Community-Based Prescribing for Impetigo in Remote Australia: An Opportunity for Antimicrobial Stewardship

Abstract

BackgroundTo support antibiotic prescribing for both hospital and community-based health professionals working in remote North Western Australia, a multidisciplinary Antimicrobial Stewardship (AMS) Committee was established in 2013. This Committee is usually focused on hospital-based prescribing. A troubling increase in sulfamethoxazole/trimethoprim resistance in Staphylococcus aureus antibiograms from 9 to 18% over 1 year prompted a shift in gaze to community prescribing.What we didFinding a paucity of relevant research, we first investigated contextual factors influencing local prescribing. We also designed a systematic survey of experts with experience relevant to our setting using a structured response survey (12 questions) to better understand specific AMS risks. Using these findings, recommendations were formulated for the AMS Committee.What we learnedPrescribing recommendations in a regional Skin Infections Protocol had previously been altered in December 2014. From 15 experts, we received 9 comprehensive responses (60%) about AMS risks in community prescribing. If feasible, prescribing audits also would have been valuable. Ten recommendations regarding specific antibiotic recommendations were submitted to the AMS Committee.Strengthening AMS in remote settingsAs AMS Committees in Australia usually focus on hospital-based prescribing, novel methods such as external expert opinion could inform deliberations about community-based prescribing. Our approach meant that this AMS Committee was able to intervene in the 2017 organizational review of the regional Skin Infections Protocol used by prescribers likely unaware of AMS risks. This experience demonstrates the value of incorporating AMS principles in community-based prescribing in context of a remote setting.

High burden of infectious disease and antibiotic use in early life in Australian Aboriginal communities

“…36 While limited information was available regarding the specific antibiotics prescribed in our study, further evaluation of the appropriateness of prescribing in remote communities is needed to guide stewardship interventions relevant to this setting. 37 Ultimately, reductions in antibiotic use will only occur with reductions in the prevalence of infections, highlighting the importance of engaging with Aboriginal communities to better understand the social determinants underlying the infectious diseases burden.…”

Investigation of trimethoprim/sulfamethoxazole resistance in an emerging sequence type 5 methicillin-resistant Staphylococcus aureus clone reveals discrepant resistance reporting

“…Recent trials have demonstrated noninferiority of SXT compared to intramuscular benzathine benzylpenicillin [1] or oral clindamycin [2] for treatment of uncomplicated skin and soft tissue infections such as impetigo [1], cellulitis and simple abscesses [2]. Concern over the increasing rates of community-acquired S. aureus isolates reported as SXT resistant has resulted in recommendations against prescribing SXT for the treatment of skin and soft tissue infections in the Kimberley region of Western Australia [3].…”

Intolerable Burden of Impetigo in Endemic Settings: A Review of the Current State of Play and Future Directions for Alternative Treatments

“…The use of oral and injectable antibiotics for uncomplicated impetigo alter systemic levels of host-protective bacteria, and they are also associated with adverse effects (particularly gastrointestinal) [ 40 , 66 ]. In the long run, given the rapid emergence of community-associated methicillin-resistant S. aureus (CA-MRSA) in remote areas [ 67 , 68 ], exhausting currently available systemic antibiotics for the treatment of diseases, such as impetigo, can have serious ramifications [ 40 , 66 , 69 ]. Based on a seven-year descriptive study conducted in New South Wales [ 70 ], 33.4% of Aboriginal children were found to have skin infections with CA-MRSA, indicating that CA-MRSA is a significant public health problem in these settings.…”