Doctor, I need an antibiotic!

All doctors have heard this statement over and over again. It is wrong, totally and absolutely wrong, to consider that an antibiotic is the solution to treat all sorts of diseases. But it is not easy to talk people out of this generalised idea.
The facts show that at least one-third of outpatient antibiotic prescriptions may be inappropriate.

As a consequence of the fact that antibiotic overuse has undoubtfully increased the amount of antibiotic-resistant infections and in order to understand the reality better, a large study was done from 2010 to 2011. This study concluded that antibiotics were prescribed for outpatients across all conditions at a rate of 506 per 1,000 population. Only an estimated 353 of these, however, were likely appropriate, suggesting that 30% of these antibiotics may have been unnecessary.

These findings, published in the May 3 issue of JAMA, Journal of the American Medical Association, highlight the need to set a new way for antibiotic use.

“Half of antibiotic prescriptions for acute respiratory conditions may have been unnecessary, representing 34 million antibiotic prescriptions annually,” the authors write. “Collectively, across all conditions, an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate.”

Specifically for pharyngitis, the researchers estimate that 72.4% of cases of pharyngitis in adults and 56.2% in children were treated with antibiotics, even though most sore throat cases are not streptococcus A-related. In recent literature, only 37% of children with sore throat tested positive for this pathogen.

The findings are similar to those reported in other countries. For example, in 2015 a Dutch study shows that almost half of the antibiotic prescriptions written by general practitioners for respiratory tract infections did not comply with clinical guidelines.

“This estimate of inappropriate outpatient antibiotic prescriptions can be used to inform antibiotic stewardship programmes in ambulatory care by public health and healthcare delivery systems,” wrote Dr Fleming-Dutra and colleagues.

In an accompanying editorial, doctors from the Johns Hopkins University School of Medicine said that even if the study’s estimates were too conservative, it clarified beyond doubts the non-adequate, wrong, dangerous, outpatient prescribing practices.

There is evidence that a measure as simple as a waiting room poster stating a commitment to avoid inappropriate antibiotic prescriptions for acute respiratory tract infections can result in a 20% decrease in antibiotic prescriptions.
Clinician education with personalised audit and feedback as well as rapid point-of-care diagnostic tests might also help.

Improvements will require efforts on two fronts: changing some clinicians’ behaviour to ease their concerns about diagnostic uncertainty and above all providing patient education on antibiotics.

A 2015 study found that better physician-parent communication reduced paediatric antibiotic prescribing.

A world without effective antibiotics, although it is a terrifying idea, is a real prospect. The situation is so acute that the Director-General of the World Health Organisation, Dr. Margaret Chan, has warned of “a post-antibiotic era, in which many common infections will no longer have a cure and, once again, will kill unabated”.

Antibiotics in farming

The Alliance to Save our Antibiotics held a conference on April 14, 2016 to explore possible practical steps to reduce farm antibiotic use. At the conference, the Alliance unveiled a new report, showing that the effectiveness of fluoroquinolone antibiotics, which are classified as critically important in human medicine, is being undermined by their continued use in poultry.

The report proves that countries, which have banned these antibiotics in poultry, have much lower levels of fluoroquinolone resistance in human infections than countries that continue to use them.

The Alliance to Save Our Antibiotics is an alliance of health, medical, environmental and animal welfare groups, that works to stop the overuse of antibiotics in animal farming. Its vision is a world in which human and animal health and wellbeing are protected by food and farming systems that do not rely routinely on antibiotics and related drugs.

The use of antibiotics on farms leads to antibiotic-resistant bacteria, which are a threat to human and animal health, now and in the future.

Patients with infections caused by drug-resistant bacteria are generally at increased risk of worse clinical outcomes and death, and consume more health-care resources than patients that are not resistant when infected with the same bacteria.

WHO’s 2014 report on global surveillance of antimicrobial resistance revealed that antibiotic resistance is no longer a prediction for the future. It is happening right now, across the world and is putting at risk the ability to treat common infections in the community and hospitals.

In all regions of the world, there are high proportions of antibiotic resistance in bacteria that cause common infections, like urinary tract infections, pneumonia and bloodstream infections.

Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infections and minor injuries, which have been treatable for decades, can once again kill.

WHO is already working closely with the World Organisation for Animal Health and the Food and Agriculture Organisation of the United Nations to promote best practices and to avoid the spreading of antibacterial resistance, including optimal use of antibiotics in both humans and animals.

Antibiotics should only be prescribed and dispensed when they are truly needed and maximum care should be taken to use the right antimicrobial drugs to treat the specific illnesses.

No individual, animal or human, should ever receive unnecessary antibiotics.

Best health wishes,
Dr. Maria Alice

|| [email protected]
Dr Maria Alice is a consultant in General and Family Medicine. General Manager/Medical Director – Luzdoc International Medical Service / Medilagos. Medical Director – Grupo Hospital Particular do Algarve