Evolving clinical practice to curb antimicrobial resistance
Date published:
01 May 2025
The growing global problem of antimicrobial resistance (AMR) is accelerated by the inappropriate use (overuse, underuse, and misuse) of antimicrobials in humans and animals.
AMR occurs when bacteria develop mechanisms to resist the effectiveness of antibiotics, diminishing the utility of these medicines.
With 21.8 million antimicrobials dispensed in the community in 2022, Australia is one of the highest antibiotic prescribing countries in the developed world. Approximately 35 per cent of these were considered unnecessary.
Each year, 5,200 Australians die of antimicrobial resistance-related causes. By some appraisals, this number is projected to double by 2050.
Professor Joseph Doyle, President of the Australasian Society for Infectious Diseases, says that AMR significantly increases disease complexity and spread, making infections increasingly difficult to treat.
“Antimicrobial resistance represents a major challenge to global health systems and society,” Professor Doyle says.
“The number of critical antimicrobial resistances increased by 85 per cent from 2022 to 2023, making mitigation efforts vital.”
Steps are being taken to slow the development of AMR. These include clear governance for AMR initiatives, increased surveillance of AMR and antimicrobial usage, and strong collaborative research across sectors. New diagnostics and point-of-care technologies are also crucial in the fight against AMR.
However, the development and implementation of these advancements require time.
Fortunately, there are immediate measures that can begin to make an impact now, which can reduce the unncessary prescribing of antimicrobials which contributes to AMR.
" Australia is at a critical inflection point when it comes to antimicrobial resistance. Healthcare providers can use the RACP’s Evolve Top-Five recommendations to improve the value and efficiency of their care and to curb the development of AMR."
RACP President Professor Jennifer Martin
The Evolve initiative
Evolve is a flagship initiative led by the Royal Australasian College of Physicians (RACP) along with its partners in the healthcare sector, physicians, and paediatricians. It aims to reduce low-value care in physician practice, thereby enhancing patient care and optimising resource utilisation.
Through the Evolve initiative, the RACP partners with affiliated specialty health organisations to identify their ‘top five clinical practice recommendations’ to reduce low-value care.
Evolve asks members of speciality organisations if they consider a test, treatment, or procedure to be:
- overused, of little or no benefit, or with a potential to cause unnecessary harm?
- undertaken mainly by the specialty?
- undertaken with noticeable frequency in the specialty or the health system?
The analysis of these responses helps identify the most common areas for improvement and informs the practice recommendations for addressing these issues.
RACP President, Professor Jennifer Martin, says that Evolve is designed to help healthcare providers and patients start important conversations to improve the quality of healthcare.
“Evolve enables healthcare workers to become more active stewards in the care they provide,” says Professor Martin.
“The recommendations aim to make a difference to the safety and quality of patient care by asking specialists to step back and think about broader context of their practice.”
Evolve recommendations for infectious disease
In the infectious disease context, the Australasian Society for Infectious Diseases (ASID), whose membership encompasses infectious diseases physicians, clinical microbiologists, scientists, public health physicians, academics, policymakers, and others eminent in the field of infectious diseases, has determined their Evolve Top-Five recommendations to reduce inappropriate prescribing and promote high-value medical care through the uptake of prescribing practices.
“Adopting high-value care practices, including those championed by the Evolve initiative, are crucial to reducing unnecessary antibiotic use and slowing the development of antimicrobial resistance,” says Professor Doyle.
A core tenet of Evolve is that health care workers practice active stewardship and open communication with patients to improve the quality of healthcare.
Clinical practice recommendations in action
Asymptomatic bacteriuria
In Australia, the use of antibiotics in asymptomatic bacteriuria is of special relevance. This condition involves the presence of bacteria without clinical signs of urinary tract infection.
Asymptomatic bacteriuria was the ninth-most common indication for antimicrobial prescriptions in people in aged care homes between 2016 and 2019. Its impact is expected to increase as Australia’s population ages.
The very first recommendation on ASID’s Top-Five Evolve states that physicians (and other medical prescribers) should ‘not use antibiotics in asymptomatic bacteriuria’. This is because research has shown that treating it with antibiotics does not reduce the chance of developing a symptomatic UTI. While antibiotics eradicated the growth of bacteria in a proportion of participants, it also led to more adverse events than in participants not receiving treatment.
Additionally, treatment of an asymptomatic infection with antibiotics can increase the chance of developing an antimicrobial resistant infection.
URTIs
In their third recommendation, ASID addresses the need for a potential change in the prescribing of antibiotics for upper respiratory tract infections (URTIs), often associated with colds.
In 2020 and 2021, respectively, 64,676 and 70,165 cases of URTI were prescribed antimicrobials, yet most colds are caused by viruses, which do not respond to antibiotics, and antibiotics can cause adverse side effects, such as diarrhoea.
As such, ASID Evolve recommendation three states that physicians should:
Avoid prescribing antibiotics for upper respiratory tract infections (with the exception of sore throat in populations at high risk for complication of group A strep infection, such as acute rheumatic fever or post-streptococcal glomerulonephritis).
Additionally, oral antibiotic therapy of presumed URTIs in young infants with a fever is not only deemed low-value, but can be actively dangerous in delaying presentation to hospital. This is a major issue for paediatric primary care and ED presentations.
Continuing to evolve
With 27 sets of Top-Five recommendations already finalised, the Evolve initiative continues to pursue better care for patients.
Most recently, the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT), in collaboration with RACP, released their own Top-Five Evolve recommendations. This list focuses on promoting the appropriate use of medicines that offer high-value care and can help to prevent the unnecessary prescribing of antimicrobials.
Evolve recently released ASCEPT’s Top-Five recommendation on low-value practices for pharmacology and toxicology. These recommendations are associated with proper medicines prescribing and management practices.
Professor Martin says that Australia is at a critical inflection point when it comes to AMR, and highlights the importance of taking action.
“Healthcare providers can use the RACP’s Evolve Top-Five recommendations to improve the value and efficiency of their care, reduce unnecessary prescriptions, and to curb the development of AMR,” says Professor Martin.
This article first appeared on AMR Action + Insights. It was written by RACP Policy and Advocacy Officer, Christian White and RACP Program Implementation Lead, Stephanie Wrightman