In my last blog, I wrote about the unequal burden of the global antimicrobial resistance (AMR) crisis that stems from the inappropriately managed outsourced production of antibiotics. Today I will shift focus to the next contributor of AMR, the antibiotic prescription practice in primary health care settings. Although the contribution by the primary health care settings is not as significant relative to the hospital settings, I want to present all potential contributors for the accelerated AMR emergence.
In high-income countries (HICs), when individuals visit their physician with an acute infection such as a urinary tract infection or strep throat, the general initial antibiotic prescription process is guided by the clinical presentation to quickly alleviate discomfort for the patient. Such a practice is known as empiric antibiotic therapy. Microbiological test results are not available immediately; therefore, the drug therapy is initiated before the lab results confirm the infectious agent. Empiric antibiotic prescribing guidelines are available and regularly updated by the local public health agencies.
From my experiences, empiric therapy has mostly been successful. I usually am in severe pain when I visit a clinic with an infection, so anything that promises pain reduction is welcome. As well, I trust the physicians that I see. The concern arises if the lab results are not in agreement with the initial empiric therapy. From the physician’s perspective, you switch to the next most appropriate drug choice. For someone like me who reads research articles daily on how sub-lethal doses of antibiotics can help bacteria evolve resistance, I am terrified. To prevent such mishaps, some physicians will choose to prescribe broad-spectrum antibiotics. However, note that many priority pathogens that pose the greatest threat to human health have developed resistance to broad-spectrum antibiotics, and research and development of new antibiotics are stagnant. So, the empiric prescription of broad-spectrum antibiotics is one factor that contributes to increased antibiotic pressure, promoting AMR evolution in exchange for the patient’s wellbeing.
How about we try to assess and manage the prescription decisions? Research has shown that prescribing decisions in HICs varied widely due to factors beyond empiric therapy guidelines, such as patients’ and physicians’ characteristics (van der Zande et al., 2019). Even though there is a diminishing demand for antibiotics from patients in HICs, some physicians still felt pressured by the patients to prescribe. The physicians associated not prescribing antibiotics with the risk of missing diagnosis and legal consequences. Therefore, more AMR education for the patients may help further reduce the demand.
On the contrary, in low-middle income countries, high levels of antibiotics were used outside the formal healthcare system as it was less time consuming, cheaper, and more convenient than going through healthcare facilities (Do et al., 2021). This requires fundamental changes that will improve the state of the primary healthcare system, in addition to AMR education for the patients.
Overall, antibiotics are necessary to help overcome infections. Local infection must be treated promptly to prevent a fatal systemic infection. Not prescribing is not an option, but more questions and discussions between the physician and patient may help reduce the antibiotic demand, which can significantly slow down the overall AMR evolution.
van der Zande, Marieke M., et al. “General practitioners’ accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices.” BMC family practice 20.1 (2019): 1-11. https://doi.org/10.1186/s12875-019-1065-x
Do, Nga TT, et al. “Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach.” The Lancet Global Health 9.5 (2021): e610-e619. https://doi.org/10.1016/S2214-109X(21)00024-3
Image by Steve Buissinne from Pixabay
