Promoting prudent antibiotic use
Once again, the European Union is today marking European Antibiotic Awareness Day. There is no doubt these initiatives have helped to focus the attention of both the public and the medical professions on the challenge of bacterial resistance to antibiotics and the need for better use of this special group of medicines and it appears the message is permeating through. Indeed, in a recent Eurobarometer study undertaken within all EU countries, Maltese respondents showed significant awareness of the problem with 94 per cent agreeing that unnecessary use of antibiotics will render them ineffective.
Despite this improved awareness, I fear many look at antibiotic resistance as a hypothetical event and are not actually aware this is a situation already posing significant challenges to our ability to treat infections. What does this mean in practice?
At best, common occurrences, such as urinary infections, would not respond to the frequently-used oral antibiotics. The patient will not get better, remain with his/her uncomfortable symptoms and would need further tests and alternative treatment to be cured. However, these same organisms are also responsible for more serious infections such as blood infections, which require urgent hospitalisation followed by rapid and effective antibiotic therapy. If these life-threatening infections are caused by a resistant microbe, there is a high risk the initial treatment would not work. However, this would not be confirmed before laboratory tests are available a few days after the patient has been admitted. By this time, it may already be too late.
Faced with this conundrum, one might advocate the routine use of new and more potent antibiotics that are effective against these resistant strains. There are two major flaws in this argument. First of all, the pipeline for new antibiotics has literally dried up and no genuinely new classes of antibiotics are envisaged to be available on the market within the next decade or so. In addition, routine use of the more potent agents (the few that remain) will only hasten the vicious circle of resistance and result in even less drugs remaining effective. Untreatable bacterial infections are again a reality in medical practice and threaten an Armageddon scenario that harks back to more than 50 years ago, when common infections were a common cause of death until Sir Alexander Fleming discovered penicillin.
Faced with such a challenge, the only solution is to ensure antibiotics are used judiciously and only when genuinely required. In this respect, there is clearly major room for improvement. The same Eurobarometer study showed that, whereas in the European Union, an average 40 per cent of people take at least an antibiotic once a year, in Malta this figure is 55 per cent.
Even more worrying is the fact that more than half of Maltese respondents said they took the antibiotic for flu, a cold or a sore throat. These three conditions are rarely caused by bacteria but, rather, by viruses, against which antibiotics are not effective. Unfortunately, the same study showed that 75 per cent of Maltese wrongly believe that antibiotics kill viruses and almost the same number thought that antibiotics are effective against cold and flu. This is clearly a situation we need to address quickly through better education.
There is, however, some good news from this study. Only four per cent of respondents said they had obtained their antibiotic without a doctor’s prescription – a substantial reduction from the 19 per cent who said they had obtained their antibiotic over the counter in a similar study in 2002. This shows the efforts, the campaigns and the messages have not been without reward.
The study also confirms the vast majority of antibiotics are taken after having been prescribed by doctors or dentists.
Every medical student is taught about the ineffectiveness of antibiotics for viral infections such as colds, sore throats and flu. It is the responsibility of every prescriber to use his/her knowledge and skills to identify the mild infections where antibiotics are unlikely to make any significant difference and refrain from prescribing in such situations.
Family doctors remain the first line of contact with our patients and, therefore, have a unique responsibility in terms of correct prescribing. Patients should not pressure or instigate a doctor to prescribe an antibiotic unless that outcome comes solely as a result of a considered clinical decision on the part of the medical practitioner. Indeed, there are numerous studies showing that doctors are more likely to prescribe antibiotics if they believe (rightly or wrongly) the patient is expecting them to do so.
One continues to hear stories of patients going to doctors (or pharmacists) insisting to be given an antibiotic for a sore throat or a cold. When the antibiotic is not prescribed, they may even go to another practitioner after a day or two with greater insistence. If, ironically, they were to be given an antibiotic by the second doctor, they may misguidedly perceive that the antibiotic would have worked because the cold got better. However, by this time the cold or sore throat would have gone through its natural evolution and started to improve spontaneously. Indeed, any improvement would have been in spite, not because, of the antibiotic. The only thing such an individual would have done is to expose himself to potential side effects which antibiotics, like any other pharmaceuticals, may cause.
It is only if all of us – patients, doctors, dentists, and pharmacists – make a genuine and concerted effort to address this microbial threat that we can have a chance of slowing and, hopefully, reversing this tide of resistance and, in doing so, retain the effectiveness of these miracle drugs for ourselves and our future generations.
Dr Borg is chairman of the National Antibiotic Committee.