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New Zealand is awash with antibiotics. Each year, per head of population, we swallow more antibiotic syrups and pills,
and smear more antibiotic creams on our skin, than people in most similar developed countries. A recent study of antimicrobial
prescribing in Te Tairawhiti found that during a one year period, more than 50% of the population received at least one
prescription for an antibiotic.1 In 2012, across the whole of New Zealand, there were approximately 180 antibiotic
prescriptions dispensed for every 100 children aged less than five years. In adults aged 25–29 years (the age group with
the lowest level of antibiotic prescribing) there were more than 60 antibiotic prescriptions dispensed per 100 people.2 In
New Zealand, in every year since 2006, at least one person in 20 has been dispensed a tube of either Bactroban® or Fucidin®
antibiotic ointment.3 These levels of community antibiotic consumption greatly exceed those in the Netherlands,
Sweden or Germany, and are slightly higher than those in Spain. Of the large European countries only Italy, France, Belgium
and Greece have higher levels of antibiotic consumption than New Zealand.2 Unfortunately, not enough attention
has been focused on the excessive prescribing of antibiotics in New Zealand, and on developing strategies to reduce this
The high level of antibiotic consumption in New Zealand will inevitably have a long-term environmental impact. The situation
can be likened to other problems arising from excessive consumption, such as global warming secondary to excessive energy
consumption, waterway pollution secondary to excessive deposition of nitrogenous fertilisers on farmland and depletion
of marine fish reserves through overfishing. The common resource that we are depleting through our excessive antibiotic
use is the ecosystem of antibiotic susceptible microbes that previously colonised our mouths, intestines and skin.
Each episode of antibiotic use may (or may not) hasten the resolution of the illness for which it was prescribed, but
also will inevitably exert a selective pressure on the countless organisms colonising the patient. This selective pressure
favours the survival and proliferation of antibiotic resistant microbes in the patient’s mouth, intestines and skin, and
these resistant organisms also colonise their close contacts. The change in the microbes colonising the patient, and their
family, commonly persists for months to years. Because a high proportion of common infections arise from colonising microbes,
infections that occur in the months after an antibiotic course are very likely to be due to antibiotic resistant bacteria.
For example, the risk that a respiratory tract infection is due to an antibiotic resistant strain of Streptococcus
pneumoniae remains elevated for at least six months following brief treatment with a macrolide antibiotic. Similarly
the risk that a urinary tract infection is due to an antibiotic resistant strain of Escherichia coli remains
elevated for up to twelve months following brief treatment with trimethoprim or amoxicillin.4
Most antibiotic consumption occurs in the community, and approximately 50–80% is for patients with self-limiting respiratory
tract infections. The lack of evidence for a significant patient benefit from antibiotics in patients with self-limiting
respiratory tract infections led the National Institute for Health and Care Excellence (NICE) in the United Kingdom to
advise in 2008, that an antibiotic should not be prescribed for the overwhelming majority of patients with acute otitis
media, a common cold, acute rhinosinusitis or acute cough/bronchitis.5 Despite this advice, which is echoed
by a variety of other similar advisory panels, surveys of general practitioners in New Zealand, Australia, the United
Kingdom and elsewhere, indicate that a very high proportion of patients with these infections are unnecessarily prescribed
Doctors have a long history of prescribing medicines that turn out not to have been in the best interests of their patients:
barbiturates, benzodiazepines and opiate analgesics are some well-recognised historic and recent examples.9 Doctors
commonly place the blame for such harmful prescribing on their patients – the patients “demand” the treatment and the
doctors feel compelled to comply with these “demands”. However, doctors have a much better understanding than their patients
about the potential harms that may arise from unnecessary antibiotic prescribing and therefore are responsible to lead
the changes in antibiotic consumption that our society needs. As with other harmful drugs, doctors need to have the strength
to “just say no”.10
We also need to lift our game in terms of our decisions about which antibiotics are sensible choices for the treatment
of common infections. We all know that when a range of medicines are likely to be effective in treating a bacterial infection
we should generally select the most narrow spectrum agent, but in practice this does not always occur. The reasons commonly
given for selection of unnecessarily broad spectrum agents, e.g. convenience of dosing regimens, palatability of antibiotic
syrups, need to be reconsidered in the light of the contribution that broad spectrum antibiotics make to encouraging the
spread of antibiotic resistant bacteria.
Below are three simple changes in practice that all prescribers could, and should, consider:
- Do not prescribe an antibiotic for patients with a sore throat who are not of Māori or Pacific ethnicity and not
aged between 5 and 18 years
- Do not prescribe amoxicillin clavulanate for skin infections caused by Streptococcus pyogenes or Staphylococcus
aureus, but instead prescribe penicillin V or flucloxacillin
- Do not prescribe ciprofloxacin or norfloxacin for patients with urinary tract infections, unless the infection
has failed to respond to a more narrow spectrum agent such as nitrofurantoin or trimethoprim
It is not going to be easy to change our own established practices, and also our patients’ expectations, but present
and future generations will not look kindly on us if we continue to squander the utility of antibiotics and leave them
with markedly fewer options for treating infections in the coming decades.
- Norris P, Horsburgh S, Keown S, et al. Too much and too little? Prevalence and extent of antibiotic use in a New
Zealand region. J Antimicrob Chemother 2011;66:1921-6.
- Thomas MG, Smith AJ, Tilyard M. Rising antimicrobial resistance: a strong reason to reduce antimicrobial consumption
in New Zealand. NZ Med J 2014;127:1394:72-84.
- Williamson DA, Monecke S, Heffernan H, et al. High usage of topical fusidic acid and rapid clonal expansion of
fusidic acid-resistant Staphylococcus aureus: a cautionary tale. Clin Infect Dis 2014;59: 1451-4.
- Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance
in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- NICE Short Clinical Guidelines Technical Team. Respiratory tract infections – antibiotic prescribing. Prescribing
of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. London:
National Institute for Health and clinical Excellence, 2008.
- McGregor A, Dovey S, Tilyard M. Antibiotic use in upper respiratory tract infections in New Zealand. Family Practice
- Biezen R, Pollack AJ, Harrison C, et al. Respiratory tract infections among children younger than 5 years: current
management in Australian general practice. Med J Australia 2015;202:262-5.
- Currie CJ, Berni E, Jenkins-Jones S, et al. Antibiotic treatment failure in four common infections in UK primary
care 1991-2012: longitudinal analysis. BMJ 2014;349:g5493.
- bpacnz . Oxycodone: how did we get here and how do we fix it? Best Practice Journal 2014;(62).
- Thomas MG, Arroll B. “Just say no” – reducing the use of antibiotics for colds, bronchitis and sinusitis. NZ Med