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AN elderly family friend recently complained to me about a doctor mate of hers. Struck down by a bad cold, she’d asked him for an antibiotic prescription during a visit and was furious at his refusal.
Her narrative about what had happened was clear.
She was suffering. He could have helped her. He said no. He was not a good friend.
I tried to convince her that the antibiotics wouldn’t have helped, but she wasn’t having it.
It’s not always easy for doctors to say no to a request for antibiotics — even when they’re not dealing with a friend — but the consequences of our overuse of these precious drugs are becoming ever more obvious.
The WHO describes increasing antimicrobial resistance as “a problem so serious that it threatens the achievements of modern medicine”.
“A post-antibiotic era — in which common infections and minor injuries can kill — far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century”, its 2014 global report on antimicrobial resistance says.
Acute respiratory infections (ARIs), like the one my friend contracted, are at the heart of this story.
Anybody who’s had a dose of “flu” knows how debilitating the symptoms can be, and how refractory to treatment. Little wonder so many of us head to the doctor, desperate for something — anything — that will make us feel better and help us get back to work.
Professor Chris Del Mar of Bond University has been a long-time campaigner for reduced prescribing of antibiotics in primary care, particularly for ARIs where there is so little evidence of benefit.
In an article published earlier this year, he and colleagues cited figures showing antibiotics were prescribed for acute bronchitis in around 70% of cases in the US and Australia despite, as they put it, “evidence suggesting that the antibiotic prescribing rate for this should be near 0”.
A large study in the US veteran population, published last week, showed antibiotic prescribing rates for ARIs were actually increasing despite efforts to restrain them (up from 68% in 2005 to 69% in 2012).
In that population, 85% of patients with bronchitis received an antibiotic prescription.
Perhaps even more concerning was an apparent shift from narrow-spectrum to broad-spectrum antibiotics, given the lack of additional benefit provided by the broad-spectrum drugs in these conditions and possible increased risks of resistance and side effects.
The study found broad-spectrum macrolides accounted for 37% of antibiotic prescriptions in this population in 2005, rising to 47% by 2012.
Also last week, an editorial in Pediatrics said young children in the US received on average more than one antibiotic prescription each year, most of them for broad-spectrum drugs and 25% of them for conditions in which the drugs were unlikely to be effective.
In Australia, antibiotic use in ARIs fell towards the end of last century following a number of studies showing their lack of effectiveness, according to the RACGP.
But prescribing rates have since plateaued well above the level seen in some other countries, especially in northern Europe. It’s possible we need to look to the Netherlands for solutions.
If ever there was a multifactorial problem, this is it. The temptation to write a “just in case” prescription is fuelled by patient expectations, lack of other effective treatments, the diagnostic uncertainty surrounding some of these conditions, and an unfounded belief that antibiotics can’t do any harm.
The decision to prescribe antibiotics doesn’t take place in an abstract, philosophical space but in a private encounter between doctor and patient where, as the Pediatrics editorial puts it, “the perspectives of individuals, families and physicians often take precedence over potential future risks of resistance for society at large”.
Fundamentally, what we’re talking about here is the “tragedy of the commons”, a term coined by ecologist Garrett Hardin back in the 1960s.
When individual humans act in their own interest while sharing a common resource — whether it’s antibiotics or fish stocks — the result is disastrous for all.
Jane McCredie is a Sydney-based science and medicine writer.
Yet again we should be asking what is the result of such advice. First I cannot remember any flu patients requiring hospitalisation except for myocarditis. After seeing the rooms full of rheumatic fever patients in the Children’s Outpatients I was determined to do the best I could in the use of short and long term antibiotics. The result was that in my 40 years of general practice I had not one case of new rheumatic fever also my last case of bacterial meningitis was a 12 year old in 1972. I noticed a writer has stated the erythromycin was no use since 1968. When I challenged a pathologist who made a similar statement I asked how many throat swabs they were doing and how many respiratory infections were treated satisfactorily by erythromycin. Ilosone was excellent for under 8 yrs. I remember a pathologist in New York stated that the only way to get satisfactory cultures in tonsillitis was by collection with a syringe and needle. Normal throat swabs are useless.
Why are so many people getting pneumonia? This brings back memories of a time I was unable to practice for some months and I found patients who required careful and early intervention were being looked after by a colleague who rarely gave antibiotics were developing pneumonia frequently.
What to do? First learn from the patients history who are more susceptible to secondary infections and need antibiotics. Secondly as found in and article in the New England Journal children with recurrent tonsillitis between the age of 3 and 8 do better with tonsillectomy. As has been found time after time early antibiotic use is the best treatment for bacterial meningitis so what is the worse position some “overuse” of antibiotics or the increasing number of disasters.
Be careful.
Indeed, all shoulders to the wheel are needed, including vetinary practitioners, animal lot feeders and the totally unregulated developing countries where massive antibiotic overuse/abuse occurs and where second and even third line anibiotics are freely available OTC thanks to ‘market forces’.
A couple of straight forward questions for someone to answer for me please:
How do we, as a democratic country with signed UN Conventions by the dozen on our books, plan to stop the phenoenon of mass international travel to and from Austalia (both legal and otherwise) that has already and will continue into the future to seed our local microbiota with overseas generated MDR organisms?
Where is the researched and charted breakdown (by genetic mapping) of the sources of these MDR organisms that Australia is now dealng with so that a more objective discussion can ocur in the blogarsphere?
I’m getting a sense of Chaos Theory at work here!
This is an issue of managing patient expectations. They may not know the difference between viral and bacterial infection, or be familiar with the emerging and serious threat of multidrug resistant bacteria.
One initiative that appears to have been successful is the posting of a notice in the doctor’s waiting room decribing that antibiotic prescribing for ARI will be guideline concordant. This encouraged the more rational and parsimonious prescribing of antibiotics. (Meeker D et al. Nudging guideline concordant antibiotic prescribing. JAMA Intern Med 2014;174:425 -)