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Nov
14

Antibiotic Crisis: Avoiding Overuse

Gretchen Welby, MHA, PharmD

Gretchen Welby, MHA, PharmD

Guest Columnist: Dr. Gretchen Welby, MHA, PharmD

Dr. Welby received undergraduate degrees from Keystone College and Philadelphia College of Pharmacy and Science.  She received a Master’s Degree in Health Administration from the University of Scranton and a Doctor of Pharmacy degree from Temple University.  She currently teaches in the Biology department at the University of Scranton and Pharmacology at Marywood University in the Physician Assistant Program.

Antibiotic Resistance Crisis Prompts U.N. Intervention

The United Nations, for only the fourth time in the institution’s history, has convened a special meeting to discuss a world health crisis.  World leaders meet on September 21st to discuss solutions to combat the ever increasing problem of antibiotic resistance.

Antibiotic Resistance

Antibiotic resistance occurs when bacteria no longer respond to the drugs designed to kill them.  For almost a decade, the Centers for Disease Control and Prevention (CDC), along with other national and international agencies have supported an initiative called “Antimicrobial Stewardship”.  The hallmark of Antimicrobial Stewardship is the judicious, appropriate use of antimicrobials.

Some sobering statistics from the CDC:

  • Approximately 30-50% of antibiotics are used incorrectly with regard to indication, duration of therapy, or choice of agent.
  • Methicillin Resistant Staphylococcus aureus (MRSA) kills more Americans each year then HIV/AIDS, homicide, emphysema and Parkinson Disease combined.
  • Annually, 23,000 deaths are caused by drug resistant bacterial infections
  • Antibiotic resistance costs $20 billion per year in excess healthcare costs.

Patients and providers must take equal responsibility.  When we get sick, we often feel we need an antibiotic right away. In fact, patients often demand them.  Is this the correct approach to therapy?  Are we using antibiotics too readily?  What are the consequences of profuse antibiotic use?

In which of the following situations are antibiotics warranted?

  1. Cold symptoms (runny nose, sore throat, headache, stuffiness) with a fever of 1010
  2. Cold symptoms lasting 12 days with persistent stuffiness and headache.
  3. Cold symptoms with yellow-green mucous discharge.
  4. All of the above

The correct answer is “B”.

Let’s dissect the reasons why “B” is the best answer.

Symptoms experienced as part of the common cold can include green/yellow sputum, cough, runny nose, stuffiness, sore throat, headache, fever, and muscle aches.  This illness is caused by a virus, most likely a rhinovirus (rhino = nose).  There are currently ninety-nine identified strains of rhinovirus.

Antibiotics are formulated to destroy bacteria (not viruses).

In fact, antibiotics have no activity against viruses.  Antibiotics target specific bacterial structures or functions.  Common bacterial targets for antibiotics include the cell wall (example: amoxicillin), ribosome activity (example: azithromycin), and bacterial enzymes (example: levofloxacin).  All of those are lacking in the very primitive structure of a virus.  So, you could sit in a bathtub full of penicillin and not cure your cold!

In view of this, one might ask why antibiotics are appropriate after 10 days with cold symptoms. The typical common cold lasts between five and ten days, with symptoms peaking around days three or four and waning at day six.  If symptoms are consistent or regress and then become worse it is likely a sign of a bacterial super (on top of) infection.  How does this happen?  Normally, we carry certain bacteria with us as part of our “normal flora”.  Bacteria are commonly found in our mouth, nasal passages, large intestine, and skin.  These bacteria work with our body providing various “services”.  A viral infection disturbs the normal balance of bacteria, allowing for proliferation and a subsequent bacterial infection.

Why should we be careful about antibiotic use?

Side Effects

The most compelling answer is antibiotic resistance (more about that topic in a minute).  Beyond antibiotic resistance, antibiotics are not innocuous substances.  They have significant side effect profiles.  Adverse drug reactions associated with antibiotics can be less severe and consist of mild rash or nausea, vomiting, diarrhea.  More serious reactions include heart arrhythmias, tendon rupture, Stevens Johnson syndrome (severe skin reaction resembling thermal burns), liver damage, and kidney damage.  Remember, every drug (not only antibiotics) has the potential to cause unpredictable adverse reactions.

Resistance

Each time bacteria are exposed to an antibiotic some are destroyed while others fight to resist the antibiotic so the bacteria can live to see another day (remember Darwin’s “Survival of the Fittest”).  The theory with antibiotic therapy is that the great majority of bacteria will be destroyed and those that survive will be quickly disposed of by the body’s immune system.  Antibiotics are unique in that the more they are used, the less effective they become.  When antibiotics are used inappropriately – not taking the medication on schedule, not finishing the entire prescription, using antibiotics for viral infections – bacteria have a chance to fight to overcome the antibiotic activity.  The resistant bacteria may go on to infect others.

Limiting the risk of antibiotic resistance

Identify the causative agent if possible.

For example, a sore throat should not be treated with antibiotics until a throat culture is obtained and a bacterial cause is identified.  FYI – According to the Infectious Disease Society of America (IDSA), 90% of adult sore throats have a viral cause, not bacterial.

Use the most “narrow” spectrum of activity antibiotic

Antibiotics may cover many bacterial species (“wide” spectrum).  These “wide” spectrum antibiotics have been shown to increase resistance rates.

Compliance

All medications, especially antibiotics, need to be taken as prescribed, to decrease risk of resistance,.  This includes keeping to a daily schedule, taking the antibiotic with or without food as instructed, and completing the course of therapy.

Education

Educating the patient and prescriber will leading to proper use of antibiotics to curb antibiotic resistance.

SOURCES:

-Centers for Disease Control and Prevention, Office of Infectious Disease Antibiotic resistance threats in the United States, 2013. Apr, 2013

-Gross M. Antibiotics in crisis. Curr Biol. 2013;23(24):R1063–R1065

http://www.cdc.gov/getsmart/week/downloads/antibiotic-resistance-the-global-threat.pdf

 

Read Dr. Mackarey’s Health & Exercise Forum in the Scranton Times-Tribune every Monday. This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.