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The bitter pill on antibiotic overuse

03 Jan 2022

  • Balancing patients’ vulnerabilities and expectations against doctors’ responsibilities and restraint
BY Sumudu Chamara Sri Lanka’s health sector is one of the most affected sectors, if not the main one thus affected, owing to the Covid-19 pandemic, and it has faced unprecedented challenges which Sri Lanka was barely in a position to manage. However, amidst the pandemic and related challenges, the health authorities have had to continue their efforts to deal with challenges that existed even before the pandemic and continue to exist.  The misuse of antibiotics in Sri Lanka, which has existed for years, is one such issue. Even though the matter has been discussed before, the fact that it is continuing begs the question as to whether the steps Sri Lanka has taken to address it are adequate. Recently, the authorities reiterated the existence and seriousness of this issue, adding that they are considering taking action to streamline the process of supplying medicines in a bid to address this misuse.   Antibiotics misuse Addressing a meeting with the All-Ceylon Private Pharmacy Owners’ Association, State Minister of Production, Supply, and Regulation of Pharmaceuticals Prof. Channa Jayasumana alleged that doctors are primarily responsible for the above-mentioned situation. He added: “Certain antibiotics that those in western countries think 100 times about before giving them to someone, are largely used in Sri Lanka. There are certain antibiotics that are only used for infections and they are now being given to children for the cold and fever too. Doctors are trying to become ‘one-shots’ and when that is going on for some time only this issue arises.” Citing a recent study on kidney disease, Prof. Jayasumana also claimed that it has been revealed that many water sources in Sri Lanka are contaminated with antibiotics. However, attempts by The Morning to contact Prof. Jayasumana to learn more about the report he cited were unsuccessful. With the aim of addressing the misuse of antibiotics, he said that a programme will be formulated to curb activities such as the sale of illicit drugs and the misuse of drugs, and emphasised that the support of pharmacy owners is of great importance for that endeavour. He also claimed that various illegal drugs are being sold at present, adding that there is however no system in place to punish those responsible for such offences. Such medicines being delivered to homes, according to him, is another issue. Adding that certain provisions of the current National Medicines Regulatory Authority (NMRA) Act allow people to commit offences, he noted plans to amend the Act in the future. Speaking of the actions against the misuse of antibiotics during the meeting, he said: “I know that illegal drugs are being sold. Often, there is a small fine for such acts. Therefore, a system through which those who commit such acts can be punished should be devised. What is happening now is aiding and abetting illegal activities instead of preventing them. There is a system in place to sell drugs, such as the painkiller Tramadol and the anticonvulsant Gabapentin, illegally. The support of the pharmacy owners is vital to stop such activities.” Although The Morning attempted to discuss the alleged rise in prescribing antibiotics by doctors with several leading medical professionals and medical associations, while some were not reachable, some refused to comment on the matter. Antibiotics resistance and responsibilities  According to the World Health Organisation (WHO), antibiotics misuse and overuse is one of the practices that accelerate the condition called antibiotics resistance, a condition global medical experts fear will become a pressing issue in the near future if left unmanaged.  It occurs naturally when bacteria change in response to the use of antibiotics, and it is the bacteria, not humans or animals, that become antibiotic resistant. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria, and antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality. According to the WHO, infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis are becoming harder to treat as the antibiotics used to treat them become less effective. In a fact sheet on antibiotic resistance, the WHO underscored: “The world urgently needs to change the way it prescribes and uses antibiotics. Even if new medicines are developed, without behaviour change, antibiotic resistance will remain a major threat. Behaviour changes must also include actions to reduce the spread of infections through vaccination, hand washing, practising safer sex, and good food hygiene.” To manage this situation, the WHO recommended that individuals only use antibiotics when prescribed by a certified health professional, refrain from demanding antibiotics when health professionals decide that antibiotics are not necessary, always follow health professionals’ advice when taking antibiotics, refrain from sharing or using leftover antibiotics, and prevent infections by preparing food hygienically, avoiding close contact with sick people, and keeping vaccinations up to date. The WHO also recommended that policy makers strengthen policies and programmes. Further, the WHO recommended the implementation of infection prevention and control measures, the regulation and promotion of the appropriate use and disposal of quality medicines, and to make information available on the impact of antibiotic resistance. In addition, the WHO has issued recommendations for health professionals. Among them are prescribing and dispensing antibiotics only when they are needed, according to the existing guidelines, and talking to patients about how to take antibiotics correctly, antibiotic resistance, and the dangers of misuse. With regard to the use of antibiotics in the agriculture sector (giving antibiotics to farm animals), the WHO recommended giving antibiotics to animals only under veterinary supervision, refraining from using antibiotics for growth promotion or to prevent diseases in healthy animals, and vaccinating animals to reduce the need for antibiotics and the use of alternatives to antibiotics when available. Prescribing antibiotics Prescribing antibiotics is not a process that depends solely on medical information, and the decision-making process behind it can be a complex process, during which physicians are influenced also by medical professionals’ interactions with patients, the uncertainties that surround medical decision making, and the organisational challenges of delivering care in busy outpatient settings. This was noted in a study titled “What Drives Inappropriate Antibiotic Use in Outpatient Care?” conducted by The Pew Charitable Trusts and Centres for Disease Control and Prevention. Patient satisfaction and pressure, time constraints, diagnostic uncertainty, and externalised responsibility were also factors that affected health professionals’ judgement regarding prescribing antibiotics, according to the study. It explained that patients or their family members often expect a prescription for antibiotics when visiting a health professional, even when it is not necessary, and that some studies (“Childhood Fever: A Qualitative Study on General Practitioners’ [GPs] Experiences During Out of Hours Care” by E.G.P.M. de Bont et al. and “Public Beliefs on Antibiotics and Respiratory Tract Infections: An Internet-Based Questionnaire Study” by J.W.L. Cals et al.) have suggested that they may tend to wrongly believe that antibiotics can relieve symptoms similar to those they have experienced in the past. Some studies (“Paediatrician Perceptions’ by Szymczak et al. and “GPs Reasons” by Petursson et al.) that involved interviewing physicians have also revealed that some physicians had been swayed by this perceived pressure to prescribe unnecessary antibiotics.  The study said that patient pressure may be particularly influential in a physician’s decision-making because doctors relate to patients as both a caretaker and service provider, and that as such, they must be conscious of both patient health and customer satisfaction. Quoting a number of other studies, the study said that clinicians report that they sometimes prescribe antibiotics owing to concerns about appearing to have done nothing for their patients or out of fear of losing patients to competitors, and that in some cases, physicians may believe that prescribing antibiotics will increase patient satisfaction with the office visit. The study also said that in outpatient settings, doctors have limited time to see patients, adding that certain studies had quoted physicians as saying that workload and time pressures contribute to the over-prescription of antibiotics. One study of Norwegian GPs (“Do GPs’ Consultation Rates Influence Their Prescribing Patterns of Antibiotics for Acute Respiratory Tract Infections?” by S. Gjelstad et al.) has found that busier physicians, or those with more consultations, prescribed antibiotics at a higher rate than their less busy colleagues.  Furthermore, the report stated that health professionals prescribing and dispensing practices responded to continued challenges of access to information on resistance patterns, access to next line antibiotics, access to diagnostics, and access to patient medical records, and that health professionals across settings reported that medical or pharmaceutical representatives visiting frequently influenced their prescribing of antibiotics. Quoting two more studies (“Childhood Fever” by D. Bont et al. and “Primary Care Clinicians Perceptions” by Dempsey et al.), the study added that interviews with physicians suggest that they may quickly prescribe antibiotics because a shorter office visit allows them to see more patients or because they want to avoid lengthy explanations of why antibiotics are not needed.  In addition, uncertainty relating to diagnostics is one of the reasons health professionals tend to prescribe antibiotics, especially when patients show symptoms which are similar to many bacterial or viral illnesses. According to a study titled “Primary Care Clinicians’ Perceptions” by Dempsey et al., when the patient shows ambiguous symptoms, clinicians may tend to prescribe antibiotics immediately because they see it as the safe choice, and several studies have quoted physicians as expressing hesitance to allow sick patients to leave without treatment as they fear that the condition could worsen, potentially exposing themselves to legal action.  Moreover, “Multisite Exploration” by May et al. had found that many physicians perceive the risk of under-treating a patient to be greater than the risk from unnecessary antibiotic use. Furthermore, a report submitted to the WHO by the Antimicrobial Resistance Centre at the London School of Hygiene and Tropical Medicine, titled “Antibiotics Prescribing and Resistance: Views from Low and Middle-Income Prescribing and Dispensing Professionals” also discussed these factors. It said that when prescribing antibiotics, doctors take into consideration a multitude of factors in addition to the state of the health condition for which antibiotics are prescribed. The report said that when prescribing antibiotics, health professionals usually take into account the risks associated with prescribing, or not prescribing, antibiotics. The report was based on data obtained from nine studies conducted in six low and middle-income countries – namely India, the Philippines, Vietnam, Sierra Leone, Nigeria, and Ethiopia – in 2017. A total of 246 qualified health professionals from the six countries were part of the study, and among other things, it discussed the factors health professionals take into consideration when prescribing antibiotics and how various factors, including their knowledge and socioeconomic situations, in the settings they work contribute to their judgement.  It added that health professionals reported prescribing in terms of the empirical weighing up of risks, on the one hand of not giving antibiotics, and on the other of which antibiotic to prescribe, and that awareness of resistance, fake drugs, and the side effects of some types of drugs had led to the empirical tailoring of treatments. It added that in line with study findings across Europe, America, and low and middle-income countries (as per the study “What Drives Inappropriate Antibiotic Use in Outpatient Care?”), decisions to prescribe and dispense were often part of a risk management strategy, in which it was seen as “less risky” or “safer to” (as per the study “It is Safer to…Parent Consulting and Clinician Antibiotic Prescribing Decisions for Children with Respiratory Tract Infections: An Analysis Across Four Qualitative Studies” by C. Cabral, P. Lucas, J. Ingram, A. Hay, and J. Horwood) prescribe antibiotics than not. The report explained: “Providing antibiotics was part of a wider rationale to mitigate risk and to defend oneself against accusations of neglect. Across the Indian study sites in particular, doctors reported cases of physical violence against clinicians perceived by families to have under-treated patients. Veterinarians also reported prescribing or dispensing antibiotics to reduce the chance of conflict or economic compensation expected by clients if livestock were lost. This situational context led informants to refer to antibiotic prescribing and dispensing as a form of ‘defensive medicine’.” While prescribing antibiotics is the responsibility of health professionals, many international experts have stressed responsibility on the part of patients as well, especially in the case of over-the-counter antibiotics. While some countries have banned or imposed restrictions to limit patients purchasing antibiotics without a prescription, according to reports, it is a common practice in many countries despite the legal situation. Therefore, efforts to prevent the adverse effects of antibiotic misuse should also focus on raising awareness among the public about their responsibility, because it is their health that is at stake.


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