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New Drugs Antibiotics

The Judicious Use of Antibiotics An Investment


towards Optimized Health Care
Aditya H. Gaur1,2 and B. Keith English2
1

Department of Infectious Diseases, St. Jude Childrens Research Hospital, and 2Department of Pediatrics,
University of Tennessee Health Science Center, Memphis, Tennessee, USA

Abstract. During the past century the excitement of discovering antibiotics as a treatment of infectious diseases has given
way to a sense of complacency and acceptance that when faced with antimicrobial resistance there will always be new and
better antimicrobial agents to use. Now, with clear indications of a decline in pharmaceutical company interest in anti-infective
research, at the same time when multi-drug resistant micro-organisms continue to be reported, it is very important to review
the prudent use of the available agents to fight these micro-organisms. Injudicious use of antibiotics is a global problem with
some countries more affected than others. There is no dearth of interest in this subject with scores of scholarly articles written
about it. While over the counter access to antibiotics is mentioned as an important contributor towards injudicious antibiotic use
in developing nations, as shown in a number of studies, there are many provider, practice and patient characteristics which
drive antibiotic overuse in developed nations such as the United States. Recognizing that a thorough review of this subject goes
far and beyond the page limitations of a review article we provide a summary of some of the salient aspects of this global
problem with a focus towards readers practicing in developing nations. [Indian J Pediatr 2006; 73 (4) : 343-350]
E-mail: aditya.gaur@stjude.org

Key words : Antibiotics; Anti-microbial agents; Multi-drug resistant micro-organisms

Antibiotic resistance is a natural phenomenon resistant


strains of micro-organisms have been noted close on the
heels of antimicrobial discovery. 1 It is undeniable that
antibiotic use (and overuse) contributes to development of
resistance. The development of newer antibiotics, in part
responding to the emergence of resistant microorganisms,
has resulted in a sense of complacency on the part of the
general public and medical care providers. Now, with
clear indications of a decline in pharmaceutical company
interest in anti-infective research, at the same time when
multi-drug resistant micro-organisms continue to be
reported, it is very important to review the prudent use of
the available agents to fight these micro-organisms.2
The dictionary meaning of judicious is having or
showing reason and good judgment in making
decisions. With reference to antibiotics, judicious use
implies using an antibiotic only when indicated, choosing a
cost-effective agent which provides appropriate
antimicrobial coverage for the diagnosis that is suspected
and prescribing the optimal dose and duration of the
antimicrobial. The WHO Global Strategy for Containment
of Antimicrobial Resistance defines the appropriate use of

Correspondence and Reprint requests : Dr. Aditya Gaur, MD,


Department of Infectious Diseases, St. Jude Childrens Research
Hospital, 332 N. Lauderdale Street, Memphis, TN 38105-2794. USA.
Fax: (901)-495-5068.

Indian Journal of Pediatrics, Volume 73April, 2006

antimicrobials as the cost-effective use which maximizes


clinical therapeutic effect while minimizing both drugrelated toxicity and the development of antimicrobial
resistance (http://www.who.int/drugresistance/
WHO_Global_Strategy_English.pdf).
Injudicious use of antibiotics for both humans and
animals3 has long been recognized as a global problem.
While over the counter access to antibiotics is mentioned
as an important contributor towards injudicious antibiotic
use in developing nations, as shown in a number of
studies there are many provider, practice and patient
characteristics which drive antibiotic overuse in
developed nations such as the United States. Numerous
approaches have been proposed as a solution to this
complex, multi-factorial problem. While some countries
have shown a striking improvement in antibiotic use, in
some cases associated with a drop in the problem of
antimicrobial resistance, 4 there is abundant opportunity
for improvement in most of the world.
IMPLICATIONS OF INJUDICIOUS ANTIBIOTIC USE
There is no dearth of original research articles and reviews
on this subject; there has been ongoing research in this
area for many decades and yet the problem is far from
being solved. An understanding that the roots of this
problem are entrenched in societal and cultural beliefs
and expectations is the first step in attaining a solution.
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Aditya H. Gaur and B. Keith English


There are complex reasons that drive continuation of a
habit and it is important not only to review the laundry
list of possible dire consequences of the habit but also to
be cognizant that amongst the list there will be some
reasons which may motivate the individual and some
with more societal implications that may only motivate
policy makers.
Injudicious use of antibiotics effects the individual and
society in a number of ways. At the outset we should
clarify that there is some debate about how much
antibiotic use and overuse contributes to the development
of resistance, 5,6 and what expectations are realistic in
terms of gains that can be made in reversing resistance
with more prudent use of these agents,7;8 While one group
of researchers reported finding relatively high levels of
antimicrobial resistance in commensal enterobacteria
isolated from wild rodents in the British countryside,5
(suggesting that the development of resistance might be
common in the absence of antibiotic exposure), other
groups have failed to detect antibiotic resistance in E. coli
isolated from wild animals in more remote locations (e.g.,
northern Finland), 6 where prior exposure to
antimicrobials is extremely unlikely. Some studies
suggest that antibiotic resistance, once acquired, is lost
very slowly. Examples include the persistence of
streptomycin9 or sulfonamide resistance in E. coli7 despite
decrease in antibiotic use and the persistence of
vancomycin-resistant enterococci in Norway after the
avoparcin ban.10 Such debates should not distract us from
the undeniable fact that there is no rationale for using
antibiotics inappropriately i.e. an unindicated use or
incorrect choice of antibiotic, its dose or treatment
duration. First, there is clear evidence that antibiotic
resistance develops under antibiotic pressure. While this
may not be the only factor contributing to the
development of antibiotic resistance and reduction in
antibiotic use may not always be followed by a decrease
in resistance, a decrease in antibiotic overuse will remain
the number one intervention in our attempts towards
slowing down the development of antimicrobial
resistance. Second, injudicious use of antibiotics comes
with a cost. Not only is there a cost of paying for a
medication that was not needed, there is the cost of
adverse drug reactions11 and ultimately, the inevitable
cost of managing resistant microorganisms.12 In the US in
1998, an estimated 76 million primary care office visits for
acute respiratory tract infections resulted in 41 million
antibiotic prescriptions. Antibiotic prescriptions in excess
of the number expected to treat bacterial infections
amounted to 55% (22.6 million) of all antibiotics
prescribed for acute respiratory tract infections at a cost of
approximately $726 million.13 Third, injudicious use of
antibiotics clearly influences the ecosystem. Antibiotic use
in humans and animals has been shown to change the
microbial flora of the gut and the ecosystem. Finally,
ongoing antibiotic misuse perpetuates a culture of
injudicious use where every contributor to this
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undesirable practice makes it more difficult to change the


habit. Of all the reasons cited above, the possibility of
avoidable side effects and unnecessary cost would most
likely appeal to individuals while reducing antibiotic
resistance, minimizing the detrimental impact on the
ecosystem and reversing the evolving culture of antibiotic
misuse should motivate the physician community,
governments and policy makers.
UNDERSTANDING THE PATHOGENESIS OF
INJUDICIOUS USE OF ANTIBIOTICS
There are numerous factors varying by geographical
region, social circumstances and existing health care
systems that influence antibiotic use and misuse in
various parts of the world. In this productivity driven
society, patients may seek a fast fix to every illness and
find waiting for the natural evolution of a viral illness
unacceptable. Doctors may experience real or perceived
pressure from their patients to prescribe an antibiotic
pressure that is compounded by fear of losing a patient to
another provider or fear of the possibility of medico legal
implications if they failed to catch something treatable
early. Economic pressures that influence patients and
physicians to antibiotic overuse are often talked about but
less well studied. The pharmaceutical industry may feel
the pressure to sell their product to realize the costs of the
investments made and in doing so may reach out to its
clients including both patients and physicians in
questionable ways. Under such circumstances it is a
wasted effort to identify the sinner because no one is
innocent, but it is appropriate to accept that regardless of
the reasons that drive injudicious use of antibiotics every
person who contributes to the problem by being a
participant perpetuates this deep rooted practice.
Various patient and provider characteristics that are
associated with antibiotic use and misuse are summarized
below. The nontherapeutic use of antibiotics in animal
agriculture has recently been reviewed elsewhere.14
PROVIDER CHARACTERISTICS
Provider experience. Numerous studies have shown
widespread unnecessary use of antimicrobials in patients
with viral upper respiratory tract infections. 15,16
Interestingly, we recently found that antibiotic
prescribing in the context of an outpatient visit for a
diagnosis suggestive of a viral respiratory tract illness
occurs more commonly among staff physicians than
trainees, and among staff physicians, more commonly in
non-teaching compared to teaching institutions.15 This
study used data collected from ambulatory clinics
associated with hospitals in the United States as part of
the National Hospital Ambulatory Care Survey from 1995
to 2000. Among other things we speculate that trainees
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The Judicious Use of Antibiotics An Investment Towards Optimized Health Care


may feel protected in an academic environment and
perceive less medico-legal risk when withholding
antibiotics in specific clinical situations compared to
practicing clinicians in hospital based outpatient
departments. Additionally our findings may represent a
cohort effect; trainees may be more familiar with
recently administered guidelines and may be more
comfortable with antibiotic restraint than providers who
trained and practiced prior to the dissemination of these
guidelines. Mainous et al using information from the
Kentucky Medicaid database, reported that the high
prescribers of antibiotics for children with upper
respiratory tract infections were significantly more years
from medical school graduation (27 vs 19 years) than low
prescribers.17 In a study reported by Steinke et al, nontraining practices in Tayside, UK were in general found to
prescribe significantly more antibiotics as well as a higher
proportion of broad spectrum penicillins, a higher
proportion of newer antibiotics and a greater number of
different antibiotics per doctor compared to training
practices. 18 We and others have shown that nonpediatricians prescribe antibiotics more often to children
with colds, bronchitis and upper respiratory tract
infections (URI) than pediatricians.15,16
Time spent with the patient. Physician time constraint is
a factor that is frequently mentioned as a hypothesis for
antibiotic overuse.19 However, few studies have examined
this hypothesis. Surrogate measures for shorter visit times
as measured by number of patients seen in a week or type
of remuneration (fee-for-service) have been associated
with higher antibiotic prescription rates. The presumption
is that the necessity of shorter patient-visit times leads
physicians to prescribe antibiotics rather than take the
time to explain why an antibiotic is not indicated.
However, our findings in a study examining the
relationship between physician visit time and antibiotic
prescribing in the context of other factors that may play a
role in antibiotic prescribing for viral respiratory tract
infections, do not support the contention that it takes
longer not to prescribe antibiotics in ambulatory care
settings.20
Inadequate information among various antibiotic
providers. Lack of knowledge contributes to
inappropriate antimicrobial use. In many countries,
including India, antibiotics are dispensed not only by
physicians but a host of other providers with variable
training backgrounds including those with no medical
training. A study from China provides a good example of
the magnitude of the problem and the challenge of
providing adequate information.21 Through multistage
stratified sampling, 100 of the 1508 Heath Care Workers
(HCWs)s working in a county in China were selected for
observation of their management of acute respiratory tract
infections (ARI). Assessment of diagnostic standards,
antibiotic abuse and appropriateness of antibiotic use was
based on the WHO definition. There were three categories
of HCWs in the county: (1) doctors who after a
Indian Journal of Pediatrics, Volume 73April, 2006

Bachelors degree and a competitive entrance


examination, have undergone 4 to 6 years of training at an
University; (2) HCWs who after middle or high school
have undergone 3 years of training in a secondary
medical or nursing school (this category includes
practitioners of traditional Chinese medicine); (3) village
workers who have only 6 to 24 months of training on the
local level. Not sampled but present in the county were
traditional healers who also provided antibiotics.
Antibiotics available in the county included penicillins
(principally penicillin G and ampicillin); sulfonamides
(mainly trimethoprim-sulfamethoxazole); macrolides
(mostly erythromycin, medemycin, spiramycin); and
lincomycin. Before the parents sought medical care, 47%
of children in the county hospitals, 25% of those in the
townships and 18% of those in the villages had already
received antibiotics available without prescription.
Among the HCWs, antibiotic abuse (antibiotics for
presumably viral disease) was detected in the treatment of
97% of cases, and severe abuse (such as prescription of
two incompatible antibiotics) was detected in 37%. Most
(197 of 200) patients with bacterial disease received
antibiotics, but inappropriate antibiotic treatment (dose or
type) was observed in 63% of these cases. HCWs with
University training and those with higher test scores on
knowledge and attitude prescribed antibiotics more
judiciously than those lacking those attributes. This
situation is not unique to this county in China and
symbolizes the problems with the health care
infrastructure of many countries. Contributing to this lack
of knowledge of appropriate choice of antimicrobials may
be factors such as limited access to updated, unbiased
information especially regarding local antibiotic resistance
patterns, and the availability of treatment guidelines that
provide a cost-effective approach to common clinical
syndromes using available antibiotics. It is not uncommon
for drug company sales representatives and the
commercially oriented publications they provide to be the
main sources of information for many prescribers.22
Real time monitoring of antimicrobial resistance and
ongoing feedback to the prescribers in a community is
very important. Medical care costs and lack of affordable
culture and sensitivity tests often limits the availability of
patient specific information. Under such circumstances
empiric therapy of real or perceived treatable infections
with broad spectrum agents is common. Additionally,
prescribing just to be safe increases when there is
diagnostic uncertainty, lack of prescriber knowledge
regarding optimal diagnostic approaches, lack of
opportunity for patient follow-up, and/or fear of possible
litigation. 19,23 Diagnostic uncertainty can be viewed as
having two components an uncertainty of whether a
patient has a bacterial infection or not and/or if a
bacterial infection, the uncertainty of what antibiotic to
use. It is important to acknowledge that even in the hands
of the best clinician there will be patient case scenarios
associated with a diagnostic uncertainty and in
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situations where the potential consequences of
misdiagnosis are great such as a patient with suspected
meningitis, empiric antibiotic use is unavoidable and
understandable. In sharp contrast is the diagnostic
uncertainty of an otitis media where the consequences
of a delayed diagnosis are minimal.
Cultural and Economic factors. In some cultural settings,
antimicrobials given by injection are considered more
efficacious than oral formulations. This tends to be
associated with the over prescribing of broad-spectrum
injectable agents when a narrow spectrum oral agent
would be more appropriate. Gumodoka et al reported that
one in four patients in their medical districts received
antimicrobials by injection and that approximately 70% of
these injections were unnecessary.24 Prescribers may fear
the potential loss of future patients and revenue if they do
not respond to perceived demands for antimicrobials.25 In
focus group studies, prescribers expressed concern that, if
they did not prescribe antimicrobials, patients would seek
other sources of care where they could obtain
antimicrobials. Furthermore, in some countries,
prescribers profit from both prescribing and dispensing
antimicrobials, so that it is in their financial interest to
prescribe antimicrobials even when they are not clinically
indicated. Additional profit is sometimes gained by
recommending newer and more expensive antimicrobials
in preference to older and cheaper agents. In countries
where physicians are poorly paid, pharmaceutical
companies have been known to pay commissions to
prescribers who use their products.26
PATIENT CHARACTERISTICS
When a parent or child has received an antibiotic
prescription for an illness in the past, that experience
engenders expectations that the same therapy is required
should such symptoms recur. 27 Parental expectation is
often cited as a reason for antibiotic prescriptions. 28
However, at least one study shows that physicians
perceptions of parents expectations are not always
correct.29 In this study while physicians were significantly
more likely to inappropriately prescribe if they believed a
parent desired antimicrobials, there was poor agreement
between actual pre-visit expectations reported by parents
and physician-perceived expectations. Actual parental
expectations did not have an effect on the decision to
prescribe after controlling for covariates. Of interest, this
study found that when physicians thought a parent
wanted an antimicrobial, otitis media and sinusitis were
both significantly more likely to be diagnosed.
Additionally, studies have also shown that
misconceptions regarding antibiotic use are widespread
among patients and parents.30-32
In a study by Macfarlane et al the authors assessed
patients views and expectations when they consult their
general practitioners in the UK with acute lower
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respiratory symptoms and the influence these have on


management.33 They found that most patients think their
symptoms are caused by infection, think an antibiotic will
help, and want antibiotics. Three quarters of previously
well adults in this study consulting with the symptoms of
an acute lower respiratory tract illness received antibiotics
even though their general practitioners assessed that
antibiotics were definitely indicated in only a fifth of such
cases. Patients expectations and views and doctors
concern that the patient may otherwise reconsult had a
powerful effect on doctors decision to prescribe. Patients
who did not receive an antibiotic that they wanted were
more likely to be dissatisfied and reconsulted twice as
frequently. In a survey of 3610 patients conducted by
Branthwaite and Pechre, 34 over 50% of interviewees
believed that antimicrobials should be prescribed for all
respiratory tract infections with the exception of the
common cold. It was noted that 81% of patients expected
to see a definite improvement in their respiratory
symptoms after three days and that 87% believed that
feeling better was a good reason for cessation of
antimicrobial therapy. Most of these patients also believed
that any remaining antimicrobials could be saved for use
at a later time.
These and other patient misconceptions combined
with access to antimicrobials without a prescription in
many countries creates the perfect environment for
injudicious use of antibiotics. In a Brazilian study, it was
determined that the three most common types of
medication used by villagers were antimicrobials,
analgesics and vitamins. The majority of antimicrobials
were prescribed by a pharmacy attendant or were
purchased by the patient without prescription35 despite
having prescription-only legal status. In addition to
obvious uncertainty as to whether the patient has an
illness that will benefit from antimicrobial treatment, selfmedicated antimicrobials are often inadequately dosed36
or may not contain adequate amounts of active drug,
especially if they are counterfeit drugs. 37 Patients may
shop by brand name of antibiotics not realizing that
different brand name products may contain the same
antibiotic. Specific patient demand caused one pharmacy
in South India to stock more than 25 of the 100 or so
brands of co-trimoxazole.38 In countries with such free
access to antibiotics there is often unregulated growth of
companies that manufacture these products. This raises
concern about the quality of many antibiotic products and
ultimately the impact this would have on the problem of
antimicrobial resistance.
Direct-to-consumer advertising allows pharmaceutical
manufacturers to market medicines directly to the public
via television, radio, print media and the Internet. Where
permitted, this practice has the potential to stimulate
demand by playing on the consumers relative lack of
sophistication about the evidence supporting the use of
one treatment over another.39
Poor adherence to medication doses and duration of
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The Judicious Use of Antibiotics An Investment Towards Optimized Health Care


therapy is a well recognized cause of resistance. This is
especially so with illness requiring long term therapy such
as tuberculosis and HIV. Adding to the complexity of the
problem is the fact that in many countries most of the
patients pay out of pocket for medical treatment. It is not
unusual for patients to buy aliquots of medications
based on what they can afford and to skip doses or take
inadequate doses when feeling well or when short on
money.
INTERVENTIONS TO PROMOTE JUDICIOUS USE OF
ANTIBIOTICS
A number of interventions have been tried to promote
judicious use of antibiotics around the world. The
applicability of these interventions differs not only based
on the clinical setting of antibiotic use i.e. management of
acute infections in an outpatient setting vs. inpatient
setting vs. treatment of chronic infections, but also on a
number of other factors such as site characteristics
(private practice vs. academic setting), available resources
(such as electronic data management and electronic
prescriptions) and patient characteristics (literacy, cultural
beliefs, socio-economic status). No single intervention is
likely to have a significant impact by itself and a
combined approach using multiple interventions is
necessary. Additionally, while the enormity of the
problem and the degree to which it has become pervasive
in society, especially in some countries may be daunting,
every effort that is made to promote judicious antibiotic
use will have some benefit. A list of ideas and
interventions is provided below realizing that not all of
them may be practical or applicable to every country or
clinic setting. This list includes some recommendations
made as part of the WHO Global strategy for containment
of antimicrobial resistance (http://www.who.int/
drugresistance/WHO_Global_Strategy_English.pdf), a
review of interventions reported successful in various
studies and authors opinion. The WHO Global strategy
for containment of antimicrobial resistance is a
comprehensive source of information regarding judicious
antibiotic use and other measures to address the problem
of antimicrobial resistance. Readers are encouraged to
browse the cited WHO Global Strategy link to get
complete details on this topic. Based on existing resources,
feasible options should be considered.
Interventions directed to patients and the non-medical
community:
1. Education: Physicians have cited patient/parent
pressure as one of the factors that influences their
antibiotic prescribing practice. For this and other
reasons educating patients and the general public is
critical to the efforts to promote judicious antibiotic
use. Educational messages should be directed on the
following themes:
a. Education regarding common diseases and the
Indian Journal of Pediatrics, Volume 73April, 2006

role of antibiotics (where they work and where


they do not)
b. Efforts to increase awareness of antibiotic
resistance and its impact on individuals and the
society.
c. Education to discourage self-initiation of
treatment and encourage appropriate and
informed health care seeking behavior.
Education on suitable alternatives to
antimicrobials for relief of symptoms should be
provided where applicable.
d. Education to promote adherence to the
prescribed treatment.
As with any other public health related intervention
creative use of locally available and applicable resources
that take into account patient literacy should be done to
effectively impart education related to the above
mentioned themes. These messages can be delivered by
the media, in clinic waiting rooms, 40 during prescriberpatient interaction and during dispenser-patient
interaction. Based on patient literacy, information leaflets
can be provided.41 A number of websites provide patient
education material and evidence based recommendations
on antibiotic use. Examples of such resources from US
based organizations are the Center for Disease Control
and Prevention (www.cdc.org) and Alliance for the
Prudent Use of Antibiotics (http://www.tufts.edu/med/
apua/). Among other things the CDC website provides
the template for a prescription pad that can be used in
patients with a viral illness. Such information can be used
to create patient information material in regional
languages with the message modified where necessary to
fit the local culture and beliefs. Some drug resistant
bacteria i.e. super bugs have caught the media attention
and this limelight should be used to present information
regarding judicious antibiotic use to the community. In
addition to the media, information can be provided at
community health events and through local community
leaders as part of other public health messages that
increase overall health awareness in the community.
2. Incentives and reassurance: Patients seek reassurance,
symptomatic relief (often a quick fix) and especially
when paying out of pocket for the medical services
they expect something concrete out of the visit to
justify the money or time they have spent to access
care. Keeping this in mind, some interventions that
can be considered, include:
a. The use of delayed prescribing techniques. 19 A
strategy of providing the patient with a
prescription for an antibiotic but asking that the
prescription not be filled unless symptoms do
not get better within a few days has been
successfully used in one study.41
b. Some physicians say that they promise a free
return visit if the patient feels that a reconsultation is necessary because they did not
receive antimicrobials.19 Another approach (if the
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resources are available) is to arrange for the
office staff such as a nurse to make a follow-up
phone call to the patient. This can potentially
decrease the insecurity felt by a patient/parent
when leaving the clinic without an antibiotic
prescription.
c. Suitable alternatives to antimicrobials for relief of
symptoms should be provided where applicable.
d. From acute care to comprehensive care: For
patients with poor access to health care, visits for
acute illnesses are the window of opportunity for
the physician to provide health-related
education, immunizations, and treatment of
common illnesses such as anemia and
helminthiasis.
Interventions directed to the prescribers and
dispensers of antibiotics:
1. Education: While the need for ongoing education of
all clinical care providers regarding judicious use of
antibiotics is widely accepted the question of who
should do it and how should it be done in
preferably an evidence based manner needs to be
answered based on local health care and political
infrastructure. While it is important to provide this
information as part of all clinical provider training
programs (medical schools, pharmacy schools etc),
based on information we presented earlier the value
of continuing medical education for practicing
physicians cannot be over emphasized. As with
patient education, multiple avenues to disseminate
information have to be identified. These include
printed materials (journals, periodicals, newsletters),
continuing medical education (CME) activities
(meetings, conferences, online access), and point of
care services (pop up prompts triggered by electronic
prescribing). 42 Previous studies have shown that
didactic sessions alone do not help.43-45 Educational
outreach or academic detailing, which consists of
brief, targeted, face-to-face educational visits to
clinicians by specially trained staff, 44;46 is successful
but may not be practical or cost-effective in many
countries. Engaging local opinion leaders in the
process of disseminating targeted educational
messages to their peer group has been shown to be
another successful strategy.40,47
2. Affordable, reliable microbiology laboratory services:
Reliable culture and antimicrobial susceptibility
studies are critical to optimizing antimicrobial use in
the hospitals and the community. Access to such
services is often unaffordable or under utilized in
developing countries. Diagnostic uncertainty as
described before (does the patient have a bacterial
infection and if so what empiric antibiotic to use) is
often cited as a reason for over prescribing and
broad-spectrum antibiotic use. Availability of low
cost microbiology facilities for individual patient care
348

is desirable but in many countries is not always


feasible. Especially in such settings, systematic
collection of reliable and comparable antimicrobial
resistance data by regional government and private
laboratories and dissemination of this information on
a regular basis to prescribers in the community is
very important.
3. Clinical care guidelines: Clinical care guidelines can
address both forms of diagnostic uncertainty. Access
to updated regionally appropriate treatment
guidelines for common infections facilitates evidence
based standard of care.48 These guidelines should be
based on existing antibiotic resistance patterns. In
1998 the CDC and the American Academy of
Pediatrics published evidence based principles to
define judicious antimicrobial use for pediatric upper
respiratory tract infections that account for majority
of outpatient antimicrobial use in the United States.49
Dissemination of such guidelines using multiple
methods including CME activities, academic
detailing, local opinion leaders and others will
optimize the impact of these guidelines.
4. Education for other clinical care providers: In many
countries including India the presence of nonphysician providers with no formal training who
continue to provide health care services to a large
section of society is well recognized. These providers
persist because of cultural, financial or lack of
affordable alternative reasons. Recognizing the
logistical difficulties of removing such nontraditional providers and dispensers, taking steps to
provide them with drug and disease related
education, including judicious antibiotic use may
reduce antibiotic misuse.
5. Hospital therapeutic committees and antibiotic
audits: While the major contributor to the overall
volume of antimicrobial overuse may be outpatient
prescribing, measures to address judicious antibiotic
use in the hospitals are also important. Besides the
overall benefits of promoting judicious antibiotic use,
hospital based interventions may affect the
prescribing habits of not only trainees but community
physicians with admitting privileges. The beneficial
role of hospital therapeutic committees in the
promotion of rational prescribing habits, monitoring
of drug usage and cost containment is well
established in developed countries.50 There is paucity
of literature about the feasibility and effectiveness of
such committees in developing nations. Such
committees are responsible for development of
written policies and guidelines for appropriate
antimicrobial usage in the hospital, based on local
resistance surveillance data. They assist in selection
and provision of appropriate antimicrobials in the
pharmacy after consideration of local clinical needs.
Additionally they define an antimicrobial utilization
review program, with audit and feedback on a
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The Judicious Use of Antibiotics An Investment Towards Optimized Health Care


regular basis to providers, and promotion of active
surveillance of the nature and amount of
antimicrobial use in the hospital. Despite the
logistical challenges of creating and empowering
such committees in hospitals where a culture of
complete physician autonomy exists the potential
benefits of having such a self regulating committee
should be explored.
Interventions directed to Governments and other
policy makers: It is beyond the scope of this article to go
into the nuances of some of the suggested interventions
and how they would be applied based on the unique
political healthcare infrastructure and societal
circumstances of each country. For example, a crackdown
on antibiotic dispensing to make these available only with
a prescription without looking into the feasibility of
patients to access a prescription provider or the ability
to authenticate the credentials of the person who writes
the prescription is unlikely to be effective and may have
other undesirable ripple effects including breeding
corruption. In many countries overall or region specific
(for e.g. in rural areas) lack of trained health care
providers combined with poverty, low literacy rate and
out of pocket expenses for medical care have allowed
untrained prescribers of antibiotics to flourish. It is also
not unheard of for the drug dispensers and pharmacies to
offer free medical advice including suggestions about
antimicrobials. Understanding these problems and
suggesting a remedy to them is not easy and requires
government initiative and policy changes.
The importance of taking the essence of each of the
recommendations and distilling them into practical,
regionally appropriate actions cannot be overemphasized.
1. Governments and physician organizations should
provide funding and resources to educate patients,
prescribers and dispensers as delineated in the
previous paragraphs.
2. Governments should develop and enforce regulations
limiting over-the-counter purchase of antimicrobials.
3. Governments should develop and enforce regulations
to ensure the quality of antibiotics that are available in
the market.
4. Governments and physician organizations should
link professional registration requirements for
prescribers and dispensers to requirements for
training and continuing education.
5. Government schemes should subsidize the creation of
affordable microbiology laboratory services.
6. Governments and physician organizations should
provide funding and collaboration to optimize
antimicrobial resistance surveillance.
7. Government schemes should subsidize the cost of
certain preferred antimicrobials and/or provide free
access to them through specific centers. This is
especially important for medications used for chronic
illnesses such as tuberculosis and HIV.
Indian Journal of Pediatrics, Volume 73April, 2006

8. Governments should control and monitor


pharmaceutical company promotional activities and
direct-to-consumer advertising and limit these to only
those that have educational benefit.
CONCLUSION
Many parts of the world have witnessed a change in
societys views about smoking, diet and obesity a
similar level of awareness and motivation is needed in
regards to antibiotic use. Measures to improve the use of
antibiotics are not limited to addressing this problem
alone but are far overreaching. In a way the interventions
discussed earlier go towards creating a society of
informed consumers who receive rationale health care.
While the goal is far from being reached, a reader who
makes it to the end of this review article is encouraged to
pause for a moment, reflect on his practice and decide
what he as an individual can do to address this problem.
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Indian Journal of Pediatrics, Volume 73April, 2006