7.1 ANTIBIOTIC PRESCRIBING SURVEILLANCE
For any antibiotic stewardship activities to succeed, continued prescribing surveillance in the outpatient setting is critical. To-date no coordinated electronic system exists in Maltese pri- mary care to collect electronic prescribing data but also to provide prescribers with access to electronic prescribing guidelines. This also means that there is little accountability for antibi- otic prescribing. Furthermore, without such a necessary resource, it is near impossible to un- derstand antibiotic prescription patterns in the community, monitor trends and evaluate inter- ventions.62 Audit and feedback with peer comparison specifically, has the potential of im- proving GPs’ prescribing habits and is recommended. Furthermore, research on prescriber concordance to guidelines is necessary and will not be possible without much needed surveil- lance data. To this end, a more comprehensive antibiotic prescribing surveillance system is critically needed in Malta.
7.2 NATIONAL ANTIBIOTIC GUIDELINES
So far, it appears that national antibiotic guidelines have not been widely accessible, partly due to GPs’ lack of awareness of their availability. This suggests that updated national guide- lines must be better disseminated among GPs in both the private and public sectors and their availability be more widely known. Making guidelines available on mobile applications could make them easier to carry around and potentially increase their usability, however this re- quires further investigation. Furthermore, guidelines should include other diagnostic criteria that pose dilemmas to GPs, such as what to prescribe to patients with specific antibiotic sensi- tivities, preferences, co-morbidities or to smokers. When it comes to DAP recommendations, guidelines should better promote DAP through diagnosis-specific suggestions that take the natural progression of illness into account.
7.3 DELAYED ANTIBIOTIC PRESCRIBING
Given the potential that DAP has to reduce antibiotic use for RTIs, formal and standardised implementation of DAP could aid curb antibiotic overuse and help the general public under- stand that antibiotics are not always necessary for RTIs. Prescription pads specifically de- signed for post-dated antibiotics could help serve this purpose. However, this must be cou- pled with structured patient advice and widespread dissemination of information about the purpose and benefits of this strategy among not just doctors, but patients and pharmacists too. Furthermore, since DAP has a potential influence on patient satisfaction, further investigation on patients’ views on delayed antibiotic prescribing and how their expectations can be met is recommended.
7.4 RAPID POINT-OF-CARE TESTING
Introducing rapid POCTs could positively impact antibiotic prescribing if utilised correctly. With the right implementation strategy that ensures that barriers such as cost and time are addressed, the introduction of low-cost, rapid POCTs could prove valuable to support GPs’ prescribing decisions in this context, more so since diagnostic uncertainty was considered a problem.
7.5 CONTINUING MEDICAL EDUCATION
Educating prescribers is important to overcome antibiotic misuse.104 Currently however, con- tinuing medical education, even on antibiotics, are often sponsored by the pharmaceutical industry in Malta; a serious conflict of interest.62 Therefore unbiased, regular educational activities are needed to promote appropriate and evidence-informed antibiotic prescription practices. Although GPs with many years of experience could benefit more from continuing medical education, all GPs should be given the opportunity to participate in educational activ- ities that help raise GPs’ awareness on appropriate prescribing by indication and patient group. Educational activities should specifically target the over-prescription of broad- spectrum antibiotics and provide GPs with the latest antibiotic prescribing recommendations according to national antibiotic guidelines. GPs could also benefit from communication train- ing to facilitate decision-making and empower doctors to decline antibiotic requests. This can be combined with the introduction of educational tools for patients that can be used during consultations and help support GPs in patient education. Developing targeted sessions, tai- lored toward the specific needs of a particular GP demographic, may prove even more bene- ficial.
7.6 ACADEMIC DETAILING
Several GPs appreciated the interaction they had with drug reps and found them informative, particularly those working in solo practices that got little opportunity to interact with other healthcare professionals. However, such information is likely to be biased as drug reps are motivated to boost sales. Similar to strategies used in drug repping, in academic detailing, doctors receive one-to-one educational visits by a trained healthcare professional in their own professional setting.219 This method, is successful at reducing antibiotic prescription rates whilst improving guideline-concordance.220,221 It provides GPs with an opportunity to reflect upon their own prescription practices and get informed about the latest recommendations for appropriate antibiotic treatment.188 With enough resources, this strategy has great potential in this setting. It can be used as a means of disseminating up-to-date local antibiotic prescribing guidelines as well as data on antibiotic resistance rates in the community. It could also pro- vide a platform for GPs to discuss specific guideline recommendations with a trained profes- sional, particularly for those diagnoses where the benefits of an antibiotic prescription are limited (e.g. uncomplicated acute bronchitis and rhinosinusitis). This form of outreach is therefore likely to have great impact in this setting which is why academic detailing by relia- ble, unbiased, medical professionals is highly recommended and should be piloted to assess its effectiveness.
7.7 REVISION OF SICK LEAVE POLICIES
Currently, sick leave certification provided by a medical doctor is required from the first day of illness if one intends to claim social security benefits after the third day of illness.222 This encourages early consultations, particularly with GPs, since they are usually the patient’s first point of contact for an acute illness. Revision of this sick leave policy could help reduce un- necessary and early antibiotic prescription.
7.8 GENERAL PUBLIC KNOWLEDGE, AWARENESS AND BEHAVIOUR
More research is needed to not only better understand patients’ views on antibiotics and their appropriate use, but also how they perceive various strategies to limit antibiotic use and use them more appropriately. Further investigating their attitudes towards delayed antibiotic pre- scribing and rapid POCTs in particular, could help support our findings and better inform their successful implementation and integration into clinical practice in Malta.
Additionally, since the general public’s knowledge and awareness on correct antibiotic use remains sub-optimal, it must be improved. People need to understand the difference between viral and bacterial infections, the natural course of various infections and that viral infections do not require antibiotic treatment. They must also be encouraged to engage in self-care for simple ailments such as the common cold before visiting a doctor, in order to discourage ear- ly consultation. Nationwide campaigns that harness the power of social media could prove effective, with appropriate key messages delivered in an easy and comprehensible manner.
7.9 PHARMACIST INVOLVEMENT
To-date little is known about pharmacists’ views on their role in halting the development of antibiotic resistance in Malta which calls for further research in this area. Pharmacists are a key stakeholder, not only as dispensers of antibiotics but also educational vessels to patients and close collaborators with GPs. Their involvement in this dynamic cannot be overlooked.