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 Photo by Graham Ramsay |
Campaign Gains Strength Against Overuse of Antibiotics
It's a constant battle between us and the bugs. Though the development of antibiotics beginning in the 1940s helped shift the tide, and our powerful armamentarium of drugs against bacterial infections has since saved millions of lives, the tide may be turning once again.As the use of antibiotics has spread, so has their misuse, accelerating an alarming rise in antimicrobial-resistant organisms. These bacteria have been able to mutate in ways that make current drugs less effective and sometimes useless, demonstrating the delicate balance between bacteria and their hosts and the potential for human behavior to influence bacterial evolution.
Ensuring society has adequate and effective antibiotics is a clear example of the need to protect scarce medical resources. Understanding the development of antimicrobial resistance sheds light on the complicated nature of the problem and points to strategies currently under way to limit its growth.
Resistance and "Superbugs"
In the past several years, treating diseases such as tuberculosis, malaria, gonorrhea, staph and strep infections, among others, has been compromised by the emergence of resistant strains. One of the most alarming developments has been the rise of methicillin-resistant staph aureus. Treating this superbug, which normally infects patients in the hospital, may become even more of a challenge since a recent local outbreak took place outside of the hospital, in the Boston community, which has alarmed physicians and public health experts all the more.
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"Patients who demand antibiotics put pressure on physicians that may be difficult for many to resist." --Richard Besser |
The development of drug resistance is exacerbated by the actions of physicians and other health professionals who overprescribe antibiotics and patients who demand them and may use them inappropriately. Some people also blame aggressive advertising by pharmaceutical companies and a litigious environment, where physicians practice defensive medicine. Another culprit: the livestock and poultry industries in which the use of antibiotics to keep animals healthy has resulted in the development of antimicrobial resistance.
Poultry growers have used fluoroquinolones to treat their flocks for E. coli infection, providing the perfect environment for the emergence of fluoroquinolone-resistant Campylobacter. These resistant organisms are passed to human consumers. The Food and Drug Administration's Center for Veterinary Medicine has been addressing overuse of antibiotics by proposing changes in the FDA's management and approval of these drugs as well as increased monitoring of antimicrobial resistance. Ciprofloxacin (cipro), well known as a treatment for anthrax infection, is a fluoroquinolone.
Damned If You Do
"All antibiotic use, whether for appropriate or inappropriate reasons, selects for resistance. We are all part of the problem," said Richard Besser, medical director of the CDC's Campaign for Appropriate Antibiotic Use in the Community. "Patients who demand antibiotics put pressure on physicians that may be difficult for many to resist. Physicians and others who prescribe antibiotics for viral conditions, in which they have no effectiveness, are the other side of the problem."In fact, a recent study funded by the Agency for Healthcare Research and Quality found that parents often pressure pediatricians into prescribing antibiotics even in cases where the physician believes the illness to be viral. Educating parents about the uses and misuses of antibiotics appears to be a challenge. In a recent issue of the journal Pediatrics, Boston University School of Medicine's Howard Bauchner and colleagues reported that an educational video intervention aimed at increasing knowledge of antibiotics among parents had only a "modest effect on parent knowledge, beliefs, and self-reported behaviors regarding oral antibiotics." The authors concluded that "any campaign promoting the judicious use of oral antibiotics must use a multifaceted approach and target both parents and physicians."
Besser and his colleagues work with groups from around the country to develop multifaceted campaigns and interventions to address antimicrobial resistance. The CDC's effort is aimed at the reduction of inappropriate antibiotic use and the reduction in the spread of resistance to antibiotics. Currently, the campaign is working on developing and distributing educational materials promoting appropriate antibiotic use, funding states in their local efforts, developing a medical school curriculum promoting appropriate use of antibiotics, developing Health Plan Employer Data and Information Set (HEDIS) measures for appropriate antibiotic use, and funding a national advertising campaign promoting the appropriate use of antibiotics. Besser believes that aligning payment mechanisms for physicians to promote judicious use of antibiotics may encourage appropriate prescribing.
The Good Fight
As part of the government's efforts to address antimicrobial resistance, the National Antimicrobial Resistance Monitoring System (NARMS) was established to monitor the development of resistance in human and animal enteric bacteria to 17 antimicrobial drugs. NARMS is a collaborative effort of the FDA's Center for Veterinary Medicine, the U.S. Department of Agriculture, and the CDC. The information collected by NARMS is disseminated to physicians, veterinarians, and food animal producer groups.Even politicians are jumping into the fray. In February 2002, Representative Sherrod Brown (D-OH) introduced the Preservation of Antibiotics for Human Treatment Act of 2002 (H.R. 3804). At the same time, Brown, with Representatives Louise Slaughter (D-NY) and Henry Waxman (D-CA), introduced the Brown-Waxman-Slaughter Preservation of Antibiotics for Human Treatment Act (H.R. 3266), requiring drug companies that make antibiotics used to promote livestock growth prove that such use does not harm human health due to increased antibiotic resistance. This bill would revoke FDA approvals for the nontherapeutic use of penicillins, tetracyclines, macrolides, lincomycin, bacitracin, virginiamycin, aminoglycosides, and sulfonamides in animals, while still allowing for sick animals to be treated. The bill would also phase out fluoroquinolone use in poultry, a step that has already been taken up by the private sector: McDonald's, Wendy's, and Popeye's fast food franchises have announced they will not purchase poultry treated with fluoroquinolones.
It is clear that dealing effectively with antimicrobial resistance is going to require the cooperation and coordination of individuals and organizations in both the public and private sectors. What is needed is a shift in society's attitude toward the use of antibiotics--an understanding that this scarce resource can be guarded by changes in the behavior of physicians, parents, and others. This shift is illustrated by Besser's view of the ideal encounter between physician and patient: "Instead of requesting antibiotics, we would like patients to ask for the best treatment for their particular illness. Instead of prescribing an antibiotic when it might not be effective, we would like clinicians to take the time to explain to their patients the difference between bacterial and viral infections and why the treatment is different."
--Erica Seiguer, a fourth-year MD-PhD student at HMS
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.