While people are constantly
talking about the abuse of antibiotics, I see a trend in the abuse of
anti-antibiotic measures. I would like
to draw the attention of the abusers and those being abused to this unhealthy
trend. The following is an analysis of
the similarities and undesirability of the two abuses.
The use
Antibiotics are very useful in
treating bacterial infections. Since
their invention, lethal bacterial infections and epidemics are much better
controlled. Once, antibiotics were
regarded magic bullets. However, even
magic bullets have their limitations. You
need to properly aim your targets before the bullets can hit them. And, if your targets are wearing
magic-bullet-proof vests, antibiotics lose their halos.
To guard against blind-shooting
and the development of antibiotic resistance, measures against the abuse of
antibiotics are very important. These
measures are multi-faceted. You can
increase the knowledge of the public and the medical profession. You can modify the practice of antibiotic uses
through legislation such as classifying antibiotics controlled medicine, or
through education such as launching campaigns. Since the awareness of the need to control the
abuse of antibiotics, most antibiotics are still very effective against common
infections.
The abuse
Because of one reason or another,
doctors began to abuse antibiotics. Abuse
is the use when there is no indication, or when the harmful effects outweigh
the desirable effects.
It is true that over 80% of upper
respiratory tract infections do not need antibiotics. However, it is also true that over 80% of
doctors do not need to be reminded of this fact. As in the use of antibiotics, we need to
consider the indications, the spectrum, the doses, the durations and the
side-effects when instilling measures against antibiotic abuses. Targeting all doctors with over-potent and
too-board-spectrum measures is obviously an abuse. Asking patients to take pictures of all
medications for all consultations so as to guard against antibiotic abuse is
obviously worse than prescribing antibiotics to all patients, no matter they
come for upper respiratory tract infections, or for consultation of mood
disorders.
The lethal side-effect
One of the major reasons for the
need of justified use of antibiotics is to prevent undesirable effects, among
which is the disturbance of the normal flora of the body. Abuse of anti-antibiotic measures will not
kill the patient, nor the doctor; but they will kill the important trust
between the patient and the doctor. Undermining
the trustworthiness of doctors in their prescriptions will naturally prompt
patients to query the diagnoses and the management. Without trust, how can the doctor convince the
remaining 20% of the “URTI patients” who suffer from scarlet fever,
Streptococcal pharyngitis and pneumonia to take antibiotics?
Just like antibiotic resistance,
there might also be group effect for mistrust. Instead of rendering the individual advice on
antibiotic use for upper respiratory tract infection useless, mistrust can
affect other decisions on the use of antibiotics. Alarmingly, mistrust, like antibiotic
resistance, is also communicable among patients.
Another serious side-effect for
antibiotics is drug allergy. We cannot
accurately predict which individual will develop drug allergy towards which
antibiotic. However, a significant
percentage of individuals will have drug allergy is a certainty. 10% of the population is sensitive towards
penicillin. Actually, people can have
adverse reactions towards measures against antibiotic abuse. In the anti-antibiotic campaign, it is
interesting that seeming no one has addressed this hypersensitivity issue. There are individuals who over-react to the
anti-antibiotic messages and see antibiotics as evil. Hypersensitive parents might put their
children at risks of fatal bacterial infections.
Evidence-based practice
Some, if not most, cases of
antibiotic abuse are out of good will. It
is just that the doctor does not know that antibiotics do not help. Clinical judgments on the causative agents of
infection might not be accurate. Even
some bacterial infections, such as otitis media, might not need antibiotics. These are the reasons that evidence-based
practice is important. Epidemiology
tells us the prevalence of viral pharyngitis. Clinical trials tell us that antibiotics might
not be useful for cough.
The appeals for judicial use of
antibiotics are out of good wills. However,
chanting the mantra of antibiotic abuse is only self-serving the chanters. Calling for outrageous actions will have no
effect apart from side-effects. Behavioral
modification is the biggest challenge in community medicine and family
medicine. It needs expertise and it
needs skillful means. It is time to go
back to evidence-based practice in the control of antibiotic abuse.
The Abuse by others
Doctors are not the only
contributors for antibiotic abuse. Despite
being controlled medicine, antibiotics can easily be purchased by patients
without prescription in Hong Kong. In
agriculture and fisheries, antibiotics are abused to a much greater scale. Tons of antibiotics are routinely used in the
hope of preventing diseases. It is
important to behave ourselves. But it
would be irresponsible if we ignore the big picture and never mention the other
sources of antibiotic abuse. In doing so
would divert the public attention, scapegoat the doctors, and at the same time
would not solve the problem.
The relation between the medical
profession and the public has also been undermined by various other sources. Some attack doctors for not being able to
treat the root causes of diseases. Some
claim that their treatments are better as they are without side effects. Some claim that doctors are poisoning their
patients with all kinds of drugs. Some
are manipulating patients’ spines to treat rhinitis and irritable bowel. Some say that they are natural and thus
superior.
Facing all these frivolous, yet
appealing, claims, it is important to avoid acts that would further undermine
the trust on our profession. The
anti-antibiotic abuse needs to be stopped.
