Originally published in The Ottawa Citizen January 21, 2003
Original Title: So many bugs, so little time

Educational campaigns alerting physicians and the public about the dangers of indiscriminate prescribing and use of antibiotics is beginning to raise awareness of the problem. This is a worldwide health issue. In many developing countries, prescriptions are not a requirement to purchase antibiotics. In the West, the indiscriminate use of antibiotics in livestock and fish further complicates matters.

More than 40 per cent of all antibiotics are used as livestock growth promoters in animal feed on U.S. farms. This misuse of antibiotics promotes the development of resistant strains of bacteria poses a risk for the human population. The gradual discontinuation of antibiotic use in animals is a recommendation from a World Health Organization Panel.

What is bacterial resistance? Long-term exposure to the same antibiotic can cause some bacteria to change. Sometimes they accomplish this on their own accord. These changes can enhance the germ’s ability to defend itself against antibiotic attack. Increasingly, they are winning the fight. They can reproduce even while you are taking an antibiotic. This is what germs being “resistant” to an antibiotic mean.

The news reports talk of hospital superbugs, methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE), resistant to every available antibiotic. Although once the domain of hospitals, there is concern that these bugs will eventually end up in the community. Indeed, there are resistant strains of tuberculosis present in certain areas of North America.

We are virtually defenseless against these germs. There are few new antibiotics on the horizon to counter this threat. Are we to face the same helplessness and suffering that was so common prior to the advent of antibiotics in the 1940’s?

In 1998, the Workshop Report: Forum on Emerging Infections, Division of Health Sciences Policy, Institute of Medicine, Washington, D.C. estimated that 20 to 50 percent of antibiotic prescriptions prescribed by community primary care physicians in the United States were unnecessary. So too were 25 to 45 per cent of all U.S. hospital-based prescriptions.

The report urges primary care physicians to adjust their prescribing behaviors to ensure that the crisis does not worsen.

What have we learned about antibiotic resistance?

• The longer the antibiotic use in the general population to treat a specific infection, the more likely resistance will appear.
• Resistance progresses from low to high levels. The reverse is less likely to happen.
• Once a microbe becomes resistant to one antibiotic, it often will do so again against another.
• Antibiotic resistance will not disappear. It may slowly reverse itself with the cessation of indiscriminate use.
• The antibiotic alters germs within a person’s body. These germs can spread to other people in the surrounding environment.

You and your doctor must work together in order to better control antibiotic resistance. Childhood vaccinations and routine boosters through adulthood reduce the risk of certain bacterial infections.

Physicians sometimes prescribe an antibiotic because of patient demand. Some insist they receive an antibiotic for their sore throat because their previous physician always prescribed one. This form of prescribing strengthens the patient’s belief that antibiotics treat all forms of sore throat. The expectation of an antibiotic prescription means that the patient is more likely to return to the doctor’s office for every sore throat.

The Workshop report recommends that physicians take the time to educate patients about antibiotic use. They state physicians prescribe antibiotics only if there is convincing medical evidence of a bacterial infection.

In family practice, it is common to encounter complaints of sore throat, cough, earache, sinus congestion and urinary bladder pain. These problems are not always bacterial in origin.

If the diagnosis of a bacterial cause for these infections is unclear, several tests can help the physician determine whether there is a need for antibiotics:

• Send a throat swabs to the lab for a bacterial culture or perform a five-minute rapid Strep throat test in the office.
• A chest x-ray can help diagnose pneumonia.
• A one-minute simple urine test strip can diagnose a bladder infection.
• Not all earaches and sinus congestion require antibiotics. Sometimes it is prudent to wait a day or two to monitor its progress before initially opting for antibiotic therapy.

In the event of a positive test, complete the full course of antibiotics in order to eradicate all the disease-causing bacteria. Stopping treatment at the mid-way mark encourages resistance among the few surviving bacteria.

Your doctor should take the time to explain why antibiotics are not used to treat viral infections. Most people want reassurance that their illness is not serious. Accurate information empowers patients to understand the nature of their illness. Many accept the explanation and learn from the experience.

Next week’s column will review the differences between bacteria and viruses. How do antibiotics work? Get your microscopes ready.