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Sunday, November 4, 2001
Keeping fit

When overuse makes a boon a curse
B.K. Sharma

ANTIBIOTICS are the chemical substances produced by micro-organisms which have the capacity to inhibit the growth or to kill other micro-organisms. Antibiotics which were originally produced by living organisms have subsequently been produced synthetically. The beginning of antibiotic era is a fascinating story.

A beginning was made by Pasteur and Jouvert in 1877, but the substance produced appeared too toxic to be used in human beings. The real antibiotic era started in 1928, when an English microbiologist, Alexander Flemming, who was working on the growth of certain bacteria went on vacation for two weeks and on his return found that on certain areas of his petri-dishes wherever there was a little mould, the growth of bacteria had been inhibited. This mould was penicillium-notatum and thus was born as the first antibiotic — penicillin.

The uses of antibiotics

This, indeed, is self-evident and I hardly need to mention that antibiotics have played a great role in alleviating the sufferings and saving countless lives. One has always wondered how did the doctors practice medicine before this era. For the treatment of infections they had only agents like arsenicals and other very toxic compounds. Respiratory infections like pneumonia and bacterial throat infections, treatment of typhoid fever and other intestinal infections like dysentery, tuberculosis, sexually transmitted diseases like gonorrhoea and syphilis, of the nervous system like meningitis, infective diseases infecting the heart and its valves, osteomyelitis of the bones and now AIDS, all came under the spell of antibiotics. This list is not at all exhaustive but only an example of common diseases.

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Indeed the improvement was so dramatic that it led to some degree of complacency as well as misuse resulting in the problem that we are facing now. It is this complacency that led to the remarks by a USA Surgeon General that "time has come to close the chapter on infectious diseases". I am sure this was said too early and the microorganisms must have had a hearty laugh at this statement.

The problem of resistance

It is very tempting for the doctor as well as the patient to use an antibiotic whenever there is an infection or the possibility of an infection. It is perhaps not in public knowledge that the use and abuse of antibiotics is as common in the veterinary practice as it is the humans. According to a report of the Task Force on Antibiotic Resistance of the American Society of Microbiology, 50 per cent antibiotics are used in the humans and 50 per cent in animals.

Among the humans early 20 per cent are used in the hospital setting and 80 per cent in the community. In the animals 20 per cent in use for therapeutic purposes and 80 per cent as growth promoters. It was estimated that 50 per cent among the humans and may be over 50 per cent in the animal kingdom, the use was questionable and unscientific.

This widespread use brought a stage where resistance to antibiotics has emerged as a major problem in medicine. It was not realised early enough that it is not possible to eradicate bacteria, in fact it is not desirable either. Pushed to the wall, bacteria used very ingenious methods to survive and started becoming resistant to the antibiotics. The bacteria become resistant either by changing their internal genetic make up or borrow a piece of genetic material from other bacteria which were already resistant.

To begin with, this resistance was noticed in the hospital setting where antibiotics were used rather intensively. As expected, it has gone to the community now. Amongst the bacteria producing pneumonia, tuberculosis, urinary tract infection and sore throat, the resistance is now prevalent in the community at large. As noted in these columns earlier, the multidrug resistance in tuberculosis in the world at large and in our country particularly is playing havoc.

In a meeting held at Copenhagen, 1998, on antibiotic resistance, the famous microbiologist from Guys’ Hospital, London, Dr Norman Simmons, put it rather candidly, "We screwed up and we are to say so and apologise. Doctors were given the wonderful gift of antibiotics, but are destroying them through indiscriminate use". A committee has recently been set up in United Kingdom on the recommendations of House of Lords to go into the problem. The committee is headed by Prof Richard Wise. According to him, of the antibiotics used in the community, 60 per cent are given for upper respiratory infections like sore throat and common cold and over 80-90 per cent of these infections are viral in nature where antibiotic has no role. He compared the prescribing of antibiotics to smoking, hard to give up because the link between action taken and reward is not immediate.

Antibiotic resistance is not an iesoteric subject. This concerns every doctor and patient. I have seen antibiotic resistance emerging in typhoid, urinary tract infection, tuberculosis, pneumonias, meningitis and other diseases. In typhoid, for instance, drug like chlorophenicol, Septran and ampicillin became useless one after the other and resistance is becoming evident to the present set up of antibiotics.

Same is true about the tuberculosis and others. The problem has to be recognised by the leaders of medical profession, pharmaceutical industry, doctors in the community and public at large. The menace of freely ‘on the counter’ available antibiotics in our country makes the problem much worse than in the western society where antibiotics cannot be purchased without proper prescription.

Some guidelines for the use of antibiotics

Educating the medical profession and public is the main weapon that we need to employ for this. Like charity it must start at the home of the profession and intense education, reorientation and restrain are required in the use of antibiotics.

  • The recognition of the problem is the most important step both for the doctors as well as the public.

  • Both during the training and practice, doctors should be repeatedly updated with knowledge on the prevalence of sensitivity and resistance of bacteria to antibiotics.

  • Surveillance of resistance should be carried out at the local, national and international levels. This is the most important step in tackling this problem as without this it is not possible to know the problem.

  • Data generated by many laboratories should be reviewed and circulated to all concerned so that they can reorient the use of antibiotics.

  • As mentioned above, the use of antibiotics in common cold and throat infection should be restricted unless there is a clear-cut indication. This is a major area of antibiotic misuse.

  • Coordinated research to evaluate the problem in specific diseases should be carried out to decrease the resistance and the policy to restrict the use of a particular antibiotic or to rotate the antibiotics should be instituted.

  • Self-prescription and over the counter sale of antibiotics should be curbed. The law already prohibits it but it needs to be enforced.

  • Patient should strictly follow the dose and duration of the prescription.

  • Be patient with common colds and sore throats. It has been said that ‘cold’ is cured in one week with antibiotics otherwise it takes seven days.

  • It should be remembered that many diseases in the developed countries were controlled even before the antibiotics were available and they were based on good public health measures like improving hygienic conditions, availability of clean drinking water, good sewerage disposal, public education for clean personal hygienic practices and control of hospital acquired infections.

  • Immunisation is a better alternative to the use of antibiotic or chemotherapy. Diseases like small pox, polio, measles, chicken pox, tetanus, whooping cough and, now, hepatitis are brought under check by the use of immunisation, and not antibiotics.

Dr Oliver Wendel Holmes, an American Physician, had said, "if all materia medica (read drugs) were to be sunk in the sea, it will be good for the mankind, but too bad for the fishes". This may not exactly apply to the use of antibiotics that have played great role in controlling diseases and epidemics, including the currently prevalent HIV infection and God forbid, the scary spread of anthrax by biological terrorism.

But let us not fritter away this wonderful pharmaceutical weapon against diseases by injudicious use.


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