Questions and Answers for Health
Practitioners
1. Why was the review undertaken?
- Rising rates of antimicrobial resistance have evolved into a
significant public health concern. The morbidity, mortality and
financial costs of multiple drug resistant infections for which there
are few or no effective therapies pose an increasing burden for health
care systems.
- The purpose of this review was to assess the increasing threat of
antimicrobial resistance and, as part of a broader strategy, to ensure
that all antibiotics listed in the Ontario Drug Benefit
Formulary/Comparative Drug Index are being used appropriately in
accordance with current clinical evidence.
2. What are the
key resistance concerns?
- In Canada, concerns have focused primarily on resistance to common
causes of community-acquired infectious diseases and selected
hospital-acquired infections.
- The most important strains of resistant bacteria are
penicillin-resistant Streptococcus pneumoniae (PRSP),
methicillin-resistant Staphylococccus aureus (MRSA), and
vancomycin-resistant enterococci (VRE).
3. Was this a
cost-containment issue?
- No. While cost-effective drug therapy is one of the priorities of
the Ontario Ministry of Health and Long-Term Care, this review was
undertaken primarily to address rising concerns about the increasing
threat of antimicrobial resistance.
4. What are the key
changes? Why?
- Ciprofloxacin, levofloxacin and ofloxacin will now be listed as
Limited Use products; nor-floxacin will remain a General Benefit because
the review showed that the product is generally being used
appropriately. There was particular concern about increasing rates of
resistance to
- the quinolones and the spread of cross-resistance from older to
newer quinolones.
- Three agents - clarithromycin, azithromycin and
amoxicillin/clavulanic acid will remain as General Benefit products on a
conditional basis; their respective usage and resistance patterns will
be reassessed in one year's time.
5. Why are you making it
harder for me to prescribe some specific antibiotics?
- The listings for ciprofloxacin, levofloxacin and ofloxacin have been
revised in order to ensure the most appropriate use of these agents and
to limit the spread of resistance.
- The Limited Use Criteria outlined for each of the fluoroquinolones
are in keeping with current clinical evidence.
6. The Limited
Use system is a burden. Why doesn't the Ministry simplify it?
- As part of the Ministry's ongoing process to simplify the Limited
Use process, a new Limited Use prescription form was introduced on July
1, 1999. The new prescription form has been stream-lined and simplified
to make it easier to complete.
- A Limited Use tripartite committee of the Ontario Medical
Association, the Ontario Pharmacists' Association and the Ministry of
Health and Long-Term Care meets regularly to discuss ways to improve the
Limited Use process.
- A drug utilisation review on the use of anti-infectives has been
commissioned by the ministry. This will assist in determining future
courses of action.
7. Do you have any tips for discussing the
role of antibiotics with my patients?
- Yes, the Ministry has created a pamphlet for patients explaining the
role of antibiotics and antibiotic resistance.
- Prescription pads are available explaining why antibiotics have not
been prescribed. For example, the Canadian Committee on Antibiotic
Resistance (CCAR) and The Canadian Infectious Disease Society (CIDS)
have produced a template that is available on the internet at : www.infectnet.com/Contents/Antibiotics/Ant_Links_Pro/ant_links_pro.htm
- Other patient information is available on the CCAR web site : www.ccar-ccra.org.
8. What impact can I, as an individual doctor, have?
- Every physician has a part to play to ensure that antibiotics are
used judiciously with a goal tolimiting the spread of antimicrobial
resistance.
- Since general practitioners prescribe approximately 75% of all
antibiotics in Canada, the combined effect of each physician acting
locally can have a significant impact on this important provincial,
national and global public health problem.
9. What are other
provinces and jurisdictions doing?
- Other provinces (e.g. Saskatchewan, Manitoba, Nova Scotia and Prince
Edward Island) have also restricted the use of the quinolone antibiotics
for similar reasons as those given by the Ministry of Health and
Long-Term Care.
- A number of national and international programs have been
established around the world to track antibiotic usage and antimicrobial
resistance, and to disseminate educational materials. Please see
Appendix B of the attached DQTC Bulletin for more details.
10. Is any action being taken on the use of antibiotics in
veterinary medicine?
- Health Canada and individual provinces, including Ontario, have
initiated a number of activities to address this area of concern.
Information about what is being done in Ontario can be found at the
following web site : www.gov.on.ca/OMAFRA
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