Antibiotics: Safe and Effective Use
Antibiotics kill or inhibit the growth of bacteria. In 1928, Alexander Fleming accidentally discovered penicillin, but it was not routinely used until the early 1940’s. With the help of Ernst Chain and Howard Florey, penicillin was purified and was able to be used. Amazingly resistance was noted only three years after it was introduced in the mid 1940's.
The first commercially available antibiotic was Prontosil, which was available in the late 1930’s. This was a sulfa drug that was effective at killing multiple types of bacteria. It was developed in Germany and was effective against a type of bacteria called gram-positive cocci.
Antibiotics have changed the way medicine is practiced and has saved many lives. In today’s health care setting, antibiotics are used too frequently and their effectiveness has been minimized by their overuse. Over the last 10 years most bacteria have developed some degree of antibiotic resistance.
Forty-five million antibiotics are prescribed each year[i]. Antibiotic prescriptions are written far to often for conditions that do not necessitate an antibiotic. Forty-four percent of those with a common cold, 75% of those with bronchitis and 46% of those with an upper respiratory tract infection are given an antibiotic[ii]. These conditions will be discussed later, but most of the time each condition does NOT require an antibiotic. How is that for over prescribing?
Uses for antibiotics
Antibiotics are indicated for many infectious illnesses. Even when an antibiotic is indicated, it is not always necessary. For example, multiple antibiotics are indicated for inner ear infections (acute otitis media), but antibiotics are not always needed in the management of ear infections. The body is perfectly capable of fighting off many cases of ear infections.
Primary reasons antibiotics are given in the outpatient primary care setting include:
· Ear infection – 22%
· Sore throat– 19%
· Sinusitis – 17%
· Upper respiratory tract infections – 17%
· Bronchitis – 17%
Overuse of Antibiotics
Antibiotics are overused. Multiple reasons exist to explain why antibiotics are given more often than they are needed. Some examples include the health care provider:
· Is unaware that an antibiotic is not the ideal treatment.
· Often underestimates the harm that can come from antibiotics.
· Is unaware of the cause of the symptoms and consequently treats the patient to avoid missing a bacterial cause of the symptoms and risk the development of complications.
· Gives into pressure from patients or perceived pressure from patients. Patients who ask for an antibiotic or give off clues that an antibiotic is what they desire are more likely to get one. Patients often feel that an antibiotic is the reason that the patient makes an appointment. If they do not get an antibiotic they feel that they have wasted their time and money. Clinicians do not want to disappoint patients and often cater to their needs.
Prescribing antibiotics is a cycle. For example, a patient has a viral illness and present to their doctor reporting that they have had a runny nose for three days. Today the nasal discharge changed from clear to thick green. An antibiotic is given and the patient is better in two to three days.
The patient would have gotten better if they took the antibiotic or they did not take the antibiotic, but the patient will attribute getting better to taking the antibiotic. The next time they get a viral infection they will want and expect an antibiotic.
One of the most common reasons an antibiotic is given is for the common cold. More than two hundred viruses have the potential to cause the common cold.
The most common presentation is the cold starting out with a sore throat followed by nasal congestion, cough, fever (which lasts 2-3 days), sneezing and headache. Nasal discharge starts clear and thin, but often becomes thick and turns yellow or green after about 3-4 days. The common cold typically lasts between 7-11 days.
The common cold does not warrant an antibiotic and does warrant symptomatic treatment. You should watch for any bacterial complications after a cold. This may include persistent fever and symptoms such as purulent nasal discharge, facial pain that increases with bending over, persistent headache and a poor response to decongestants that lasts longer than 10 to 14 days.
Complications of antibiotics
Many reasons exist to not use antibiotics. The reasons range from life threatening to minor annoyances. Resistance, side effects, drug interactions are common reasons to avoid antibiotics.
Antibiotic resistance occurs over time as organisms improve their ability to survive when attacked by antibiotics. Resistance is not a new phenomenon. Before penicillin was even available for public use, the research team that helped bring it into clinical use demonstrated that Staphylococcus was able to develop resistance to it.
After its development, penicillin was used inappropriately. It was put in multiple products including soap, throat medication and mouthwash. By the late 1940’s almost seventy percent of Staphylococcus aureus (a bacteria that commonly causes skin infections) was resistant to penicillin.
Resistance appears as the resistant bacteria survives the attack of antibiotics and then multiply. The surviving bacteria are stronger and able to survive the next attack by antibiotics. The molecular causes of resistance are variable and are beyond the scope of this article.
Causes of antibiotic resistance
Multiple reasons contribute to antibiotics resistance.
· Improper prescribing the dose based on the person’s weight may lead to incomplete eradication of the bacteria.
· Prescribing antibiotics inappropriately also contributes to resistance, such as prescribing an antibiotic for a viral infection.
· Patients who do not take the entire course of antibiotics or take the antibiotic incorrectly facilitate resistance. When the antibiotic is only taken for 5 days when it should have been taken for 10 days, not all the bacteria are killed off. The strongest bacteria remain. Now they have seen that antibiotic in the past and may have learned a way to fight that antibioic so it is no longer effective in its erridacation.
· Agriculture also contributes to antibiotic resistance as antibiotics are often given to farm animals as growth promoters in the absence of disease. Organisms that come from animals such as Salmonella, Campylobacter, Escherichia coli, and Enterococcus have contributed to the development of antibiotic resistance because of antibiotics used in animals.
Severity of the problem
Some bacteria are now resistant to more than one and in some cases all antibiotics. Treatment of antibiotic resistant infections costs the United States 4-5 billion dollars every year.
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that gets a lot of press. Staphylococcus, more commonly known as Staph, has been around for a long time. It commonly causes skin infection and other types of infections such as pneumonia or blood stream infections.
More recently Staph has become resistant to certain antibiotics. It is a strain of Staphylococcus aureus that is resistant to methicillin. Methicillin is synthetic penicillin, which is rarely used today. MRSA represents a bacterium that is resistant to penicillin.
Staphylococcus infections occur when there is skin-to-skin contact with someone who is infected, or contact with an object that is infected with Staphylococcus. It is more common in those with poor hygiene or those living in crowded conditions. It can get into the body through openings in the skin.
Staphylococcus aureus is carried in the nose or on the skin in up to half of the population. These carriers typically do not get sick from the organism, but are said to be colonized. If Staphylococcus is able to get into the body, infection may ensue.
MRSA is very common in the hospital, but it has recently spread to the community. MRSA has been seen far to common among athletes. Many notable professional football players have been afflicted with MRSA infections. It is possible to bet MRSA by sharing towels, razors, clothes and washcloths. It is also often received when illegal tattoos are given.
When MRSA affects the skin and presents with redness, pain, swelling, warmth and pus-filed pimples or boils.
Tips for preventing MRSA
· Do not share clothes, washcloths, towels, lotions, creams or razors
· Clean any area of broken skin and cover any sore
· Frequently wash your hand with soap and water or an alcohol based sanitizer
· Shower in warm water and wash completely after participating in contact sports
· Clean sporting equipment
Side effects of antibiotics
Side effects are a common problem associated with antibiotic use. While many side effects are specific to individual medications, some side effects are common across a variety of medications. Common side effects with antibiotics prescribed for common infections include: allergic reactions, diarrhea, nausea, vomiting and yeast infections.
Clostridium difficile is a bacterial infection that results in diarrhea. The diarrhea can range form mild to life threatening. It usually occurs after antibiotic use and is more common in those who are older and/or live in the nursing home or have recently been in the hospital.
Clostridium difficile often goes away when the antibiotic is stopped. Those with more severe disease may need antibiotic treatment. If diarrhea lasts more than three days, there are more than 3 episodes of diarrhea per day, there is a fever, blood in the stool, or severe abdominal pain or cramping than a visit to the doctor is important.
The greatest risk of antibiotics is allergic reaction. Most allergic reactions are mild, but some can be severe. Swelling of the throat can occur and may lead to death. This is not common, but it can happen. Always report any allergic reaction to every health care provider you see. Include the type of reaction. For example, was it hives, a rash or an upset stomach? Be specific.
Drug interactions are also specific to medications but certain medications have an effect across mutliple classes of antibiotics. Drugs can interact with mulitple things including other drugs, food or disease states. Therefore, caution must be utilized in every instance of taking a new drug.
Drug interactions may reduce the efficacy of the medication, increase the effects of the drugs or intensify the side effects. This can result in one or both of the drugs causing harm to the body or one or both of the drugs not working.
When ever a new drug is added it is important to check with your health care provider or pharmacist to determine if there is an interaction. This is especially important if you are on mulitple drugs. Key questions to ask are included in Table 1.
Table 1: Questions to ask you health care provider about new drugs
· Is this drug safe to take with other drugs I am taking?
· How long will this drug be active in my body?
· Should certain foods, drinks or other products be avoided when taking this drug?
· What are some potential drug interactions to watch for?
· Where can I find more information?
The efficacy of the contraceptive pill is reduced by antibiotic therapy. Not all studies conclusivly agree with this statement. None-the-less it recommended to use a back up contraceptive method for individals on oral contraceptives and antimicrobial therapy
Alcohol is another medication that does not interact well with antibiotics. Some antibiotics are more problematic than others. Trimethoprim-sulfamethoxazole, metronidazole and some cephalosporins have more significant interactions with alcohol. The use of alcohol with antibiotics is generally not recommended. Alcohol may reduce the level of doxycycline and erythromycin succinate.
If you are on multiple medications, the addition of antibiotics or even over the counter medications have the risk of having a combined effect and either increasing the activity or reducing the activity of one of the other medications.
Strategies to improve antibiotic use
Appropriate use of antibiotics will result in fewer adverse events, less antibiotic resistance and more effective future use of antibiotics. Patients and health care providers alike have a responsibility to use antibiotics safely and judiciously.
Education is a key strategy in the improvement of the use of antibiotics. Education needs to occur on many levels. Clinicians need to have a firm grasp on guidelines for diagnosing and treating illnesses. They need to be able to reliably differentiate between a bacterial and viral infection. Clinicians need to be able to prescribe the correct antibiotic in the proper dose for the proper amount of time.
There is not much you can do as a health care consumer to assure that your doctor follows proper guidelines with the possible exception of going to a good doctor. But, there are strategies you should follow.
Doctors are more prone to prescribe antibiotic to patients who they think expect them, but they do a poor job determining who expects them. Doctor’s only identify about 25% of patients who expect antibiotics[iii]. Therefore, health care consumers should not demand antibiotics for every illness.
Consumers are not trained health care providers, but they ideally should have a general grasp of clinical guidelines for common health care problems. Many people may argue with this statement, but I think it is critical. If you understand what science has shown about the use of antibiotics, you will be less likely to place pressure on clinicians to prescribe antibiotics. Health care providers are highly influenced by the patient's desire.
Many of us grew up or had parents that grew up in the era of antibiotics coming into common use. Penicillin was thought to be such a great product it was put into products such as soaps and mouthwashes. Many people have misinformation about antibiotic use.
Antibiotics were hailed as a magic bullet in the 1940s as it was able to save many patients who would have died before antibiotics became available. Many times antibiotics can be life saving, sometimes they can reduce the duration of the illness and sometimes they do not help at all.
Education can come in the form of public education efforts as well as one-on-one education in the office. The more a patient can be educated, the more likely they will want to avoid the use of antibiotics. Key points for discussion between patient and health care provider in the face of an acute illness include:
· The cause of the illness making the patient sick
· The optimal treatment plan including the necessity (or non-necessity) for antibiotics
· Over the counter medications and other remedies that can help reduce symptoms
Preventing infections will also help reduce the incidence of antibiotic misuse. When there is less infection, there is less chance that antibiotics will need to be used or used incorrectly.
Multiple strategies should be implemented to reduce the risk of common infectious diseases.
· Frequent hand washing with soap and water
· Carry around a bottle of alcohol based sanitizer and wash your hands regularly
· Vaccination (including routine childhood vaccinations as well as the flu shot and pneumococcal vaccine) reduces illnesses that need antibiotics
· Avoid places where there are a lot of sick people
· Use a tissue when you cough or sneeze and do not cough or sneeze into your hands. If you have to cough or sneeze do it into a tissue or your arm.
· Live a healthy lifestyle. This includes: exercising, eating well, not smoking, drinking adequate fluid and getting adequate rest.
· Use a virus killing disinfectant and disinfect items commonly touched as viruses can live on surfaces for hours and sometimes longer.
· Use nasal saline regularly – especially in the winter or in low humidity environments.
Ways to improve the health of America
How can we accomplish the goals laid out in this book? It will require two major steps.
1. Improve clinician’s skills to NOT prescribe antibiotics
2. Educate American society about infectious disease, how to manage it and the risks and harms of antibiotics
Step number one is out of the hands of most Americans, but it is important to understand none-the-less. Health care providers – including everyone from the doctors who prescribe the medication, to the pharmacists who dispense the medication, to the nurses who give the medication, to the aids who care for the patients – should understand the clinical utility of antibiotics. A consistent message across the board will reduce mixed signals being sent.
The American public needs a re-education. Over the last 60 years, antibiotics have become a remedy of far too many illnesses. People are misinformed about their use and under informed about their risk. This puts the health care system in extreme jeopardy.
[ii] Nyquiest AC, Gonzales R, Steiner JF & Sande MA. Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections and Bronchitis. Journal of the American Medical Association 1998; 279(11): 875-877.
[iii] Spurling GKP, Del Mar C, Dooley L & Foxlee R. Delayed Antibiotics for Respiratory Infections. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004417.
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