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LETTERS: Shah Ebrahim and George Davey Smith Ecological studies are a poor means of testing aetiological hypotheses BMJ 1998; 317: 678 [Full text]

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Scapegoats

Ian Phillips   (30 January 1999)

Scapegoats 30 January 1999
Ian Phillips, Emeritus Professor of Microbiology St Thomas' Hospital, London SE1 7 EH Send response to journal: Re: Scapegoats	EDITOR, The enthusiasm for action to prevent or reverse antibiotic resistance that characterises most of the papers in the BMJ of 5 September(1) is heartening to many of us who have spent much of our time in the pursuit of these goals. However, the readiness with which reservations and deficiencies in our knowledge, although mentioned, are swept aside for "empirical and commonsense strategies", is alarmingl. This is true both of what we do and how we measure its effects. By a strange cooincidence, a letter on a totally different topic in the same issue of the Journal2 reminds us that "ecological analyses are a weak means of testing aetiological hypotheses", yet these are largely the imperfect means available to us when we try to assess the effects of our efforts3. Thus in the past, we have attributed success to our measures, when other factors, such as the passing of an epidimic, were more probably responsible. The decline of the "hospital staphylococcus" of the 1960's in apparant response to the first antibiotic prescribing policies is a warning to those with long memorie, and may, as John Turnidge points out1, explain recent experience with Streptococcus pyogenes. Many would agree with Claude Carbon anbd Richard Bax, despite your rather hostile introduction to their contribution1, that restriction of antibiotic use in man is not a clearly proven answer to our problems. The same reservations must apply to assumptions that the restriction of use of antibiotics in animals would contribute significally to alleviation of human problems. In your later Editorial on the Copenhagen meeitng (the Microbial Threat)5 you quote Norman Simmons incompletely: as I recall he said "...the vets also have role to play, but a small one". However, there is a real danger that the controversy about the use of antibiotics in animals, whether for growth promotion,prophylaxis or therapy, will divert attention from the use of these drugs in man- the more likely cause of most of our resistance problems. If all animal use were terminated today, there is no evidence that human health would measurably benefit, while animal health would certainly suffer, and possibly human health as a consequence. Although it is agreed by all parties that antibiotics should be used prudently, a substantial minority in Copenhagen-not all of them in thrall to specific interest groups- held that decisions to ban or restrict antimicrobial agents in animals should be based on the fullest practicable risk assessments, based on EU procedures. Ian Phillips, Emeritus Professor of Microbiology, c/o Dept of Microbiology, St Thomas' Hospital, London SE1 7 EH References. 1 BMJ 1998; 317:609-690 2 Ebrahim S, Davey Smith G. Ecological studies are a poor means of testing aetiological hypotheses. BMJ 1998; 317: 678. 3 Phillips I. The subtleties of antibiotic resistance. J Antimicrobial Chemother.1998; 42:5-12. 4 Phillips I. Lessons from the past: a personal view. Clin Infect Dis 1998; 27 (suppl 1): S2-4. 5 Smith R. Action on Antibiotic Resistance BMJ 1998; 764-5