Health Committee on June 15th, 2017

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

My questions are for Shelita Dattani.

The overuse or misuse of antimicrobials has arisen from different causes, including over-prescribing by doctors, failure by patients to complete a course of antibiotics as prescribed, and the medical and non-medical use of antibiotics. According to Antimicrobial Stewardship Canada's brief, about 23 million antimicrobial prescriptions are written every year. The brief says that 30% to 50% of the prescriptions are not necessary. It is costing lots of money, $70 million to $80 million. It boggles my mind when I see this happening.

You said your organization has done something, like education. Have you worked with other health care providers like the CMA or the Royal College of Physicians and Surgeons of Canada? What steps have you taken to correct this unnecessary over-prescribing?

[Shelita Dattani]

Thank you very much for your question. You are right that there are a lot of unnecessary prescriptions, particularly—I always think of that 30%—in community environments where practitioners are often a little more siloed and aren't in formal microbial stewardship programs.

CPhA has taken some good leadership over the last year in increasing the awareness to its own profession, particularly in primary care, where there hasn't been a lot of education, and even more so for primary care pharmacists, regarding how they can step up.

I agree with you on the next step. To echo my colleagues, Yoshiko and others, this is a team sport, and without collaboration we can't solve this, so it's very important to have a very strong interprofessional focus on education, on practice, on prescribing, on patient education, and on all elements of antimicrobial stewardship. That's definitely something we will be looking at this coming year, starting with education.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

What steps has your organization taken to support patient compliance with respect to the use of antibiotics as prescribed?

[Shelita Dattani]

In terms of our organization specifically, as I mentioned earlier, we participate and relay the messages of campaigns, like Do Bugs Need Drugs? and Choosing Wisely to help.

As I mentioned previously, I think we all feel that patients don't have the understanding they should have about the risks and unintended consequences of antibiotics versus the benefits and the notion of them as a cure-all. As an organization, we specifically have some Choosing Wisely recommendations coming out. We also endorse recommendations from other organizations and societies that are more specific to antibiotics, and we espouse those in relaying messages to patients every day.

Part of our ongoing educational campaign and knowledge translation to members of our profession is going to be to arm them with those tools so they can use an evidence-based approach to encourage the public and patients to also be stewards. We're all stewards. Andrew is a steward. I'm a steward. Members of the public need to be stewards. This is really a public safety issue, so we need to arm them with the right information, and we're doing that.

[The Chair, Liberal, Bill Casey]

Dr. Morris, you wanted to add something?

[Dr. Andrew Morris]

I just want to point out that it's a common misconception that not completing a course of antibiotics leads to drug resistance. That's been thrown around for decades. It's not correct. It may put people at risk of relapse of their infections, but as I pointed out before, the only thing that leads to drug resistance is ongoing exposure to antibiotics. I just wanted to make that clear.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

My next question is for you.

The upfront cost here is maybe 30% to 50% of $70 million to $80 million for unnecessary prescriptions. These are prescribed, and patients take them. Are there any side effects? What kind of cost is there to society for this?

[Dr. Andrew Morris]

Sorry, who's that question directed to?

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

You can answer it and—

[Shelita Dattani]

I'll start.

In terms of costs, I think Andrew is going to be able to answer this question much more effectively than I am, but I'll give you an example.

The second most common reason for a drug-related adverse event when a patient presents to an emergency department is an antibiotic-related adverse event. The costs—and the health system costs associated with that—are significant. Unintended consequences, such as Clostridium difficile, the superinfection that can arise with overuse of antibiotics, have significant costs.

I can't necessarily put numbers to those costs. I don't have those off the top of my head. I'm sure Andrew can expand on this, but those are two examples that I'd offer you.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Dr. Morris.

[Dr. Andrew Morris]

As Shelita mentioned, a paper that came out just this week showed that one out of every five patients who receives antibiotics gets adverse effects that are directly related to the antibiotic. Those adverse effects lead to increased lengths of stay in hospitalized patients. For a patient, one extra day of hospitalization alone trumps another 10 or even 100 patients receiving antibiotics on any one day. If we're talking about one out of every five, you can just imagine what that impact is on the health care system.

Out in the community, it's much more difficult to quantify the costs associated with it. We know, for example, that about 20% of human antibiotic prescribing in the community is done by dentists. Most of those are unnecessary. Many of those result in adverse effects that are mostly mild gastrointestinal effects, but in using back-of-the-napkin math, we can figure out that there are probably dozens of deaths in Canada each year from patients receiving unnecessary antibiotics for dental procedures.

The costs are in lives.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you.

According to the World Bank—

[The Chair, Liberal, Bill Casey]

Very quickly.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Very quickly? Okay.

They are talking about trillions of dollars if we don't do anything about this microbial resistance. To what extent has your organization been engaged in the development of the federal government's pan-Canadian framework on this?

[Dr. Andrew Morris]

I chair the AMMI Canada antimicrobial stewardship and resistance committee. Over the past year, that committee has developed and disseminated tools primarily targeting long-term care facilities initially, around unnecessary antibiotics—

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

What are the critical components in the framework?

[Dr. Andrew Morris]

I'm sorry. I'm misunderstanding the question.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

What are the critical components in the framework to address this?

[Dr. Andrew Morris]

To address the costs and the threats?

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

The microbial....

[Dr. Andrew Morris]

I think the 10 action points of Canada's antimicrobial stewardship are all key. I was heavily involved. I chaired that group. It had broad consultation, research prior to that, and follow-up after that. We meet regularly. That pan-Canadian group of experts laid out very clearly 10 things that needed to be done with, I'm going to say, a relatively modest investment, in comparison to the anticipated costs if we don't act.

[The Chair, Liberal, Bill Casey]

Okay. You're done.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you.

[The Chair, Liberal, Bill Casey]

We're starting our five-minute sessions now.

Dr. Carrie, you have five minutes.