fever requires antibiotics and broader-spectrum isn’t always better are the key messages to teach.

Although there are many campaigns aimed at the public about antibiotics for colds, around half of patients seeing a GP still expect such a prescription. And although only half expect it, 73% receive one. Those who don’t are twice as likely to present for another consultation.

There are two factors at play here – patients' expectation of a prescription and general practitioners' understanding of what patients expect. More worrying still is that doctors think that their prescribing doesn’t impact resistance.

Methicillin-resistant Staphylococcus aureus NIAID/NIH

The result is a tragedy of the commons – patients may be aware of the risks of antibiotics in general, but feel the benefit for them outweighs the risks to the community, as superbugs only happen to someone else. In fact, the opposite is true - for viral infections patients receive no benefit from antibiotics but all of the risk.

In addition to education, a well-designed antibiotic stewardship program can significantly improve antibiotic use in hospitals. As well as improving care quality, these programs can also reduce costs and decrease length of stay in hospital and the rates of hospital-acquired infection.

Although doctors often bristle at restrictions on their practice, acceptance of these programs is surprisingly high.

Antibiotic resistance is currently seen as a clinical problem for doctors and hospitals, rather than a more general health issue. The key to overcoming it is reframing resistance as a problem of public health importance and getting the public more engaged, as has been done with hand washing. Rather than patients asking for a prescription, we need them to ask “do I really need antibiotics for this?”

Superbugs are complex and pose a serious health threat. Only by working together, and prescribing smarter instead of broader, will we keep them at bay.

This is the third article in Superbugs vs Antibiotics, a series examining the rise of antibiotic-resistant superbugs. Click on the links below to read the other instalments.

Part one: Washing our hands of responsibility for hospital infections

Part two: Superbugs, human ecology and the threat from within

Part four: The hunt is on for superbugs in Australian animals

Part five: The last stand: the strongest of the superbugs and their antibiotic nemesis

Part six: Unblocking the pipeline for new antibiotics against superbugs

Part seven: A peek at a world with useless antibiotics and superbugs

Part eight: Trading chemistry for ecology with poo transplants

Part nine: New antibiotics: what’s in the pipeline?

Join the conversation

21 Comments sorted by

  1. Stiofán Mac Suibhne

    Contrarian / Epistemologist

    This article adds little to the debate on poor compliance with prescribing guidelines by medical practitioners or the pull factor of patients clamouring for antibioitics. In terms of emerging resistance the agricultural use of antibiotics must be off significance.

    I have never seen a comparison between resistance problems in countries where the supply to patients is mainly medically controlled such as in Australia or where they can be purchased at the pharmacy without a script as is common in Spain.

    1. Ken Harvey

      Adjunct Associate Professor, School of Public Health and Preventive Medicine at Monash University

      In reply to Stiofán Mac Suibhne

      The following references are relevant:

      Food Animals and Antimicrobials: Impacts on Human Health.

      Self-medication with antibiotics in Europe: a case for action.

      Relative impact of clinical evidence and over-the-counter prescribing on topical antibiotic use for acute infective conjunctivitis,

      Cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (Over The Counter) in Surabaya, Indonesia.

      The sale of antibiotics without prescription in pharmacies in Catalonia, Spain.

      Availability of antibiotics for purchase without a prescription on the internet.

    2. Reema Rattan

      Editor at The Conversation

      In reply to Stiofán Mac Suibhne

      Good point, Stiofan. The next article in this series covers agricultural use of antibiotics and will be published at 11 am.

  2. Graeme Harris


    Firstly you, and to my understanding no one has drawn a causality link between inappropriate antibiotic prescribing in General Practice and the general population.
    To my understanding and experience antibiotic resistance has developed in hospitals with in many cases heroic and unnecessary surgery. Frail elderly people are subjected to major surgery with multiple bits placed in the body. It is these foreign pieces in people with diminished immune system activity that breed the antibiotic resistance that you are outlining.
    The second 800 kg gorilla in the room that no one talks about is the widespread agricultural use of antibiotics as growth promoters. This has been shown to be a major reserve of antibiotic resistance.

    1. Michael Macdonald


      In reply to Graeme Harris

      You just have to look Graeme.

      Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.

      Chung A, Perera R, Brueggemann AB, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007;335:429

  3. Ian Clarke

    Director, Pacific Strategy Partners

    The good old price mechanism has an important role to play here. As antibiotics become less effective, the most effective ones should be most expensive at the point of use so they are kept in reserve.

    We could also consider providing GPs with a placebo to prescribe to help avoid use when no they is no clinical benefit.

  4. Jan Golembiewski

    Researcher in Environmental Determinants of Mental Health at University of Sydney

    Other commentators seem to have a point- I'm no expert in this field, but when I was last in Berkeley , I met a PhD student in the School of Public Health, who was studying superbugs (sorry, I can't recall his name). He said that human antibiotic usage is like ducking under the table when a Nuclear bomb goes off relative to the abuse that goes on in the livestock industry.

    Farmers in many countries - including the USA, don't need prescriptions to feed their livestock antibiotics, and it is widespread practice to mix antibiotics into feed to fatten the stock quickly. This practice is completely unregulated, and the researcher I spoke with believes this practice creates a haven for superbugs to evolve.

    1. Scott Parkes

      Physician, Specialist in Intensive Care

      In reply to Jan Golembiewski

      I don't think we can rely on that. In my field (intensive and critical care) we regularly breed our own "superbugs". The "tragedy of the commons" metaphor is particularly apt for us; too narrow a spectrum can result in treatment failure of infection in a critically ill patient with avoidable death as a consequence. Consequently ICUs use very broad spectrum antibiotics, and unsurprisingly are the hospital's breeding ground for antibiotic resistance. This pattern would not be expected if agricultural use was the main driver of antibiotic resistance by orders of magnitude. Instead, we see a consistant relationship between antibiotic use in a closed medical environments (a hospital and its sub-units) and antibiotic resistance. All of us who work in health care need to take responsibility for this.

    2. Karsten Mohr

      Cat Herder

      In reply to Jan Golembiewski

      One just has to look at the aqua culture industry. The use of anti biotics in the UK/Chile on Atlantic Salmon has created issues with the wild Salmon. When they used lots (tonnes in 1 year) ABs in Tasmania's Salmon industry they could detect ABs in the local native fish population.

  5. Trent Yarwood

    Infectious Diseases Physician, Associate Lecturer at University of Queensland

    Thanks all for all the comments already.

    Peter Collignon has already discussed agricultural antibiotic use on TC recently ( so I didn't cover them in this article.

    @Ian Clarke: each treatment is an interaction between bug and drug and patient; there is no "most effective" antibiotic that would easily fit into this system you describe. Also, drugs are already a major part of the health budget and increasing costs would mean…

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  6. Steven Rudolphy

    GP & Part Time Senior Lecturer in General Practice (Cairns Campus) at James Cook University

    Prescribing antibiotics always seems black and white to the academics. It is just is a sea of grey to me in general practice. GPs apply alot of common sense to their decision making generally.

    Our practice is on the 25th percentile for antibiotic prescribing (figures sent to us via NPS and PBS /Medicare prescribing data) .

    New registrars are zealously low antibiotic prescribers until a few pneumonias and hospital admissions happen on patients they saw just a couple of days ago. Experienced doctors have gone from 50th percentile to 25th after arriving at our practice.

    How do we define the happy medium? Academics please apply your expertise.

    The study you want is to take 2 high precribing practices have one apply strict evidence based guidelines one as control and see if there is a rise in complication rates. If there is, is it worth the reduction in antibiotic use. Try getting that one past an ethics committee.

    1. Steven Rudolphy

      GP & Part Time Senior Lecturer in General Practice (Cairns Campus) at James Cook University

      In reply to Steven Rudolphy

      Thanks, the article's conclusion is "The aim of this review was to weigh the complex
      balance between risk and harm and to begin to quantify
      both sides of the equation" . Still needs doing in primary care prospectively.

    2. Sue Ieraci

      Public hospital clinician

      In reply to Steven Rudolphy

      You are right, Steven Rudolphy - one of the factors to balance here is risk aversion - both amongst providers and patients.

      So long as there are Coronial inquiries into cases of missed meningitis in children, there will be tighter calls for giving antibiotics when there is doubt. A recent example has resulted in the proposal to routinely give antibiotics to all children with fever of greater than 38.5oC. We all know that the vast majority of these infections will be viral but who wants to be held accountable for the infectious death of a child?

      And yet, we also know that inappropriate antibiotic use should be minimised. Any guidelines for antibiotic use in our community should take account of real world practice and concerns - not just post hoc identification of organisms, but pre hoc clinical problems.

    3. Trent Yarwood

      Infectious Diseases Physician, Associate Lecturer at University of Queensland

      In reply to Steven Rudolphy


      Part of the problem with antibiotics is that people are cognitively biased towards remembering their undertreatment-related adverse events, rather than the flipside.

      Everyone has a nanna or two that ended up in hospital as you describe. How many people do you have with severe, life-threatening adverse drug reactions to antibiotics they didn't need? I have a few, and I've also caused my share of anaphylaxis (touch wood).

      Also, antibiotic resistance is a slow burn on a population scale. You'll never be able to point to a single prescription that caused resistance, but it is a relentless creeping doom.

      This is why my argument is for a population health approach; clinicians will always (mostly appropriately) take an individual-patient first view.

    4. Sue Ieraci

      Public hospital clinician

      In reply to Steven Rudolphy

      A reply to Trent Yarwood about taking a population-based approach: that will only work if the motivating factors for prescribing are addressed.

      Of course prescribers are more worried about missing something life-threatening than the long-term effects of each prescription. There are understandable reasons why this is so - not the least of which is the public holding-to-account for cases like the death of a child from - say - missed meningitis.

      How would you encourage GPs at the coalface to take a population-based approach to antibiotics prescribing while working in our risk-averse culture?

  7. Rex Gibbs


    I design and build waste water treatment plants. We use bacteria to break down the waste. I use intermittent processes not steady state processes and a fundamental part of the design is to maximise selective pressures to breed bacteria that do what we want. My Eureka moment that changed the whole way we do this was watching a Catalyst program about 15 years ago on how MDR organisms were selected and the impact of conjugation as a means of genetic information transfer. We now use techniques doctors…

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  10. Philippa Binns

    Clinical Adviser at NPS MedicineWise, public health physician and GP

    The challenge of antimicrobial resistance provides a strong argument for One Health initiatives and the establishment the Antimicrobial Resistance Standing Committee (reporting to the Australian Health Protection Principal Committee) is a promising move towards bringing the key players in animal and human health together in the fight against antibiotic resistance.

    Trent’s article addresses some of the broad public health challenges posed by antimicrobial resistance and highlights the success…

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  11. Comment removed by moderator.