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Why this love for antibiotics in India?

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6209 (Published 02 October 2012) Cite this as: BMJ 2012;345:e6209
  1. Pankaj Vohra, senior consultant, pediatrics/pediatric gastroenterology, Max Healthcare, New Delhi, India
  1. pankajvohramd{at}yahoo.com

Patient’s mother: “Doctor, can you please prescribe an antibiotic. My 4 year old child has been suffering from diarrhoea for the past three days.”

Doctor: “Madam, there’s no need for an antibiotic. This is a viral infection, which is self limiting. Antibiotics may, in fact, make the child worse.”

Mother: “But doctor, I have only come to you to get antibiotics. I am already doing the rest of the treatment. What is the point in my spending two hours getting the child here, taking half a day’s leave from the office, and paying your fee, without getting an antibiotic? I could have ordered norfloxacin from the chemist and spent less money and less time.”

Doctor: “Madam, your time and money have been well spent. You are paying to protect your child from antibiotics—and for the reassurance that the illness will pass in a week.”

Mother: “A week? No, doctor, that’s too much. The child has important examinations at school. I should not have listened to you in the first place and started norfloxacin on day one. Please refund my money, and I will get the drug from the chemist. I thought you were a good doctor but I won’t come to you again.”

An estimated half of prescriptions for antibiotics are unnecessary and a leading cause of bacterial resistance.1 Remember the carbapenem-resistant New Delhi metallo-beta-lactamase 1 Enterobacteriaceae? The effect of bacterial resistance is seen worldwide but it is most acute in developing countries, where expensive medical care pushes thousands into poverty every day. So why do we use so many antibiotics?

Most general physicians and paediatricians forget that viruses cause almost 90% of febrile illness. Most doctors have trained in busy government hospitals where the concept of viral illness rarely exists, at least in outpatient departments. Patients with illness that lasts a short time, such as viral fever, upper respiratory tract infection, or non-dehydrating acute gastroenteritis, are unlikely to present to the emergency department or outpatient department. So students don’t receive training, and teachers don’t see viral illness and rarely if ever get an opportunity to follow such patients.

Almost 80% of all Indian prescriptions include an antibiotic whether it is needed or not, and that is what students learn.2 Diagnosis is rare, and even when one is made, a broad spectrum antibiotic is often prescribed. Recently I prescribed oral penicillin. The patient came back from the pharmacy saying, “Is the doctor trying to kill this child—this drug is not available because it is extremely dangerous.” But allergic reaction is much more likely with injectable rather than oral penicillin, and the more easily available amoxicillin and amoxicillin-clavulanic acid combinations are also penicillins and carry the same risk.

In busy outpatient practices, doctors find it easier to give antibiotics in case they are unsure or might have missed something. And patients have had the idea ingrained into them that only antibiotics can cure disease. In rural India, patients often demand injectable antibiotics.

It is often easier and quicker to give antibiotics than to spend time explaining to patients that antibiotics are not needed. Some patients with viral illness will develop a secondary infection. An antibiotic might then have to be prescribed, with a further consultation taking up time and costing money. The doctor may now feel awkward because he or she has to give an antibiotic and decide to charge the patient again. So why not just give the antibiotic to begin with?

Patients with non-resolving illness often seek a second or a third opinion, and antibiotics are likely to be added or changed. The first doctor is all too aware of this and may be worried about losing the patient to another doctor’s care. Subsequent doctors will rarely contact the first doctor but will have the advantage of the first doctor’s diagnosis.

Few insurance companies cover outpatient drugs, so doctors are rarely checked about rates of antibiotic prescribing, and pharmacies prefer to sell expensive drugs. And without adequate counselling patients tend to stop using antimicrobials once fever resolves, encouraging resistance.

Physicians commonly prescribe antibiotics for three days, but other than for azithromycin this is absurd. This prescribing pattern is copied by junior doctors and by pharmacists who dole out antibiotics without prescriptions. So now we have too many prescriptions with a smaller number of doses and incomplete courses. It is also possible that some dubious manufacturers include less of the active ingredient in their formulation to keep costs down.3

Laboratories with outdated technology contribute to false positive and false negative results. Both scenarios help justify antibiotic use because for negative results doctors say, “Often the illness does not show up in the test and hence treating it is important.” For example, most enteric fever is diagnosed by the typhidot test on the third day of illness but the test is positive in fewer than half of cases in the first week of illness.4

Some investigations, such as stool rotavirus antigen testing, lack availability, resulting in millions of doses of antibiotics being given to children admitted for dehydrating diarrhoea. Fortunately, antibiotics rarely have severe adverse effects. Most doctors will never witness Stevens-Johnson syndrome, and this too favours overprescription.

In most cases the treating physician’s poor training or lack of confidence is to blame. Regulating the sale of antibiotics; having an active feedback programme, involving the media on the scourge of bacterial resistance; and spending time to reassure patients might also help to curb unnecessary antibiotic use, as will research and good practice guidelines.

Remember we carry home vancomycin-resistant enterococci, are often exposed to carbapenem-resistant Klebsiella pneumonia, and multidrug resistant tuberculosis. Can you imagine your patient or loved one dying from bacterial infection, tuberculosis, or malaria that is resistant to all known drugs? Infections that need antimicrobials are more common in developing countries, but responsible use is the key.

Notes

Cite this as: BMJ 2012;345:e6209

Footnotes

  • Competing interests: the author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

References