Antibiotic resistant bacteria are becoming a major problem. Calls to action on increasing rates of resistance have been made by the World Health Organization, the US Centers for Disease Control (CDC), and by the Australian Societies for Infectious Diseases (ASID) and the Australian Society for Antimicrobials (ASA).
Drivers of resistance
Antibiotic resistance is caused by excessive antibiotic use. If bacteria aren’t exposed to antibiotics, there’s no impetus for them to become resistant. But much modern medicine would be impossible without antibiotics (most surgery, for instance) so they are a necessary “evil”.
More than 80% of antibiotics are prescribed in general practice, and much of this is for upper respiratory tract infections (such as colds). These are mostly caused by viruses and almost never need antibiotics.
Patients treated with antibiotics are almost three times more likely to experience a side effect (mainly nausea), for no benefit because antibiotics won’t affect the duration of their illness. And resistance can develop even after a short course of antibiotics.
Hospital patients are usually sicker than patients who visit a GP. Sometimes, they’re very sick and need urgent treatment. In severe infections, the time delay until antibiotics are given is a major risk for mortality.
Since antibiotic resistance is now a fact of life in hospitals around the world, it’s understandable that doctors want to give their patients the best treatment available. This can lead to “antibiotic armageddon” where the biggest, most broad-spectrum antibiotic is felt to be the best way to proceed.
Australia has excellent prescribing guidelines that are easily available for doctors to refer to when prescribing antibiotics. In practice, though, studies in Australia and elsewhere show fairly consistently that only between half and three-quarters of antibiotic prescriptions are in keeping with such guidelines.
I performed an audit of antibiotics prescribed to in-patents of a hospital I worked at. It was based on a review of their medication charts and comparison with Australian Therapeutic Guidelines. This is what I found:
dosing errors – 13%;
choice of drug different from guidelines – 11%;
unnecessarily prolonged treatment – 8% and;
antibiotics not required at all – 8%.
The three “Es”
The solution can be simplified into three “Es” – education, expectations, and enforcement.
As medicine becomes more complex, it’s increasingly difficult to teach junior doctors everything they “must know” in order to practice. Education on good prescribing habits and the importance of rational antibiotic use are critical when doctors are in the formative stage of their careers.
Doctors' expectations are also important. Not every fever requires antibiotics and broader-spectrum isn’t always better are the key messages to teach.
Although there are many campaigns aimed at the public about antibiotics for colds, around half of patients seeing a GP still expect such a prescription. And although only half expect it, 73% receive one. Those who don’t are twice as likely to present for another consultation.
There are two factors at play here – patients' expectation of a prescription and general practitioners' understanding of what patients expect. More worrying still is that doctors think that their prescribing doesn’t impact resistance.
The result is a tragedy of the commons – patients may be aware of the risks of antibiotics in general, but feel the benefit for them outweighs the risks to the community, as superbugs only happen to someone else. In fact, the opposite is true - for viral infections patients receive no benefit from antibiotics but all of the risk.
In addition to education, a well-designed antibiotic stewardship program can significantly improve antibiotic use in hospitals. As well as improving care quality, these programs can also reduce costs and decrease length of stay in hospital and the rates of hospital-acquired infection.
Although doctors often bristle at restrictions on their practice, acceptance of these programs is surprisingly high.
Antibiotic resistance is currently seen as a clinical problem for doctors and hospitals, rather than a more general health issue. The key to overcoming it is reframing resistance as a problem of public health importance and getting the public more engaged, as has been done with hand washing. Rather than patients asking for a prescription, we need them to ask “do I really need antibiotics for this?”
Superbugs are complex and pose a serious health threat. Only by working together, and prescribing smarter instead of broader, will we keep them at bay.
This is the third article in Superbugs vs Antibiotics, a series examining the rise of antibiotic-resistant superbugs. Click on the links below to read the other instalments.
Part nine: New antibiotics: what’s in the pipeline?