WHAT CAN BE DONE NOW ABOUT ANTIBIOTIC RESISTANCE?

4. WHAT CAN BE DONE NOW ABOUT ANTIBIOTIC RESISTANCE?

As a microbiologist I can see the need for yet more research into the microbial and genetic aspects of resistance and the subtleties of its relationship to antibiotic use but as a practising clinician with an overview of how antibi- otics are misused in both the hospital and community, I am sure that we know enough about such relationships to inform our prescribing in a useful way right now. The really urgent agenda is to change prescribers’ habits. Futhermore, while continued development of new antibiotics is desirable, it is really just feeding the “addiction” of doctors to antibiotic prescribing. It is not addressing the underlying problems although it has served us well in the past (but for how much longer is it possible?).

What is likely to pay the most dividends in the shortest time is to research into and act on the determinants of antibiotic abuse—the factors that can influ- ence the prescriber and patient alike—such as cultural, social, educational, economic, and regulatory differences between countries. A lot is already known about these issues (Eng et al., 2003; Harbarth, 2002) and how they can influence the antibiotic prescribing process. In addition, more emphasis needs to be put on public health issues of antibiotic resistance, infection control, and use of diagnostic tests.

One example of this approach is that GPs in some countries are addressing the problem by successfully reducing the number of inappropriate antibiotic prescriptions, at least in children where many of the new “evidence based” guidelines are targeted. Where this has been most successful it has often been linked in with a multifaceted educational approach, targeting patients and the general public through multimedia campaigns, not to demand unnecessary antibiotics from their GP (Belongia and Schwartz, 1998; Bengoa et al., 2002; McCaig et al., 2003; Perz et al., 2002) (Table 1). Patient demand (and use of

Antibiotic Use—Ecological Issues and Actions 709

ANTIBIOTICS ANONYMOUS

Table 1. CDC’s national campaign Current campaign activities include

1. Developing and distributing educational materials promoting appropriate antibiotic use. 2. Funding states to develop, implement, and evaluate local campaigns. 3. Developing and pilot testing a medical school curriculum promoting appropriate

use of antibiotics. 4. Developing and testing Health Plan Employer Data and Information Set (HEDIS) measures for appropriate antibiotic use.

5. Funding a national advertising campaign promoting the appropriate use of antibiotics. Source: www.cdc.gov/drugresistance/community.

often illegal, over-the-counter antibiotics) is known to be highly variable, even within Europe. Although data from hospitals is lacking, there is little to suggest such widespread successes in hospitals where approaches have tended to be targeted to single institutions.

In a study of outpatient antibiotic use and prevalence of antibiotic resistant pneumococci in France (13%) and Germany (7%), the sociocultural differ- ences seemed paramount (Harbarth, 2002). There were markedly different rates of antibiotic prescribing for respiratory tract infection (RTIs). These were

710 Ian M. Gould not to do with microbiologically defined need but complex reasons such as

patient demand associated with health belief differences, social determinants such as different child care practices, regulatory issues, and economic factors (retail prices for pharmaceutical products are much lower in France than Germany). Finally, Japan is well known to have high levels of antibiotic resis- tance because doctors and hospitals rely on profits from drug sales as a source of income.

The last part of the equation may be the most difficult to solve—our rela- tionship as prescribers and consumers with the Pharmaceutical Industry (Pharma). I have previously called for a partnership, based on discussion and resolution of our obvious conflicts (Gould, 2001). We rely on Pharma for new agents but the economics of drug development necessitate aggressive promo- tion to recoup investment, shortening the useful life of many valuable agents by encouraging high use (Wazana, 2000). A related issue is the poor supply of key agents such as injectable trimethoprim and tetracycline which are no longer available, presumably as production is no longer economically justi- fiable, yet we find these agents valuable for treating MRSA infections. Penicillin G has previously been in short supply also (Strausbaugh et al., 2001; Harbarth, 2000).

One other area I would like to discuss, no doubt as I am involved with it every day, is the (lack of) use of the diagnostic microbiology laboratory which can play a major role in improving antibiotic prescribing. I make no apology for this indulgence as I believe that improved use of diagnostics is a very easy way, available to prescribers right now, to improve their antibiotic prescribing.