February 2004
Overuse of Antibiotics: What are the consequences?
By Gary Wheeler, M.D., Department of Pediatrics, Division of Pediatric Infectious
Disease
Arkansas Children's Hospital and University of Arkansas for Medical Sciences
One of the greatest tensions that exist in America is between individual rights
and public rights. Strangely enough, this tension has come into play regarding
the issue of antibiotics and their overuse in patients.
Patients go to the doctor to be cured of their disease. If a doctor is reluctant
to prescribe an antibiotic because there is a low chance of an infection, he
may be helping the public health. But you may see it a different way, particularly
if you are leaving on a trip to the beach. You may be willing to pay the extra
money for the insurance you won’t be sick, even if in reality, the antibiotics
probably won’t help. Still there is a chance they will, and you want to
pay for the chance.
Nobody has followed evening news reports without being aware of “super
bugs,” which now cause disease and death in patients and are resistant
to traditional antibiotics that in the past would have been effective. How have
we reached this status? Perhaps an example of how this is affecting Arkansas
would be pertinent.
As an infectious disease doctor, I frequently see patients with infections of
their skin, bones and lungs. Ten years ago, we would have used traditional penicillin-like
antibiotics to treat these infections caused by a germ known as the staphylococcus
or more simply known as “staph.”
Within the last several years, we have seen a dramatic rise in this germ’s
resistance to the common antibiotics of the past. Instead, we are forced to
consider that these patients may have resistant staph, susceptible only to antibiotics
that can be given intravenously and have side effects that require monitoring
of drug levels. As a result, patients receive longer periods of hospitalization,
in some cases longer periods of outpatient intravenous therapy, and in some
cases uncertainty about whether these infections can be cured or not.
Another childhood illness, meningitis, creates the same sort of difficulties.
Twenty years ago when I started practicing, the most common causes of meningitis
were uniquely susceptible to common antibiotics such as ampicillin. Now, we
are forced to use multiple agents, because the most common cause of meningitis
in children, pneumococcus, has developed resistance to the most common drugs
used for meningitis, the penicillins and the cephalosporins. Just like the staphylococcus
organism, treatment becomes more complicated and more expensive.
How did we get into this position? Studies of antibiotic use in America now
show that we have dramatically increased the number of antibiotics prescribed
per child during the last 20 years. In addition, antibiotics are present in
most livestock operations in this country. The result is the effects of antibiotics
can literally be measured in the water of the rivers of America.
Either from the environment or from exposure to antibiotics in our own body,
these germs mutate and develop resistance to the usual antibiotics. Studies
by the Centers for Disease Control have shown that up to 80 percent of the antibiotics
that are prescribed for children and adults are needlessly prescribed; that
is, they are prescribed for conditions that don’t require antibiotic treatment.
These include, for the most part, common viral infections affecting the sinuses
and respiratory tract.
You might ask why physicians over-prescribe antibiotics. CDC studies have found
two major factors. One is that patients want antibiotics because they believe
that medications will shorten the course of an illness. This is not the case
for viral illnesses. Another factor is that people are afraid that a simple
illness might become a complicated illness. This can happen, but it rarely does.
Physicians say patients demand antibiotics, and they don’t want to lose
them as customers. But studies show patients rarely leave doctors for this reason.
Doctors are also afraid that complications from simple infections might create
legal liability. We now know that drug treatment leading to side effects can
cause equal liability.
Investigators at UAMS recently published a study that showed patients could
be educated about the overuse of antibiotics and why they are unnecessary in
simple viral infections. Even in that setting, doctors continued to prescribe
antibiotics at high rates.
Another study has shown that physicians frequently misunderstand what a parent
or patient’s expectations for antibiotics are and prescribe them when
the patient doesn’t necessarily want them. This has come to the attention
of insurance providers and others who will begin monitoring the inappropriate
use of antibiotics by physicians in 2004 and providing report cards to them
on how they are performing in this area.
An important question is whether or not we have crossed a point of no return.
Can germs become sensitive to older antibiotics again if we use them less? Two
important studies, one in Iceland and one in Scandinavia, have shown that when
antibiotic prescribing is reduced, organisms such as “strep” can
regain their sensitivity to common antibiotics such as erythromycin.
For this reason, during the last several years the CDC has embarked on a public
information campaign to publicize the bad effects of overusing antibiotics,
hopefully engaging the public and physicians to use fewer antibiotics. You may
have heard of the “Save the Antibiotic” campaign in Arkansas carried
out by the Arkansas Foundation for Medical Care.
Despite these efforts, we continue to see high antibiotic use in our state.
The consequences are even more resistant bacteria, greater costs for therapy
and the risk of bad outcomes. We must all work together to spread the word that
antibiotics are an important tool that we waste if we over use them. We need
to save antibiotics for the times we really need them.
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