photo by ‘Sheep Purple’, flickr
Waste Not, Want Not: A Call for the Appropriate Use of Antibiotics
I do not like wasting things: time, money, energy, food. As a pharmacist, though, I definitely do not like wasting perfectly good drugs. But, every year, we waste untold amounts of money and resources by prescribing antibiotics to patients who do not need them. Not only does this practice squander the drug supply, it leads directly to antimicrobial resistance – the growth of bacteria that are resistant to current antibiotic therapies.
For 70 years, scientists have been warning patients and physicians alike not to overuse antibiotics. Alexander Fleming himself, the discoverer of penicillin, cautioned that the physician who prescribes unnecessary antibiotics for one patient is directly responsible for the death of another when that latter patient has no effective antibiotic options for his infection.
Today, we are faced with the emergence of bacteria that are resistant to some of the best therapies we have to offer: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, multidrug-resistant Pseudomonas aeruginosa, and carbapenem-resistant Enterobacteriaceae, just to name a few. Plus, there are no new immediate prospects for broad-spectrum antibiotics coming to the market.
Pharmacists have long advocated the safe and effective use of medications; we have set evidence-based standards for the use of antibiotics and we have educated patients and prescribers on the risks associated with their misuse and overuse. But, these efforts have seemed to be in vain, since nearly 50% of the antibiotics prescribed in this country every year are believed to be inappropriate or unnecessary. A recent survey of prescribers and patients indicated that antibiotics are prescribed without appropriate cause, despite the knowledge that they could be ineffective and lead to drug-resistant bacteria. The attitude that “antibiotics can’t hurt, so why not give them a try” misses the entire message of antimicrobial stewardship.
Antimicrobial stewardship programs are tools to optimize antimicrobial therapy by providing targeted antibiotics at the right dose for the right length of time. Antibiotic use is monitored and outcomes are measured. The decision to administer antibiotics is based on cultures, sensitivity and resistance data, and patient response, and prescribers are accountable for their antibiotic choices. Recent reports indicate that antimicrobial stewardship programs are achieving successes in reducing costs and delaying the emergence of drug resistance, though we have a long way to go before people stop taking antibiotics for every sniffle, cough, and fever.
Education has clearly not stopped the inappropriate use of antibiotics, but the education must continue. In addition, rapid diagnostic and molecular tests should be developed and employed to immediately assess the usefulness of antibiotics for a suspected infection. And, placing financial pressure on patients and providers not to use unnecessary antibiotics may help inspire change in these habits.
Antibiotic resources are finite, and antibiotics lose their effectiveness over time. Unlike other drugs, the usefulness of antibiotics depends on how appropriately the person before you used them. Antibiotic resistance is already a global health problem, but, even more worrisome, it is also an individual problem. If you take an unnecessary antibiotic now, the next time you really need it, it might not be effective.
Antibiotics are a public good, and antibiotics are for the public good. Together, we are waging a war on bacteria, but the more we use antibiotics inappropriately or unnecessarily, the more battles we lose.
References
Cooke J, Stephens P, Ashiru-Oredope D, Johnson AP, Livermore DM, Sharland M. Antibacterial usage in English NHS hospitals as part of a national Antimicrobial Stewardship Programme. Public Health. Aug 14 2014.
Del Arco A, Tortajada B, de la Torre J, et al. The impact of an antimicrobial stewardship programme on the use of antimicrobials and the evolution of drug resistance. Eur J Clin Microbiol Infect Dis. Aug 16 2014.
Gauthier TP, Lantz E, Heyliger A, Francis SM, Smith L. Internet-based institutional antimicrobial stewardship program resources in leading US academic medical centers. Clin Infect Dis. Feb 2014;58(3):445-446.
Gibson JL. Lessons learned from a student-initiated antibiotic awareness program. Am J Health Syst Pharm. Sep 1 2006;63(17):1590, 1592.
Goff DA, Nicolau DP. When pharmacodynamics trump costs: an antimicrobial stewardship program’s approach to selecting optimal antimicrobial agents. Clin Ther. Jun 2013;35(6):766-771.
Lim CJ, Kwong M, Stuart RL, et al. Antimicrobial stewardship in residential aged care facilities: need and readiness assessment. BMC Infect Dis. 2014;14:410.
Spellberg B. Antibiotic judo: working gently with prescriber psychology to overcome inappropriate use. JAMA Intern Med. Mar 2014;174(3):432-433.
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