A Antibiotic Abuse

PUSH Post

29 October 2008

Public United for Savings in Healthcare

Antibiotic abuse Back to the future Without a doubt, Alexander Fleming would find a place in any list of individuals who have played memorable roles in mankind's fight against disease. If Fleming were alive today, he would be appalled by what has emerged from his discovery. Spurred by penicillin, a large number of antibiotics have been introduced in the subsequent years. The spectrum of activity of these agents has widened. Unfortunately, resistance to antibiotics is increasing: the roll call of bacteria that have become resistant, lengthens with each passing year. To add to our misery, infectious agents that did not have the power to produce disease in humans have acquired traits that make them virulent. Despite this grim situation, complacency prevails. The medical profession and patients remain smug in the belief that research will continue to deliver drugs that can circumvent this dangerous situation. The truth lies elsewhere. Bacteria are acquiring powers of resistance much faster than the ability of pharmaceutical research to come up with new devices. We have gone from peaks of triumphant confidence to troughs of despair in the space of less than half a century.

Antibiotic resistance mechanism Combating antibiotic resistance - you can help No country for ostriches

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Professor Hugh McGavock, from the University of Ulster, warns us of an antibiotics crisis which could lead to thousands of people dying from treatable illnesses. The professor, who specialises in prescribing science, claims: • The crisis is as big as AIDS. • In 12 years all antibiotics could be redundant. By 2015, bacteria which cause disease will be resistant to all antibiotics and diseases that are easily treatable now, will be killers. The discovery of penicillin was heralded by confident claims of our ability to eliminate infections for ever. This prediction was sadly off the mark.

By doing many things thoughtlessly

Medical profession - Overprescription - trivial, viral infections - Broad spectrum preference - Low dose/ short course regimens - Failure to identify agent with cultures No single cause can be apportioned the lion's share of the blame. There is also no running away from the reality that the medical profession has to shoulder the largest part of the blame by the way it has failed to discipline itself in the use of antibiotics. • The vast majority of common infections – colds, flu, diarrhea and such – are caused by viruses. Antibiotics have no value and should not be prescribed. Yet, it is rare to see a doctor who will counsel against the need for antibiotics. • Penicillin has a limited range of activity (spectrum) against the hordes of different bacteria that can infect the human body. Over the years, many new drugs have been introduced that are effective against a wide spectrum of infectious agents: broad-spectrum antibiotics. Although valuable, they encourage a slip-shod attitude amongst doctors who prescribe these agents in a gun-shot manner without taking the time and trouble to identify the specific cause of the infection and treat it with a narrow- (but effective) spectrum drug. Such unthinking prescribing leads to antibiotic resistance.

© Dr Arjun Rajagopalan

• It is common to see doctors prescribing antibiotics for only a day or two. Most infections have to be treated for three to seven days to ensure complete eradication. The duration of treatment often extends for a few days after the patient feels recovered. Early cessation of treatment is another important method of promoting bacterial resistance. Hand-in-hand, it is equally common for doctors to prescribe antibiotics in doses that are below the recommended guidelines under the mistaken belief that this will reduce the likelihood of side effects. • Good practice demands obtaining cultures from infected specimens such as urine, sputum and pus from wounds. The specific cause of the infection can be identified, and, more importantly, the most effective, least toxic antibiotic can be used. Cultures are often dispensed with under the guise of saving money for the patient. Pharmacies - Sales without prescription - Over-the-counter sales - High pressure marketing - Self medication Pharmacies in India sell large quantities of antibiotics without a prescription on the basis of complaints described by patients who bypass the doctor in an effort to save money. It is equally common for patients to pop antibiotics that are lying around at home, when a sore throat or fever occurs. Both tactics are not in our best interests. Agriculture - Livestock feeds Huge quantities of antibiotics are consumed in the rearing of livestock, once again an important avenue for the entrance of antibiotic resistance.

29 October 2008

Combating antibiotic resistance

Tricks up the sleeve of evolutionary survivors

Bacteria develop the ability to produce enzymes, substances that can destroy antibiotics

A large portion of the responsibility in combating antibiotic resistance lies with patients and consumers. There are many steps that you can take to help. • Don't take antibiotics for trivial infections and viral diseases like the cold and flu. • Do not indulge in self medication. • Don't go to the pharmacist and ask for quick, short courses of antibiotics over the counter. • Talk to your doctor and ask for the reason why the antibiotic is being given – it is your body, you have every right to an explanation. • Ask for a culture of an appropriate body secretion if an infection needs antibiotics. Usually, it will be a sample of urine, sputum or pus from a wound. • When the culture report is available (usually in 48 – 72 hours) ask you doctor to switch to the simplest, safest, cheapest agent that will cure the infection. • Take the full strength of the prescribed drug for the period that is recommended by your doctor. Don't stop the drug when you are feeling better. Quite often, the drug may need to be given for a specific period to ensure eradication of the infection.

Resistance means that: • People can't be effectively treated and are at greater risk of dying from infections. • People are ill for longer. • Epidemics are prolonged. • Others are at greater risk of infection.

Mutations can occur randomly in the genetic make-up of bacteria that can confer the ability to resist antibiotics

There are several methods by antibiotic resistance can develop:

which

1.Enzymes are naturally occurring compounds that have the ability to digest and break down complex molecules into simple entities. With repeated exposure to an antibiotic, some bacterial strains develop the ability to produce enzymes that can destroy specific antibiotics. Once this happens, continued exposure to the antibiotic results in a situation known as super selection: the bacteria that don't have the capability of producing these enzymes die; those that do survive. Bacteria multiply rapidly, and within weeks to months, aided by the power of exponentiation, there are enough of these enzyme-producing, resistant strains to pose a serious problem. Worse still, sensitive organisms are eliminated over time and the field is left open to the resistant ones. Similar examples abound in the environmental and ecological setting.Within a few years of the introduction of penicillin, resistant bacteria were being detected. They produce the enzyme penicillinase that destroys penicillin. Medical research responded by producing the next generation of penicillin that was effective against penicillinase producing bacteria. The bacteria bounced back with enzymes that could digest this new product. To make a long story short,

No country for ostriches The impending crisis cannot be lightly dismissed. We cannot shelter under the complacent belief that science will discover or invent new agents to keep up the attack against bacteria. The pace of introduction of new antibiotics has come down markedly in the last decade while reports of panresistant organisms (bacteria resistant to all available agents} are growing. The process of new drug discovery and marketing takes between eight to twelve years. Bacterial

just half a century after the introduction of penicillin, we have organisms that are resistant to all available agents: panresistance is here to stay. 2.Mutations (a constant feature in the field of evolution) can occur randomly in the genetic make-up of bacteria that confer the ability to resist antibiotics. Once imprinted in the genes, it is quickly passed on to succeeding generations. As seen in the earlier instance, it is only a matter of weeks to months before there are huge numbers lurking around. Alarmingly, this genetic information can be transmitted to unrelated species, thereby conferring immunity to other bacterial types that may not have otherwise acquired this capability. Bacteria that were hitherto innocuous become virulent invaders that are antibiotic resistant. Whatever the mechanism, the longer and more intensively bacteria are exposed to antibiotics, the more likely it is that resistance will develop. Bacteria are evolutionary survivors. They predate Man by millions of years and have stored, many tricks up their sleeve. Like the anti-war protestors of the US campuses of the sixties, their slogan too, is “Hell no, we won't go!”.

resistance occurs in time frames of months to a year or two. The economics are not attractive enough for pharmaceutical companies to plough money into new antibiotic discovery. A large part of the responsibility in handling this crisis lies with the patient and consumer. There are many small areas where gentle but firm insistence from the patient can lead to changes in the behavior of doctors. We are warned that those who fail to learn from the lessons of history are condemned to repeat them. There is good evidence that the problem is rapidly escalating. To find a balance in this conflict between the two ends of the evolutionary pathway - bacteria and man - physicians, patients and the pharma industry have to work together.

© Dr Arjun Rajagopalan