In 2011, the Ministry of Health (MOH) mandated the implementation of antimicrobial stewardship programmes (ASPs) across public acute hospitals.² This spurred the creation of the National Strategic Action Plan (NSAP) on Antimicrobial Resistance in 2017, a collaborative effort involving four government agencies adopting a One Health approach.³

The Plan provides a framework to strengthen and enhance activities to combat AMR, addresses identified gaps and prioritises future interventions. It builds on many years of work to combat AMR in Singapore, and unifies existing initiatives mounted across the human, animal, food, and environment sectors. The Plan aims to reduce the emergence and prevent the spread of drug-resistant organisms through five core strategies:

However, progress in primary care has been limited due to ongoing challenges, including outdated antimicrobial guidelines since 2006, the absence of an outpatient ASP, and focus on controlling the COVID-19 pandemic.^2,4 These issues, compounded by public misconception, contribute to the prevalent problem of over-prescription and inappropriate antimicrobial use in primary care.^5,6

Concentrating efforts on addressing AMR in primary care not only has the potential to improve immediate outcomes, but also positively impact the broader systemic healthcare. Recognising the imperative for change and the pivotal role of primary care, AMR and infectious diseases have emerged as key research pillars within the Division of Family Medicine. This commitment is underscored by the collaboration with National University Polyclinics (NUP), solidifying our role as a partner institution in the MOH National Medical Research Council (NMRC) Centre Grant for Collaborative Solutions Targeting Antimicrobial Resistance Threats in Health Systems (CoSTAR-HS).

Birth of the study

The research team swiftly identified a pressing need in the national effort to enhance community AMR—update the existing knowledge and evidence related to antibiotic use in treating common infections in primary care. The team’s inaugural paper, titled “Prescribing Antibiotics in Public Primary Care Clinics in Singapore: A Retrospective Cohort Study,”⁷ published in Antibiotics (MDPI) in April 2023, detailed antimicrobial usage trends and indications.

This study pinpointed key areas for intervention, highlighting skin and soft tissue, urinary, and respiratory tract infections as the top three most common conditions requiring antibiotics in primary care. This spurred us into examining urinary tract infections (UTIs), where a previous study had found higher resistance rates of urinary Enterobacteriaceae isolates (the most common genus causing UTIs) towards ciprofloxacin and co-trimoxazole, compared with co-amoxiclav and nitrofurantoin.⁸ In-vitro microbiological resistance does not reliably predict clinical outcome and successful infection resolution.⁹

We hypothesised that prescribing empirical antibiotics with higher resistance rates will lead to incomplete bacterial eradication, resulting in an increased risk of treatment failure (persistent symptoms with re-presentation or hospitalisation due to complications). Therefore, we proceeded to compare empirical treatment using co-amoxiclav or nitrofurantoin with ciprofloxacin or co-trimoxazole, for uncomplicated UTIs. The outcome for this study was treatment failure, which was defined as re-attendance for symptoms and antibiotic re-prescription, or hospital emergency department (ED) visits or admissions for UTI complications. To acquire linked health records data, we collaborated with our National University Health System (NUHS) partners and specialist experts, such as Professor Paul Anantharajah Tambyah, Infectious Disease, National University Hospital (NUH), Dr Pradeep Durai, Urology, Ng Teng Fong General Hospital (NTFGH), and Dr Louisa Sun, Infectious Disease, Alexandra Hospital (AH).

Benefit to patients

Patients stand to gain several benefits from this study. This study directly informs physicians to prescribe antibiotics which are less susceptible to antimicrobial resistance. It also provides patients with knowledge and empowers them to participate in shared decision-making with their physicians, fostering a collaborative approach to healthcare. This directly benefits the patients as they will have reduced risk of complications and recurrent symptoms, reduced costs as they do not need to return for review and repeat prescription, or attend hospitals for failed treatments.

Members of MOH ACE UTI guidelines workgroup as part of the experts panel at the symposium.

Benefit to community

A noteworthy impact within the community is this study’s direct contribution to the knowledge necessary for MOH Agency of Care Effectiveness (ACE) to develop and release its ACE Clinical Guidance (ACG) titled “Urinary Tract Infections — Appropriate Diagnosis and Antibiotic Use for Uncomplicated Cystitis and Pyelonephritis” in November 2023. The study affirms local urinary bacteria resistance patterns compared to previous antibiograms constructed in 2015, thus revitalising outdated antimicrobial guidelines and providing primary care physicians with updated directives. This not only offers a renewed sense of direction for physicians but also fosters anticipation for forthcoming guidelines from authorities. Moreover, the community benefits from a proactive approach to combatting AMR, contributing to the overall well-being of individuals. The appropriate and complete eradication of bacteria and resolution of infection also play a pivotal role in reducing AMR, extending the usability of antibiotics for the entire population. This, in turn, leads to improvements in cost savings and overall patient and ecological health. Additionally, this approach aligns with broader efforts to preserve the effectiveness of antibiotics, ensuring that patients receive targeted and appropriate treatments tailored to their specific health conditions.