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. 1998 Nov 28;317(7171):1521. doi: 10.1136/bmj.317.7171.1521b

Resistance to antibiotics

Prescribing of antibiotics needs to be rational

Philip Pearson 1, Paul McWhinney 1, Philip Stanley 1
PMCID: PMC1114349  PMID: 9831591

Editor—We agree with Hart that undergraduate and postgraduate medical education in the use of antimicrobials needs to be increased.1 Abbasi’s news article2 is opposite a full page advertisement for an antibiotic. This advertisement seems to promote the use of a new fluoroquinolone to treat respiratory infections “even [due to] Streptococcus pneumoniae” in the community. Most strains of S pneumoniae remain sensitive to penicillin, and there is little evidence that quinolones are needed to treat acute sinusitis or acute exacerbations of chronic bronchitis.

The only other advertisement for an antibiotic in that edition of the BMJ occurs in the middle of a meta-analysis of antibiotic prophylaxis in critically ill people.3 The presence of these advertisements emphasises the likely difficulty in changing patterns of antibiotic prescribing.

Footnotes

p.j.stanley@leeds.ac.uk

References

  • 1.Hart CA. Antibiotic resistance: an increasing problem? BMJ. 1998;316:1255–1256. doi: 10.1136/bmj.316.7140.1255. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Abbasi K. Report calls for action on antibiotic resistance. BMJ. 1998;316:1261. doi: 10.1136/bmj.316.7140.1261. . (25 April.) [DOI] [PubMed] [Google Scholar]
  • 3.D’Amico RD, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. BMJ. 1998;316:1275–1285. doi: 10.1136/bmj.316.7140.1275. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1998 Nov 28;317(7171):1521.

Restricted prescribing resulted in reduction of resistant strains

Morten Lindbaek 1, Per Hjortdahl 1

Editor—Abbasi’s news article1-1 and Hart’s editorial1-2 about resistance to antibiotics raise interesting questions. Most antibiotics are prescribed in general practice, and how general practitioners deal with the problem of resistance is crucial. Resistance is closely related to the total amount of antibiotics prescribed and the proportion of broad spectrum antibiotics. In Finland, a high frequency of resistant streptococci has been reported, and a clinically significant reduction of resistant strains was found after recommendations for more restricted prescribing were implemented.1-3

In Norway, the prescription rate of antibiotics has risen by 40% from 1980 to 1993, but it is now declining. We have a minor problem with resistance to antibiotics in primary care. Pneumococci are still sensitive to phenoxymethylpenicillin, and the frequency of resistant Haemophilus influenzae has constantly been 10% of cases during the past years. The most likely reason for this favourable situation is the use of phenoxymethylpenicillin as the drug of choice for most common respiratory tract infections, such as acute otitis media, sinusitis, tonsillitis, and infections of the upper respiratory tract.

We believe that much can be done to reduce the use of antibiotics and that this may be of interest to other countries. Sixty per cent of all antibiotics are prescribed for infections of the respiratory tract, almost all in primary care. Antibiotics have been shown to be of little value in the treatment of acute otitis media and acute bronchitis. The treatment of patients with acute sinusitis is still debated.1-4 Treatment should be given only during the first week of symptoms, as the disease in many cases is self limiting. The treatment of sore throat is also debated, and only patients with group A streptococci are in need of antibiotic treatment. The differential diagnosis and treatment in infections of the lower respiratory tract are difficult when the diagnosis is based on clinical evaluation alone. We have shown that a rapid test of C reactive protein, done in the general practitioner’s office and providing an answer within 10 minutes, can be helpful in identifying patients who need to be treated with antibiotics.1-5 The test contributed to reducing the consumption of antibiotics by a quarter in our investigation. Another rapid test diagnosing group A streptococci is useful to assess patients with sore throat.

Paramedical reasons, such as forthcoming examinations or imminent holidays, can influence the amount of antibiotics prescribed. General practitioners should be aware of these factors and not accept them as a reason to presribe antibiotics.

Footnotes

morten.lindbak@samfunnsmed.uio.no

References

  • 1-1.Abbasi K. Report calls for action on antibiotic resistance. BMJ. 1998;316:1261. doi: 10.1136/bmj.316.7140.1261. . (25 April.) [DOI] [PubMed] [Google Scholar]
  • 1-2.Hart CA. Antibiotic resistance: an increasing problem? BMJ. 1998;316:1255–1256. doi: 10.1136/bmj.316.7140.1255. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Seppala H, Klaukka T, Vuopio-Varkila J, Moutiala A, Helenius H, Lager K, et al. The effects of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med. 1997;337:441–446. doi: 10.1056/NEJM199708143370701. [DOI] [PubMed] [Google Scholar]
  • 1-4.Lindbaek M, Hjortdahl P, Johnsen UL-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxicillin in treatment of acute sinus infections in adults. BMJ. 1996;313:325–329. doi: 10.1136/bmj.313.7053.325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-5.Lindbaek M, Hjortdahl P. C-reactive protein in primary care—a useful diagnostic tool in infections. Tidsskr Nor Laegeforen. 1998;118:1176–1179. [PubMed] [Google Scholar]
BMJ. 1998 Nov 28;317(7171):1521.

Expert controlling bodies need to be established

Anthony Tucker 1

Editor—Hart’s editorial on antibiotic resistance asks questions that ignore scientific history.2-1 Thirty years ago the BMJ published a paper by Anderson on antibiotic resistance, its mechanisms of transmission, and implications, which embraced essential answers.2-2 This paper refers to the Swann committee, a temporary body then gathering evidence but dissolved in 1969 after it had reported an urgent need to limit antibiotic use in animal husbandry. Anderson’s concluding emphasis was that the public health implications of antibiotic resistance are so serious that a powerful standing body is needed for medical and public protection. In the event, even the limited restrictions on antibiotic use imposed in Britain in the light of the Swann report proved so unpalatable to affected industries that pressure saw them quietly eroded after a change of government.

A damaging gap in public health history and comprehension has since developed. The BMJ would do itself and the worlds of microbiology and medicine a great service were it to reprint this meticulous early paper. The clarity, power, and high quality of its science might stimulate the serious professional and government response that the problem requires. It seems extraordinary that, after 30 years, no standing expert controlling body has been established in Europe. Government and professional ambivalence together have allowed most of the predicted public health problems to become a worldwide reality, even though the practical and educational measures needed for effective control are attainable and remain unchanged. Research into drug resistance has moved forward and shown unexpected complexities in the mechanisms—for example, genetic interchangeability between bacterial and human cells2-3—which could bring benefits. These will, however, resolve neither massive political inertia nor the scientific amnesia blocking progress on this important issue. Realisation that the fiscal costs of poor control of drug resistance are as high as the costs in human and animal misery is perhaps the trigger that will eventually set policy rolling.

Footnotes

PATalban@aol.com

References

  • 2-1.Hart CA. Antibiotic resistance: an increasing problem? BMJ. 1998;316:1255–1256. doi: 10.1136/bmj.316.7140.1255. . (25 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Anderson ES. Drug resistance in Salmonella typhimurium and its implications. BMJ. 1968;iii:333–339. doi: 10.1136/bmj.3.5614.333. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-3.van Veen HW, Callaghan R, Soceneantu L, Sardini A, Konings WN, Higgins CF. A bacterial antibiotic resistance gene that complements the human multidrug resistance p-glycoprotein gene. Nature. 1998;391:291–295. doi: 10.1038/34669. [DOI] [PubMed] [Google Scholar]

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