Dangerous territory

Enabling pharmacists to prescribe antibiotics for urinary tract infections (UTI) in South Australia will endanger the health of women, the AMA(SA) has warned.

In a submission to the South Australian Parliament Select Committee, the AMA(SA) notes that pharmacists are not trained to diagnose the range of conditions that might present as UTIs and pharmacies are not suitable spaces for women to discuss their symptoms.

Some women who have additional symptoms may not want to discuss them with a pharmacist and may withhold pertinent information to avoid awkward conversations. It would be usual for a doctor to ask about sexual activity and vaginal pain or discharge, questions that should be asked in private and with an understanding of what the answers mean, the AMA has explained.

AMA(SA) President Dr Michelle Atchison said interstate experiments allowing pharmacists to prescribe a range of medications were placing women’s lives at risk.

‘There is also nowhere in Australia – or anywhere else in the world – where such a move [to allow pharmacists to prescribe antibiotics] has provided evidence that an experiment like this is safe,’ she wrote.

‘Instead, there is mounting evidence that allowing pharmacists to prescribe antibiotics for UTIs, without proper screening and consideration of women’s clinical histories, risks missing indications of cancer and other serious conditions, and also pregnancies, during which medications should be considered very carefully.’

The submission to the Select Committee includes data and anecdotes collected by the AMA and others after the Queensland Government allowed pharmacists to prescribe UTI medication in an experiment in Northern Queensland.

An AMA Queensland survey of doctors in March 2022 identified at least 240 cases of women who needed further treatment, including one ectopic pregnancy, a missed cancer diagnosis and antibiotic resistance. Of the women who sought treatment for UTIs from pharmacists, 97 per cent were prescribed antibiotics, whether they needed them or not.

‘Also In Queensland, the pilot is under investigation as posing a serious threat to patient safety, with the people delivering it having a financial conflict of interest in its results,’ Dr Atchison says.

‘This is not how we trial medical programs in this country in 2022. It is certainly not the basis for expanding the pilots into different jurisdictions and for more conditions and treatments.’

While it is acknowledged that access to general practitioners is reaching crisis point – with Medicare funding failing to provide an economically feasible model for delivering services – broadening the scope of practice for those with different training is not the answer, says AMA(SA).

Patients need to be able to attend GP clinics to discuss their symptoms and medical history to make an accurate diagnosis.

Whereas the South Australian government suggests that women with frequent UTIs might benefit from being able to readily access antibiotics from pharmacies, the AMA(SA) says this risks serious problems being overlooked.

The AMA(SA) submission says the Pharmacy Guild capitalised on Queensland’s one-house parliamentary system to introduce medical reforms with questionable benefit for patients but unquestionable benefits for pharmacies.

The AMA(SA) says the law in Queensland also fails to address a fundamental conflict of interest in having the people selling the antibiotics prescribing them which is likely to result in an increase in the use of antibiotics.

This occurs at a time when medical bodies around the world, including the World Health Organization and the AMA, are describing growing resistance to antibiotics as ‘one of the biggest threats to global health and development’.

Enabling pharmacists to prescribe antibiotics without reference to a patient’s history undermines efforts to monitor and enforce compliance with best-practice approaches for appropriate and judicious antimicrobial use, as required in Australia’s ‘National Antimicrobial Resistance Strategy 2020 and Beyond’, warns the AMA(SA) submission.

While Queensland Health pointed to ‘pharmacist models of care in comparable countries’, the AMA(SA) says the ‘models’ were not comparable.

New Zealand pharmacists must have a postgraduate clinical diploma or equivalent and have several years of clinical experience in a specialised area before applying for the 12-month postgraduate course.

United Kingdom pharmacist prescribers must have a minimum standard learning time of 26 days’ worth of structured learning and a 90-hour practical. Most work in general practices.

In Canada, limited emergency prescribing and prescription extension powers in 10 of 13 provinces. One province (Alberta) allows pharmacists to apply for additional prescribing authorisation. All information must be relayed back to the patient’s doctor. If it is a new condition, the pharmacist must refer the patient to a doctor for formal diagnosis and treatment.

The submission reports the model in New Zealand does not occur in isolated community pharmacies but in an integrated model with doctors. Likewise, the United Kingdom does not permit the scope of pharmacist-prescribing permitted in the NQ Pilot. The model in Alberta lacks sufficient scientific evidence to be relied upon and incorporates far more stringent requirements for referral to a doctor and record-keeping than that included in the NQ Pilot.

At the same time, the AMA(SA) observes pharmacists are not trained to prescribe safe alternatives when the commonly prescribed antibiotics are unavailable – a common problem currently in Australia.

‘Doctors do not want to compete with pharmacies, but to work with them to ensure all South Australians can access safe and effective care,’ says Dr Atchison.