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Rapid Responses: Rapid Responses published:
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Antibiotic Resistance: Who is the real culprit?
- Shazia Qasim Jamshed, Zaheer-ud-din Babar, Mohamed Izham Mohamed Ibrahim (8 August 2008)
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Good guidance on antibiotic use: but is this the right question?
- James A Dickinson, CL Teng, Associate Professor, Department of Family Medicine, International Medical University, Seremban, Malaysia. (9 August 2008)
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Rational Use of Antibiotics: Academic Detailing is Needed
- Dr Mohamed Azmi Ahmad Hassali (10 August 2008)
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Periodic update for family physicians
- N.P. viswanathan (10 August 2008)
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Otitis media and antimicrobial overuse - can other countries learn something from Iceland?
- Vilhjalmur Ari Arason (11 August 2008)
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? Need for separate set of guidelines
- Seshu B Gosala (13 August 2008)
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Shazia Qasim Jamshed, PhD scholar Social and Administrative Pharmacy Universiti Sains Malaysia, Zaheer-ud-din Babar, Mohamed Izham Mohamed Ibrahim
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Antibiotic Resistance-Who is the real culprit? In a span of ten years time I got three severe viral infections in three different places of the developing countries. In all three health settings in Pakistan, India, and Malaysia dispensing doctors made the correct diagnosis of viral illness on the basis of severity of signs and symptoms. Getting the prescription of antibiotics for viral illnesses put me in disarray. A pharmacist- cum- pharmacologist by profession I did not stop myself to inquire about the “status quo” and prospects of giving antibiotics in viral infections. In Karachi my family doctor ascertained the probability of bacterial attacks in viral infections as the immunity is compromised in diseased state. In Delhi the practitioner prescribed on the assumption of having mixed infection i.e. bacterial and viral both, which was not all in all an easy diagnosis (as per practitioner). In Penang the doctor simply avoided my interrogation during viral conjunctivitis and instructed to instill Chlormaphenicol eye drops thrice a day clearly stating viral membrane formation in both eyes. Now see the other side of the coin. During my clinic visits, I had come across many patients (with little medical know-how) nagging general practitioners to prescribe antibiotics for sinusitis and self-limiting upper respiratory tract infections such as acute sore throats. This antibiotic seeking behavior is presumably related to quick and instant relief from the symptoms and illness. Even large body of medical evidences relates inappropriate use to the patient’s desire for antibiotics.[1-3] Thus no one is solely responsible as both players are performing according to the circumstances. The caregiver is honoring the selective knowledge given by pharmaceutical representatives (more correct to say pharmaceutical blabbers). The receiver at the other end desperately needs succor and immediate relief as natural as native language learning. Although a natural phenomenon, bacterial resistance is now emerged as a menace and thanks to mankind for making the bacteria succumb to societal factors such as patients’ demands and inappropriate usage of antibiotics. Now what is truly required is a sense of morality on the part of provider to come up with ethics of excellence and their prescribing habits should be relied upon careful thoughts, which caters to the patients’ needs in the best clinical interest. On the other hand patient must sense the ethical motive for the demands; better to avoid needless poking to the practitioner. In my opinion still there is one actor behind the curtain who can play a major role in at least minimizing this scourge of antibiotic resistance and that is truly pharmaceutical industry. As we all know Pharmaceutical manufacturers are the most skillful composers in carving, instituting, and estimating promotional journeys for their products. Why not a promotional campaign for the rationality of antibiotics? A promotional campaign on the awareness of antibiotic misuse along with the marketing of antibiotic products will be a milestone to serve humanity besides earning huge profits. Patient education teaching tools such as pamphlets or flyers will also help in arresting the problem. Just as it is written on the packet of cigarettes “Smoking is injurious to health”, “Avoid antibiotic misuse” is not a weighty proposition as an information attached to every antibiotic. In a nutshell, pharmaceutical manufacturers can directly save the humanity from this modern day Frankenstein. Voltaire a French philosopher popular for his wit stated “The art of medicine consists of amusing the patient while nature cures the disease.” REFERENCES 1. Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001;50: 853–58. 2. Byarugaba DH. A view on antimicrobial resistance in developing countries and responsible risk factors. Int J Antimicrob Agents 2004; 24:105–110. 3. McGarock H. Unjustified antibiotic prescribing in the community: a major determinant of bacterial antimicrobial resistance. Pharmacoepidemiol Drug Safe 2002; 11: 407–8. Shazia Jamshed
Dr Zaheer-ud-din Babar
Dr Mohamed Izham Mohamed Ibrahim
School of Pharmaceutical Sciences, Universiti Sains Malaysia Competing interests: None declared |
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James A Dickinson, Professor of Family Medicine University of Calgary, Alberta, Canada. T2N 1M7, CL Teng, Associate Professor, Department of Family Medicine, International Medical University, Seremban, Malaysia.
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Thank you for publishing the articles about the NICE guidelines for antibiotic (non) prescribing for patients with respiratory tract symptoms. We are surprised by the omissions from both the articles and the NICE literature review and concerned that the practical questions of patients and clinicians are not really addressed. [1,2] The guidelines assume that the research studies they are based on include patients who represent the full spectrum of disease. However, nearly all the original papers excluded patients that the parents and/or trial physicians felt were so ill they must be offered antibiotics. Thus the data is mostly about patients with only moderate disease. Possibly in recent years as participating doctors became more confident about not using antibiotics, fewer patients were excluded, but few studies report their exclusion criteria and rates well enough to be sure. The guidelines omit social class and living conditions, but they do note that some social groups receive higher prescription rates. Rheumatic fever and other complications of streptococci have virtually disappeared among urban dwellers in developed countries so that sore throat trials since 1960 have insufficient power to demonstrate an effect.[3] Carapetis[4] shows that high rates persist in undeveloped countries, and among severely disadvantaged groups in developed countries. In Hong Kong these diseases disappeared as people were moved off the ground into clean dry high-rise apartments.[5] In Malaysia, as the country is developing, scarlet fever and rheumatic fever are also disappearing though glomerulonephritis is still common. Pyogenic complications of other “minor” respiratory illness, such as perforations, mastoiditis and intracranial abscess after otitis media are also related to poor social conditions. Thus it is still appropriate to prescribe antibiotics early and vigorously for patients from severely disadvantaged backgrounds. While preferences for antibiotic treatment were considered, there was no discussion about the reasons why so many patients come to doctors: because they feel unwell and they want us to help them[6]. The guidelines suggest that we ask what the parents have already done about symptomatic treatment, but give little guidance on how doctors should prescribe or recommend such treatment, apart from fever. Those with allergic tendencies are an increasingly prevalent group in modern societies. These often present initially with persistent cough and discharge after viral respiratory infections. Thus antihistamines help many patients with upper airway cough syndrome, while inhaled asthma treatments assist lower tract symptoms. If doctors learn to treat bothersome symptoms well, fewer will feel a need to give antibiotics to “do something”, fewer patients will ask, and the goal of reducing inappropriate antibiotic use will come closer. References: 1. Tan T, Little P, Stokes T; Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ. 2008;337:a437 2. National Institute of Health and Clinical Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. Draft guideline. March 2008. 3. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD000023. DOI: 10.1002/14651858.CD000023.pub3 4. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5:685-694. 5. Newman TB, Dickinson JA, Bisno AA. Acute pharyngitis. N Engl J Med. 2001; 344:1479. Correspondence. 6. van Driel ML, de Sutter An, Deveugele M, Peersman W, Butler CC, de Meyere M, De Maeseneer J, Christiaens T. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006;4: 494- 9. Competing interests: None declared |
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Dr Mohamed Azmi Ahmad Hassali, Pharmacy Lecturer, Universiti Sains Malaysia,Penang
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The article by Tan et al "Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance BMJ 2008; 337: a437" gives an insight on how to deal with the current "epidemic" of irrational antibitioc prescribing for respiratory tract infections. For most doctors especially in developing countries, they tend to prescribe antibiotics to patients with viral illness in order to prevent secondary bacterial infections.Furthermore doctors in these countries are not bound to follow the stipulated guidelines as the cost of healthcare in the private sector are not regulated.The alarming use of new generation antibiotics for treating common viral illness was also alarming. In order to overcome these problems, respective health regulatory authorities need to come out with effective academic detailing methods to educate doctors on rational use of antibiotics.In Australia for example,the National Prescribing Service (NPS) had used an effective campaign in educating doctors on rational prescribing for viral respiratory illnesses such common cold.The sucess story of the Australian NPS in educating prescribers should be emulated by other countries as treatment such as common cold needs only "common sense" Competing interests: None declared |
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N.P. viswanathan, Family physician svclinic,gmpalya,Bangalore-560075,India
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Periodic update for family physicians is required regarding proper use of antibiotics.Antibiotics is not a remedy for all respiratory illness.First differentiating between viral and bacterial infection is very important.Education of the patients is also required.Doctors should not prescribe antibiotics indiscriminately.It is always a good policy to delay presription of antibiotics.The authors have brought out important message. Competing interests: None declared |
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Vilhjalmur Ari Arason, GP Health Center Fjordur, Hafnarfjordur
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Antimicrobial usage is higher in Iceland than in the other Nordic countries where like in many other western countries the usage is decreasing. Studies on influences of antimicrobials on the resistance development in Iceland were performed over a ten year period, 1993-2003 and published in five papers (1), the first in BMJ 1996 (2). Children under age of seven consumed over 20% of the total antimicrobial consumption and over 50% were because of diagnosed acute otitis media. The antimicrobial consumption has increased after the study period from 20.1 DDD (defined daily dose) /1000 inhabitants/day, 2003 to 23.2 in 2007 (3). These new sales figures are very disappointing, especially because of the causal connection between antimicrobial use shown in our studies and risk of carrying penicillin nonsusciptable pneumococci (up to 30% of all children receiving antimicrobials), and also even to increased risk of relapsing ear infections (acute otitis media). Tympanostomy tubes placement rate was also very high or up to 44% of all children in the area where the antimicrobial usage was highest 2003. Eradication of susceptible pneumococcus in the nasopharyngeal flora and interference on natural balance of microbial species in the nasopharynx by antimicrobials means that new strains can emerge thereafter and hence may increase the likelihood of new episodes of acute otitis media (4,5). Associated with a decreased rate of successful eradication of resistant pathogens from middle-ear fluid when otitis media is treated by antimicrobials may also be a tendency toward relapsing acute otitis because of superinfections by resistant strains (6). The positive effect of decreased antibiotic use on antibiotic resistance and even infection rate may therefore outweigh the possible benefit of earlier symptom resolution attributed to antibiotic treatment in the case of mild acute otitis media which are very common among young children, especially in connection with unspecified upper respiratory tract infections (common cold). References: 1) Arason,V.A. (2006) Use of Antimicrobials and Carriage of Penicillin-Resistant Pneumococci in Children. Repeated cross-sectional studies covering 10 years. PhD thesis University of Iceland. http://www.hirsla.lsh.is/lsh/bitstream/2336/11250/3/use_of_arason_ot_1.pdf 2) Arason, V.A., K.G. Kristinsson, J.A. Sigurdsson, G. Stefansdottir, S. Molstad and S. Gudmundsson (1996). Do antimicrobials increase the carriage rate of penicillin resistant pneumococci in children? Cross sectional prevalence study. BMJ 313(7054): 387-91. 3) Icelandic Medicines Control Agency (2008) http://lyfjastofnun.is/Tolfraedi/Lyfjanotkun_og_velta/ 4) Syrjanen, R.K., K.J. Auranen, T.M. Leino, T.M. Kilpi and P.H. Makela (2005). Pneumococcal acute otitis media in relation to pneumococcal nasopharyngeal carriage. Pediatr Infect Dis J 24(9): 801-6. 5) Ekdahl, K., I. Ahlinder, H.B. Hansson, E. Melander, S. Molstad, M. Soderstrom and K. Persson (1997). Duration of nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae: experiences from the South Swedish Pneumococcal Intervention Project. Clin Infect Dis 25(5): 1113-7. 6) Dagan, R., E. Leibovitz, D. Greenberg, P. Yagupsky, D.M. Fliss and A. Leiberman (1998). Dynamics of pneumococcal nasopharyngeal colonization during the first days of antibiotic treatment in pediatric patients. Pediatr Infect Dis J 17(10): 880-5. Competing interests: None declared |
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Seshu B Gosala, Chief Medical Officer Visakhapatnam 530017
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One should be careful in treating children with malnutrition and with doubtful vaccination history which is a common profile of children presenting with URI symptoms in many developing countries. Many a time healthy children with apparent URI ? viral etiology deteriorate rapidly and develop fatal pulmonary and neurological complications. In places where laboratory facilities are not available, it is a good strategy to treat emperically. Competing interests: None declared |
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