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Public United for Savings in Healthcare
Antibiotic abuse
Back to the future
Without a doubt, Alexander Fleming
would find a place in any list of
individuals who have played
memorable roles in mankind's fight
against disease. If Fleming were alive
today, he would be appalled by what
has emerged from his discovery.
Spurred by penicillin, a large number
of antibiotics have been introduced in
the subsequent years. The spectrum of
activity of these agents has widened.
Unfortunately, resistance to antibiotics
is increasing: the roll call of bacteria
that have become resistant, lengthens
with each passing year. To add to our
misery, infectious agents that did not
have the power to produce disease in
humans have acquired traits that make
them virulent.
Despite this grim situation,
complacency prevails. The medical
profession and patients remain smug
in the belief that research will continue
to deliver drugs that can circumvent
this dangerous situation. The truth lies
elsewhere. Bacteria are acquiring
powers of resistance much faster than
the ability of pharmaceutical research
to come up with new devices.
We have gone from peaks of
triumphant confidence to troughs of
despair in the space of less than half a
century.
Antibiotic resistance -
mechanism
Combating antibiotic
resistance - you can help
No country for ostriches
Much more at:
Professor Hugh McGavock, from the University of Ulster, warns
us of an antibiotics crisis which could lead to thousands of people
dying from treatable illnesses. The professor, who specialises in
prescribing science, claims:
• The crisis is as big as AIDS.
• In 12 years all antibiotics could be redundant. By 2015,
bacteria which cause disease will be resistant to all antibiotics and diseases that
are easily treatable now, will be killers.
The discovery of penicillin was heralded by confident claims of our ability to
eliminate infections for ever. This prediction was sadly off the mark.
By doing many things thoughtlessly
Medical profession
- Overprescription - trivial, viral infections
- Broad spectrum preference
- Low dose/ short course regimens
- Failure to identify agent with cultures
No single cause can be apportioned the
lion's share of the blame. There is also
no running away from the reality that
the medical profession has to shoulder
the largest part of the blame by the way
it has failed to discipline itself in the use
of antibiotics.
• The vast majority of common
infections – colds, flu, diarrhea and such
– are caused by viruses. Antibiotics
have no value and should not be
prescribed. Yet, it is rare to see a doctor
who will counsel against the need for
antibiotics.
• Penicillin has a limited range of
activity (spectrum) against the hordes
of different bacteria that can infect the
human body. Over the years, many new
drugs have been introduced that are
effective against a wide spectrum of
infectious agents: broad-spectrum
antibiotics. Although valuable, they
encourage a slip-shod attitude amongst
doctors who prescribe these agents in a
gun-shot manner without taking the
time and trouble to identify the specific
cause of the infection and treat it with a
narrow- (but effective) spectrum drug.
Such unthinking prescribing leads to
antibiotic resistance.
© Dr Arjun Rajagopalan
29 October 2008
• It is common to see doctors
prescribing antibiotics for only a day or
two. Most infections have to be treated
for three to seven days to ensure
complete eradication. The duration of
treatment often extends for a few days
after the patient feels recovered. Early
cessation of treatment is another
important method of promoting
bacterial resistance. Hand-in-hand, it is
equally common for doctors to
prescribe antibiotics in doses that are
below the recommended guidelines
under the mistaken belief that this will
reduce the likelihood of side effects.
• Good practice demands obtaining
cultures from infected specimens such
as urine, sputum and pus from wounds.
The specific cause of the infection can
be identified, and, more importantly,
the most effective, least toxic antibiotic
can be used. Cultures are often
dispensed with under the guise of
saving money for the patient.
Pharmacies
- Sales without prescription
- Over-the-counter sales
- High pressure marketing
- Self medication
Pharmacies in India sell large quantities
of antibiotics without a prescription on
the basis of complaints described by
patients who bypass the doctor in an
effort to save money. It is equally
common for patients to pop antibiotics
that are lying around at home, when a
sore throat or fever occurs. Both tactics
are not in our best interests.
Agriculture
- Livestock feeds
Huge quantities of
antibiotics are
consumed in the
rearing
livestock, once again an important
of
avenue for the entrance of antibiotic
resistance.
29 October 2008
Combating antibiotic
Tricks up the sleeve of evolutionary survivors
resistance

Bacteria develop the ability to produce

A large portion of the
responsibility in combating
antibiotic resistance lies with
patients and consumers. There are
many steps that you can take to
help.
• Don't take antibiotics for trivial
infections and viral diseases like
the cold and flu.
• Do not indulge in self medication.
• Don't go to the pharmacist and
ask for quick, short courses of
antibiotics over the counter.
• Talk to your doctor and ask for
the reason why the antibiotic is
being given – it is your body, you
have every right to an explanation.
• Ask for a culture of an
appropriate body secretion if an
infection needs antibiotics.
Usually, it will be a sample of
urine, sputum or pus from a
wound.
• When the culture report is
available (usually in 48 – 72 hours)
ask you doctor to switch to the
simplest, safest, cheapest agent
that will cure the infection.
• Take the full strength of the
prescribed drug for the period that
is recommended by your doctor.
Don't stop the drug when you are
feeling better. Quite often, the drug
may need to be given for a specific
period to ensure eradication of the
infection.
enzymes, substances that can destroy
antibiotics
Mutations can occur randomly in
the genetic make-up of bacteria
that can confer the ability to resist
antibiotics
There are several methods by which
antibiotic resistance can develop:
1.Enzymes are naturally occurring
compounds that have the ability to digest
and break down complex molecules into
simple entities. With repeated exposure to
an antibiotic, some bacterial strains
develop the ability to produce enzymes
that can destroy specific antibiotics. Once
this happens, continued exposure to the
antibiotic results in a situation known as
super selection: the bacteria that don't
have the capability of producing these
enzymes die; those that do survive.
Bacteria multiply rapidly, and within weeks
to months, aided by the power of
exponentiation, there are enough of these
enzyme-producing, resistant strains to
pose a serious problem. Worse still,
sensitive organisms are eliminated over
time and the field is left open to the
resistant ones. Similar examples abound in
the environmental and ecological
setting.Within a few years of the
introduction of penicillin, resistant bacteria
were being detected. They produce the
enzyme penicillinase that destroys
penicillin. Medical research responded by
producing the next generation of penicillin
that was effective against penicillinase
producing bacteria. The bacteria bounced
back with enzymes that could digest this
new product. To make a long story short,
Resistance means that:
• People can't be effectively treated
and are at greater risk of dying from
infections.
• People are ill for longer.
• Epidemics are prolonged.
• Others are at greater risk of
infection.
just half a century after the introduction of
penicillin, we have organisms that are
resistant to all available agents: pan-
resistance is here to stay.
2.Mutations (a constant feature in the field
of evolution) can occur randomly in the
genetic make-up of bacteria that confer
the ability to resist antibiotics. Once
imprinted in the genes, it is quickly passed
on to succeeding generations. As seen in
the earlier instance, it is only a matter of
weeks to months before there are huge
numbers lurking around. Alarmingly, this
genetic information can be transmitted to
unrelated species, thereby conferring
immunity to other bacterial types that
may not have otherwise acquired this
capability. Bacteria that were hitherto
innocuous become virulent invaders that
are antibiotic resistant.
Whatever the mechanism, the longer and
more intensively bacteria are exposed to
antibiotics, the more likely it is that
resistance will develop.
Bacteria are evolutionary survivors. They
predate Man by millions of years and have
stored, many tricks up their sleeve. Like
the anti-war protestors of the US
campuses of the sixties, their slogan too,
is “Hell no, we won't go!”.

No country for ostriches
The impending crisis cannot be
lightly dismissed. We cannot
shelter under the complacent belief
that science will discover or invent
new agents to keep up the attack
against bacteria. The pace of
introduction of new antibiotics has
come down markedly in the last
decade while reports of pan-
resistant organisms (bacteria resistant to all available agents}
are growing. The process of new drug discovery and
marketing takes between eight to twelve years. Bacterial
resistance occurs in time frames of months to a year or two.
The economics are not attractive enough for pharmaceutical
companies to plough money into new antibiotic discovery.
A large part of the responsibility in handling this crisis lies
with the patient and consumer. There are many small areas
where gentle but firm insistence from the patient can lead to
changes in the behavior of doctors.
We are warned that those who fail to learn from the lessons
of history are condemned to repeat them. There is good
evidence that the problem is rapidly escalating. To find a
balance in this conflict between the two ends of the
evolutionary pathway - bacteria and man - physicians,
patients and the pharma industry have to work together.

© Dr Arjun Rajagopalan