Reflections on community antimicrobial use in Australia

Australia has one of the highest rates of community antimicrobial use in the world, even when compared with countries with similar healthcare systems and disease profiles, such as England, Canada and the Netherlands.¹

The Australian Commission on Safety and Quality in Health Care (the Commission) monitors antimicrobial usage and resistance trends over time, to inform what actions are needed in the healthcare system to prevent the rise of antimicrobial resistance. To do this, the Commission established the Antimicrobial Use and Resistance in Australia (AURA) surveillance program, which collates data from a range of sources on the magnitude, distribution and impact of antimicrobial resistance and antimicrobial use. Antimicrobial prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) are used to monitor community antimicrobial use. The data primarily relate to systemic antibacterials; of note, dispensing data for antivirals are not included in the analyses. The first national AURA report was released in June 2016 and subsequent reports have been released in 2017, 2019, 2021 and 2023.^2-6

In 2024, the Commission published a report reviewing trends in community antimicrobial use.¹ Encouragingly, PBS and RPBS data have shown a continuation of the downward trend in community antimicrobial use that commenced in 2015 (Figure 1).¹ In particular, the COVID-19 pandemic had a major impact on community antimicrobial use in Australia. It resulted in a 25% reduction in antimicrobial use from 2019 to 2021. The most commonly prescribed systemic antibacterials during that period were cefalexin, amoxicillin, amoxicillin+clavulanate and doxycycline, and the largest declines were observed for amoxicillin+clavulanate (38%) and amoxicillin (33%).

There are several factors that are likely to have influenced the reduction in antimicrobial use during the COVID-19 pandemic, including restrictions on social interaction and changes in personal infection prevention and control practices, which resulted in fewer people getting viral respiratory infections and seeking treatment. Restrictions on prescribing repeats for commonly used antibacterials on the PBS and RPBS (e.g. amoxicillin, cefalexin, doxycycline) were also introduced during this time.⁷ Given antivirals are not captured in these data, the decline in antimicrobial use suggests how often systemic antibacterials have been prescribed for viral respiratory infections in Australia.

Within the context of the decline in community antimicrobial use, systemic antibacterial use has increased for residents of aged-care homes and older Australians (aged 65 years and older), according to PBS and RPBS data. For residents of aged-care homes, there was an 11% increase in the number of dispensed systemic antibacterials from 2022 to 2023, and 69.7% of residents (n=135,904) had at least one systemic antibacterial dispensed in 2023.¹ It is well documented that residents of aged-care homes are more susceptible to infections for a variety of reasons (e.g. advanced age, multiple comorbidities, poor functional status, compromised immune status). Despite this, there is still a concerningly high volume of systemic antibacterial use (2.5% of systemic antibacterials dispensed under the PBS and RPBS in 2023) and rate of dispensing per person (2.76 systemic antibacterials per resident compared with 1.34 per person in the community in 2023).^1,8

While there has been a rebound in antimicrobial use in the community over the last 3 years – up by nearly 10% from 2021 to 2022 and by 1.3% from 2022 to 2023 – the number of antimicrobials dispensed was still 17% lower in 2022 than in 2019 and 24.4% lower than in 2015. Even though the rebound is likely due to a post-pandemic increase in viral infections, the overall decline in antimicrobial use is promising, with further considerable effort required to lower levels of antimicrobial use in the community long term. The immediate priority of the Commission is to address the level of use and upward trend for residents of aged-care homes and older Australians. It is also important to re-evaluate the current listing for antibacterials on the PBS, to ensure that restrictions for access are aligned with the risk of the development of antimicrobial resistance associated with their use.

Combined strategies of antimicrobial stewardship, and infection prevention and control, are most effective in reducing antimicrobial use to address antimicrobial resistance. While these combined strategies are well developed in hospital settings, their development in community settings is at an early stage. Examples of resources to support community practices include Infection Prevention and Control Guidelines developed by The Royal Australian College of General Practitioners and the Commission’s e-learning modules on antimicrobial prescribing. The Commission has also published guidance for a range of primary care settings on meeting the antimicrobial stewardship requirements of the National Safety and Quality Primary and Community Healthcare Standards. This includes promoting access to evidence-based guidelines (e.g. Therapeutic Guidelines) to support appropriate antimicrobial prescribing in the community.

The 2024 Commission report on community antimicrobial use includes PBS and RPBS data at a regional and Primary Health Network level.¹ Once the MedicineInsight program is re-established, these data will also be included in analyses of community antimicrobial use. The MedicineInsight program will allow general practitioners (GPs) to reflect on their patterns of prescribing and how these compare with other GPs in their practice, and at local, regional and national levels.

Patient education is also vital to addressing inappropriate antimicrobial use. The Commission has produced a range of tools to help clinicians and patients share decision-making about antimicrobials for common conditions. Patient resources are also available to reinforce messaging about the role of antimicrobials in antimicrobial resistance and their effects on the microbiome, and to promote understanding of how infections spread and infection prevention and control practices in the community (e.g. respiratory hygiene and cough etiquette, staying home when unwell, getting vaccinated). The CSIRO has also recently launched an AMR Action and Insights website to assist with educating clinicians and the community about this important issue.

As the AURA program reaches almost a decade of data collection, there are opportunities to enhance surveillance of the volume and appropriateness of antimicrobial use. A particular focus will be on addressing important gaps in surveillance, such as antimicrobials dispensed outside the PBS and RPBS (estimated to be more than 5% of prescriptions dispensed in the community),⁶ nonprescription antimicrobials (e.g. over-the-counter topical antimicrobials), and prescriptions by community pharmacists and other nonmedical prescribers.

Despite the decline in antimicrobial use in recent years, community dispensing rates in Australia are still substantially higher than model countries such as the Netherlands and those in Scandinavia;⁶ however, the downward trend provides optimism that lower levels of antimicrobial use in Australia are achievable in the long term. As the link between reduced antimicrobial usage and lower antimicrobial resistance takes some years to manifest, ongoing surveillance of resistance is essential.

Conflicts of interest: the authors are employees of the Australian Commission on Safety and Quality in Health Care, which is funded by the Australian Government Department of Health and Aged Care.

 

References

1. Australian Commission on Safety and Quality in Health Care. Antimicrobial use in the community: 2023. Sydney: ACSQHC; 2024. [cited 2024 Oct 4]
2. Australian Commission on Safety and Quality in Health Care. AURA 2016: first Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2016. [cited 2024 Oct 4]
3. Australian Commission on Safety and Quality in Health Care. AURA 2017: second Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2017. [cited 2024 Oct 4]
4. Australian Commission on Safety and Quality in Health Care. AURA 2019: third Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2019. [cited 2024 Oct 4]
5. Australian Commission on Safety and Quality in Health Care. AURA 2021: fourth Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2021. [cited 2024 Oct 4]
6. Australian Commission on Safety and Quality in Health Care. AURA 2023: fifth Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2023. [cited 2024 Oct 4]
7. Department of Health and Aged Care. Revised PBS listings for Antibiotic use. Canberra; 2020. [cited 2024 Oct 4]
8. Royal Melbourne Hospital and the National Centre for Antimicrobial Stewardship. Infections and antimicrobial prescribing in Australian residential aged care facilities. Results of the 2022 Aged Care National Antimicrobial Prescribing Survey. Canberra: Department of Health and Aged Care; 2024. [cited 2024 Oct 4]