Public Health Feature -- April 2000
By Johanna Franke
When Scottish scientist Alexander Fleming discovered the first antibiotic in 1928, he probably had no idea how popular his wonder cure would become. Today, antibiotics are prescribed for all sorts of infectious conditions from otitis media to meningitis.
Unfortunately, the use of antibiotics has spread almost as quickly as the diseases for which they are prescribed, and antibiotic resistance has been fast to follow. Scientists detected resistance in gram-positive and gram-negative organisms even before the widespread use of penicillin in the late 1940s.
More than 50 years later, antibiotic resistance has grown into a major public health problem, thus the Texas Committee for Judicious Use of Antibiotics (TCJUA) has set out to teach physicians and patients how antibiotics can hurt as much as they heal.
Resistance isn't futile
The Centers for Disease Control and Prevention (CDC) estimates about 100 million courses of antibiotics are ordered by office-based doctors each year in the United States. Half of those are being prescribed inappropriately for colds, coughs, and other viral infections rather than bacterial infections.
Even appropriate use contributes to the resistance problem, as the more an antibiotic is used, the quicker it becomes useless. An article in the May 10, 1999, US News & World Report relates the growth in antibiotic resistance to natural selection. As most bacteria exposed to an antibiotic are killed, the fittest survive and pass their survival traits to their offspring. The resistant bugs multiply with continued use of the antibiotic, and they easily build resistance to other antibiotics. They also can give their survival traits to nearby, unrelated bugs. Scientists who long ago turned their attention to genetics and other cutting-edge research now are jumping back into the study of antibiotics to produce drugs to combat supergerms. For the first time in 30 years, the government is approving new antibiotics such as Zyvox and Synercid to kill germs that are resistant to everything else.
Even the General Accounting Office (GAO) has taken note of increasing worldwide antibiotic resistance. A GAO report delivered to Congress in May 1999 described how no federal agency tracks all resistant infections, so human and financial costs are hard to calculate. It has been estimated by the Texas Department of Health (TDH) that more than $60 million is spent by the state Medicaid program every year. If half of those prescriptions were eliminated, a savings of $30 million per year could be realized.
"We spend a lot of health care dollars on antibiotics," said Kate Hendricks, MD, MPH, division director for Infectious Disease Epidemiology and Surveillance at TDH. "We're throwing a lot of money away by treating something that is not there. We could use those dollars in other areas, such as prevention."
Do no harm
The economic impact of the inappropriate use of antibiotics doesn't compare to the damage it's causing the public's health.
"The physician sees his patient in the context of the individual that he is treating, but when you accumulate all of these inappropriate uses, you end up with a public health impact to which all physicians need to realize they contribute," said Sharilyn Stanley, MD, TDH associate commissioner for disease control and prevention.
Children are hit the hardest, as the majority of outpatient antibiotics are prescribed for kids under age 5. With the help of CDC, the American Academy of Pediatrics (AAP) published Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections as a supplement to the January 1998 issue of Pediatrics. These guidelines also are available on the Internet at www.pediatrics.org/content/vol101/issue1/#SUPPL1.
Soon after, TCJUA, composed of TDH officials and infectious disease specialists and pharmacists from the state's medical schools, sent a survey to 1,500 Texas physicians pulled from the American Medical Association's master list. The survey was intended to assess the need for educational activities targeted toward specialty groups caring for children, such as pediatricians, family practitioners, and emergency medicine specialists. The survey found that:
- Pediatricians are much more familiar with the AAP's guidelines than are family practice or emergency medicine specialists.
- Half to a third of all physician respondents begin antibiotics for streptococcal pharyngitis without a positive lab test.
- Only half of pediatricians and a fourth of family practitioners and emergency room specialists wait long enough (more than 10 days) to start treatment in children with suspected sinusitis.
- A third or fewer physicians refrain from prescribing antibiotics for nonspecific upper respiratory infections.
Though these results are not surprising, they're somewhat disappointing, Dr Hendricks says. "You always hope things are better than what people are saying. There's no group in Texas that takes care of children that really knows the guidelines by heart and follows them," she said. "But the pediatricians did a lot better than family practitioners and emergency physicians probably partly because the guidelines were published in Pediatrics ."
A question of time
Many primary care physicians' knowledge of antibiotic use is limited because their time is limited, says Glen Mayhall, MD, a member of TCJUA and a professor of internal medicine in the Division of Infectious Diseases at The University of Texas Medical Branch (UTMB) at Galveston. Dr Mayhall, a hospital epidemiologist, heads UTMB's Department of Health Care Epidemiology.
"You've got to make sure that patients with serious illnesses are going to be treated," Dr Mayhall said. "It's easier to put them on a lot of antibiotics, which will probably cover most anything, and then you don't have to worry about carefully analyzing the case."
But using antibiotics to kill bacteria in viral infections promotes antibiotic resistance, says Paul Glezen, MD, another TCJUA member and a pediatrician in the Microbiology Department at Baylor College of Medicine in Houston. "The data on the use of antibiotics in viral infections show that you don't prevent the bacterial complications of viral infections by using antibiotics," he said . "In fact, all you do is change the antibiotic susceptibility of the flora in the respiratory tract so that when a complication occurs, it is more likely due to a resistant bacteria."
The most effective method of combating supergerms is preventing them in the first place through AAP recommendations on influenza and pneumococcal vaccinations, Dr Glezen says. But physicians also can help fight antibiotic resistance by improving viral diagnosis in clinical settings and studying the epidemics that are popping up in their communities.
"This is a rapidly moving field with new antimicrobial agents being produced and released fairly frequently," Dr Mayhall said. "One has to keep up with those new agents and make sure what their appropriate applications are."
TCJUA is developing educational materials that physicians can use to earn continuing medical education credit and keep up with the field (see TDH and CDC Antibiotic Resistance Materials). Committee members also are developing projects for residents, interns, and medical students. In one such program under consideration, Texas medical school teams would test their antibiotic knowledge against each other and teams from other states. If approved by Texas Medical Association's Medical Student Section, the Antibiotic Bowl would kick off at TexMed 2001.
While the appropriate use of antibiotics is important, the reality is it's a customer service issue, says Dallas neonatal-perinatal medicine specialist Dolores Carruth, MD, a member of the TMA Council on Public Health.
"The patient comes to you because he doesn't feel well. Address the issues -- the cough, the runny nose, the headache -- and treat the symptoms," she said. "You're never, ever going to have a good mother or father let a child cough for 10 to 14 days as it says in the [AAP] recommendations. Your patient has come to you for help -- help him."
Meanwhile, physicians know parents will resort to over-the-counter medications, Dr Carruth says. "Help them in their quest," she said. Physicians should recommend appropriate antihistamines and decongestants and instruct parents in the use of vaporizers and other time-proven remedies like nose drops, honey, and lemon, she adds.
"And if [strep] culture results play a role in your patient's therapy, make the transmission of these results timely and easy for the patient and his family. This family is your customer, so make them satisfied customers. Such a caring attitude will go a long way in decreasing the patient demand for antibiotics," Dr Carruth said.
"Physicians, at times, really get badgered," Dr Mayhall said. "That's why the committee also is trying to educate parents about how they should let their physicians make decisions based on whether their children have infections that would respond to antibiotics as opposed to viral infections."
Though their time is tight, physicians need to teach their patients about antibiotic resistance. "I know there's a lot of pressure on doctors to get through many patients in a day, and it takes longer to educate these patients' parents than to write a prescription," Dr Hendricks said. But physicians can help patients and their parents understand the difference between viral and bacterial infections with the help of office personnel or through printed materials, available from TDH by calling (512) 458-7676 or emailing Olga.Nuno@tdh.state.tx.us.
TDH also offers the following tips for physicians when parents demand antibiotics for their children:
- Acknowledge the child's symptoms and discomfort.
- Explain to parents that only bacterial infections can be cured by antibiotics.
- Explain that unnecessary antibiotics can be harmful by promoting resistant organisms.
- Promote active management with nonpharmacologic treatments.
- Give a realistic time course for resolution.
- Convey a sense of partnership -- do not dismiss the illness as "just a viral infection."
Accepting the challenge
Aside from outpatient use of antibiotics, TCJUA is studying antibiotic resistance in hospitals, day-care centers, and long-term care facilities. Committee members also are looking at particular challenges Texas faces, such as sharing a border with Mexico.
Dr Mayhall says patients are running for the border when their physicians refuse to prescribe them antibiotics, as Mexico's pharmacies offer cheap antibiotics without prescriptions. "That sort of undirected self-administration of antibiotics for highly questionable indications is a made-to-order selection of resistance."
How physicians can fight antibiotic resistance
How patients can fight antibiotic resistance
Careful antibiotic use
TDH and CDC antibiotic resistance materials
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