From: "E-Drug" <e-drug@healthnet.org>
Subject: [e-drug] BMJ: Why this love for antibiotics in India?
Date: 14 October 2012 21:20:16 GMT+01:00
To: "'Essential Drugs in English'" <e-drug@healthnet.org>
Reply-To: Essential Drugs in English <e-drug@healthnet.org>

E-DRUG: BMJ: Why this love for antibiotics in India?
----------------------------------------------------
[copied as fair use; thanks to Kirsten for spotting; WB]

Views & Reviews, Personal View

BMJ 2012; 345 doi:  <http://dx.doi.org/10.1136/bmj.e6209>
http://dx.doi.org/10.1136/bmj.e6209 (Published 2 October 2012) 

Cite this as: BMJ 2012;345:e6209 

Pankaj Vohra, senior consultant, pediatrics/pediatric gastroenterology, Max
Healthcare, New Delhi, India 

pankajvohramd{at}yahoo.com 

Patient's mother: "Doctor, can you please prescribe an antibiotic. My 4 year
old child has been suffering from diarrhoea for the past three days."

Doctor: "Madam, there's no need for an antibiotic. This is a viral
infection, which is self limiting. Antibiotics may, in fact, make the child
worse."

Mother: "But doctor, I have only come to you to get antibiotics. I am
already doing the rest of the treatment. What is the point in my spending
two hours getting the child here, taking half a day's leave from the office,
and paying your fee, without getting an antibiotic? I could have ordered
norfloxacin from the chemist and spent less money and less time."

Doctor: "Madam, your time and money have been well spent. You are paying to
protect your child from antibiotics-and for the reassurance that the illness
will pass in a week."

Mother: "A week? No, doctor, that's too much. The child has important
examinations at school. I should not have listened to you in the first place
and started norfloxacin on day one. Please refund my money, and I will get
the drug from the chemist. I thought you were a good doctor but I won't come
to you again."

An estimated half of prescriptions for antibiotics are unnecessary and a
leading cause of bacterial resistance.
<http://www.bmj.com/content/345/bmj.e6209?etoc=#ref-1> 1 Remember the
carbapenem-resistant New Delhi metallo-beta-lactamase 1 Enterobacteriaceae?
The effect of bacterial resistance is seen worldwide but it is most acute in
developing countries, where expensive medical care pushes thousands into
poverty every day. So why do we use so many antibiotics?

Most general physicians and paediatricians forget that viruses cause almost
90% of febrile illness. Most doctors have trained in busy government
hospitals where the concept of viral illness rarely exists, at least in
outpatient departments. Patients with illness that lasts a short time, such
as viral fever, upper respiratory tract infection, or non-dehydrating acute
gastroenteritis, are unlikely to present to the emergency department or
outpatient department. So students don't receive training, and teachers
don't see viral illness and rarely if ever get an opportunity to follow such
patients.

Almost 80% of all Indian prescriptions include an antibiotic whether it is
needed or not, and that is what students learn.
<http://www.bmj.com/content/345/bmj.e6209?etoc=#ref-2> 2 Diagnosis is rare,
and even when one is made, a broad spectrum antibiotic is often prescribed.
Recently I prescribed oral penicillin. The patient came back from the
pharmacy saying, "Is the doctor trying to kill this child-this drug is not
available because it is extremely dangerous." But allergic reaction is much
more likely with injectable rather than oral penicillin, and the more easily
available amoxicillin and amoxicillin-clavulanic acid combinations are also
penicillins and carry the same risk.

In busy outpatient practices, doctors find it easier to give antibiotics in
case they are unsure or might have missed something. And patients have had
the idea ingrained into them that only antibiotics can cure disease. In
rural India, patients often demand injectable antibiotics.

It is often easier and quicker to give antibiotics than to spend time
explaining to patients that antibiotics are not needed. Some patients with
viral illness will develop a secondary infection. An antibiotic might then
have to be prescribed, with a further consultation taking up time and
costing money. The doctor may now feel awkward because he or she has to give
an antibiotic and decide to charge the patient again. So why not just give
the antibiotic to begin with?

Patients with non-resolving illness often seek a second or a third opinion,
and antibiotics are likely to be added or changed. The first doctor is all
too aware of this and may be worried about losing the patient to another
doctor's care. Subsequent doctors will rarely contact the first doctor but
will have the advantage of the first doctor's diagnosis.

Few insurance companies cover outpatient drugs, so doctors are rarely
checked about rates of antibiotic prescribing, and pharmacies prefer to sell
expensive drugs. And without adequate counselling patients tend to stop
using antimicrobials once fever resolves, encouraging resistance.

Physicians commonly prescribe antibiotics for three days, but other than for
azithromycin this is absurd. This prescribing pattern is copied by junior
doctors and by pharmacists who dole out antibiotics without prescriptions.
So now we have too many prescriptions with a smaller number of doses and
incomplete courses. It is also possible that some dubious manufacturers
include less of the active ingredient in their formulation to keep costs
down.3 <http://www.bmj.com/content/345/bmj.e6209?etoc=#ref-3> 

Laboratories with outdated technology contribute to false positive and false
negative results. Both scenarios help justify antibiotic use because for
negative results doctors say, "Often the illness does not show up in the
test and hence treating it is important." For example, most enteric fever is
diagnosed by the typhidot test on the third day of illness but the test is
positive in fewer than half of cases in the first week of illness.4
<http://www.bmj.com/content/345/bmj.e6209?etoc=#ref-4> 

Some investigations, such as stool rotavirus antigen testing, lack
availability, resulting in millions of doses of antibiotics being given to
children admitted for dehydrating diarrhoea. Fortunately, antibiotics rarely
have severe adverse effects. Most doctors will never witness Stevens-Johnson
syndrome, and this too favours overprescription.

In most cases the treating physician's poor training or lack of confidence
is to blame. Regulating the sale of antibiotics; having an active feedback
programme, involving the media on the scourge of bacterial resistance; and
spending time to reassure patients might also help to curb unnecessary
antibiotic use, as will research and good practice guidelines.

Remember we carry home vancomycin-resistant enterococci, are often exposed
to carbapenem-resistant Klebsiella pneumonia, and multidrug resistant
tuberculosis. Can you imagine your patient or loved one dying from bacterial
infection, tuberculosis, or malaria that is resistant to all known drugs?
Infections that need antimicrobials are more common in developing countries,
but responsible use is the key.

Competing interests: the author has completed the ICMJE uniform disclosure
form at www.icmje.org/coi_disclosure.pdf (available on request from the
corresponding author) and declares: no support from any organisation for the
submitted work; no financial relationships with any organisations that might
have an interest in the submitted work in the previous three years; no other
relationships or activities that could appear to have influenced the
submitted work.

Provenance and peer review: Not commissioned; not externally peer reviewed.

References

1.       Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in
ambulatory pediatrics in the United States. Pediatrics2011;128:1053-61.

2.       Ganguly NK, Arora NK, Chandy SJ, Fairoze MN, Gill JP, Gupta U, et
al. Rationalizing antibiotic use to limit antibiotic resistance in India.
Indian J Med Res2011;134:281-94.

3.       Bate R, Tren R, Mooney L, Hess K, Mitra B, Debroy B, et al. Pilot
study of essential drug quality in two major cities in India. PLoS
One2009;4:e6003.

4.       Dutta S, Sur D, Manna B, Sen B, Deb AK, Deen JL, et al. Evaluation
of new-generation serologic tests for the diagnosis of typhoid fever: data
from a community-based surveillance in Calcutta, India. Diagn Microbiol
Infect Dis2006;56:359-65.
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