Expanding horizons

Two guest speakers attended the GRIP advisory board to provide case studies from different countries and highlight their local challenges and the impact antibiotic resistance has in their contexts. Learning from these presentations allows GRIP to ensure materials and initiatives are suitable at a global level and can be adapted appropriately to address specific challenges at a local level.

Turkey

In Turkey, GPs are under significant pressure due to a shortage of consultant clinicians and a large patient load (1 physician for every 3,000 patients).

Antibiotics have had restricted reimbursement since 2003 in order to reduce overall spending, promote rational use and preserve antibiotics for the future. Antibiotics can be requested from the pharmacy without prescription and the average number of prescriptions is increasing in Turkey. Overall, one third of prescriptions are antibiotics and 14% of reimbursed medicines are for antibiotics; amoxicillin with clavulanic acid is most frequently prescribed. The majority of antibiotics are prescribed for URTIs (pharyngitis 16%, bronchitis 12.5%, sinusitis 11%, tonsillitis 11%). This differs from other countries, such as the Netherlands, where antibiotic use for RTIs is comparable with antibiotic use for urinary tract infections (UTIs). One reason for high antibiotic usage is that many parents believe antibiotics will prevent complications—a belief held by 58% of parents in one study.9 Unnecessary antibiotic prescription is another contributing factor. A study showed 74% of patients treated for acute tonsillo-pharyngitis, in Turkey, received unnecessary antibiotics.¹⁰

“Overall, one third of prescriptions are antibiotics” - Prof. Dr Tülek

High prescription rates for antibiotics are found in GP practices, with paediatricians and specialists following close behind. The defined daily dose (DDD) per 1,000 inhabitants per day is 42 for antibiotics in Turkey with an outpatient prescription rate of 36%, meaning that of all patients who consult the doctor, 36% are prescribed an antibiotic. Reasons for such high antibiotic use include a lack of education in patients, ingrained prescribing behaviours, limited consultation times and patient pressure. Common misperceptions surrounding antibiotics in the patient population are that antibiotics also kill viruses, more rapidly cure URTIs and prevent URTI-associated complications. Prof. Dr Tülek said GPs believe they are doing the best for their patients by preventing a possible secondary (bacterial) infection.

Prof. Altiner noted that in Germany, Turkish patients actively share concerns regarding complications and make requests to their GP for antibiotics. This highlights how important it is to consider cultural differences when treating patients who do not share local beliefs and values.

“Education for HCPs should include a range of cultural and country-specific beliefs and actions” - Prof. Dr Tülek

Current initiatives in Turkey include establishing an online presence, brochures, leaflets and activities to coincide with European Antibiotic Awareness Day. The general message states: “If you have flu or a common cold, protect yourself— do not take antibiotics.” An Antibiotic Resistance Study Group, part of The Turkish Society of Clinical Microbiology and Infectious Diseases, is also working at developing local guidelines for Turkey.

“Antibiotics are not antipyretics or analgesics” - Prof. Dr Tülek

Thailand

In Thailand, since 2000, antibiotics have been the most frequently sold medicines, and of the highest monetary value. The latest annual reports from the Food and Drug Administration for Thailand (2007) show that antibiotics contribute to 25–50% of total medicine use, with one quarter of diseases treated with antibiotics. Additionally, increasing numbers of patients are having longer hospital stays due to antibiotic resistance and harder-to-treat infections. Resistance is a huge problem and leads to 30,000 deaths per year.

In Thailand, patients purchase 73% of medicines themselves, even though there is a free advice and treatment service available through the Universal Coverage Scheme (UCS).

This is a government-funded scheme covering 74% of the population not enrolled on other schemes. Patients must register with a contracting unit (CUP) and care covers inpatient care, outpatient care, most curative services and preventive care. The Thai national drug policy for 2011–2016 focuses on medicine accessibility and achieving Rational Use of Medicines (RUM), particularly pertinent for antibiotics.

Antibiotic Smart Use (ASU)—a scheme primarily driven by hospitals, supported by the WHO—has been introduced in 2007, and has already demonstrated a reduction in antibiotic use with similar patient satisfaction in those not receiving a prescription for antibiotics.11 ASU tries to remove common misperceptions such as ‘infections don’t get better without antibiotics’ and pharmacies dispensing antibiotics believing that they have an anti-inflammatory effect.

Pharmacies are divided into grade I, with an in-house pharmacist, and grade II, without a pharmacist. However, due to the lack of pharmacists nationally only 30% of the 12,000 grade I pharmacies have pharmacists working in them. New regulations stipulate that for every new grade I pharmacy that opens, a working pharmacist must be employed, with a drive to make existing pharmacies grade I over the next 5–10 years.

Private clinics and metropolitan clinics are under pressure to cure disease/offer premium treatments, as patients will pay a premium for enhanced care. However, when the patient has recurring symptoms they are likely to bypass private clinics and ask the pharmacist for medications they have used previously, often expensive antibiotics.

The Good Pharmacy Practice (GPP) guidelines are strictly enforced in Thailand. Training and accreditation in GPP also allows pharmacies to join the national health security office and benefit from paid incentive programmes.

Simple counter-top aids such as educational stands with mirrors that allow patients to assess their own sore throat symptoms (throat redness, presence of pus, etc.), and training flipbooks for pharmacist use with patients are available. These aim to urge patients to try and distinguish between bacterial and viral infections. The group commented on the similarity between the physical findings in the two presentations. Ms Nitsingkarin agreed with this and maintained this is the first step for patients; to understand antibiotics are not needed all the time. Local government has also tried to limit the sale of antibiotic lozenges to pharmacy as this was contributing to antibiotic resistance and redefine the word ‘antibiotic’ due to the incorrect association between antibiotic and anti-inflammatory action.

“The first step in educating patients is to help them understand antibiotics are not needed all the time” - Ms Nitsingkarin