Judicious Use of Antibiotics 1

Indian Journal of Pediatrics, Volume 73April, 2006 343

New Drugs Antibiotics

Correspondence and Reprint requests : Dr. Aditya Gaur, MD,Department of Infectious Diseases, St. Jude Childrens ResearchHospital, 332 N. Lauderdale Street, Memphis, TN 38105-2794. USA.Fax: (901)-495-5068.

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

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

The Judicious Use of Antibiotics An Investmenttowards Optimized Health CareAditya H. Gaur1,2 and B. Keith English2

1Department of Infectious Diseases, St. Jude Childrens Research Hospital, and 2Department of Pediatrics,University of Tennessee Health Science Center, Memphis, Tennessee, USA

Antibiotic resistance is a natural phenomenon resistantstrains of micro-organisms have been noted close on theheels of antimicrobial discovery.1 It is undeniable thatantibiotic use (and overuse) contributes to development ofresistance. The development of newer antibiotics, in partresponding to the emergence of resistant microorganisms,has resulted in a sense of complacency on the part of thegeneral public and medical care providers. Now, withclear indications of a decline in pharmaceutical companyinterest in anti-infective research, at the same time whenmulti-drug resistant micro-organisms continue to bereported, it is very important to review the prudent use ofthe available agents to fight these micro-organisms.2

The dictionary meaning of judicious is having orshowing reason and good judgment in makingdecisions. With reference to antibiotics, judicious useimplies using an antibiotic only when indicated, choosing acost-effective agent which provides appropriateantimicrobial coverage for the diagnosis that is suspectedand prescribing the optimal dose and duration of theantimicrobial. The WHO Global Strategy for Containmentof Antimicrobial Resistance defines the appropriate use of

antimicrobials as the cost-effective use which maximizesclinical therapeutic effect while minimizing both drug-related toxicity and the development of antimicrobialresistance (http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf).

Injudicious use of antibiotics for both humans andanimals3 has long been recognized as a global problem.While over the counter access to antibiotics is mentionedas an important contributor towards injudicious antibioticuse in developing nations, as shown in a number ofstudies there are many provider, practice and patientcharacteristics which drive antibiotic overuse indeveloped nations such as the United States. Numerousapproaches have been proposed as a solution to thiscomplex, multi-factorial problem. While some countrieshave shown a striking improvement in antibiotic use, insome cases associated with a drop in the problem ofantimicrobial resistance,4 there is abundant opportunityfor improvement in most of the world.

IMPLICATIONS OF INJUDICIOUS ANTIBIOTIC USE

There is no dearth of original research articles and reviewson this subject; there has been ongoing research in thisarea for many decades and yet the problem is far frombeing solved. An understanding that the roots of thisproblem are entrenched in societal and cultural beliefsand expectations is the first step in attaining a solution.

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Aditya H. Gaur and B. Keith English

344 Indian Journal of Pediatrics, Volume 73April, 2006

There are complex reasons that drive continuation of ahabit and it is important not only to review the laundrylist of possible dire consequences of the habit but also tobe cognizant that amongst the list there will be somereasons which may motivate the individual and somewith more societal implications that may only motivatepolicy makers.

Injudicious use of antibiotics effects the individual andsociety in a number of ways. At the outset we shouldclarify that there is some debate about how muchantibiotic use and overuse contributes to the developmentof resistance,5,6 and what expectations are realistic interms of gains that can be made in reversing resistancewith more prudent use of these agents,7;8 While one groupof researchers reported finding relatively high levels ofantimicrobial resistance in commensal enterobacteriaisolated from wild rodents in the British countryside,5

(suggesting that the development of resistance might becommon in the absence of antibiotic exposure), othergroups have failed to detect antibiotic resistance in E. coliisolated from wild animals in more remote locations (e.g.,northern Finland),6 where prior exposure toantimicrobials is extremely unlikely. Some studiessuggest that antibiotic resistance, once acquired, is lostvery slowly. Examples include the persistence ofstreptomycin9 or sulfonamide resistance in E. coli7 despitedecrease in antibiotic use and the persistence ofvancomycin-resistant enterococci in Norway after theavoparcin ban.10 Such debates should not distract us fromthe undeniable fact that there is no rationale for usingantibiotics inappropriately i.e. an unindicated use orincorrect choice of antibiotic, its dose or treatmentduration. First, there is clear evidence that antibioticresistance develops under antibiotic pressure. While thismay not be the only factor contributing to thedevelopment of antibiotic resistance and reduction inantibiotic use may not always be followed by a decreasein resistance, a decrease in antibiotic overuse will remainthe number one intervention in our attempts towardsslowing down the development of antimicrobialresistance. Second, injudicious use of antibiotics comeswith a cost. Not only is there a cost of paying for amedication that was not needed, there is the cost ofadverse drug reactions11 and ultimately, the inevitablecost of managing resistant microorganisms.12 In the US in1998, an estimated 76 million primary care office visits foracute respiratory tract infections resulted in 41 millionantibiotic prescriptions. Antibiotic prescriptions in excessof the number expected to treat bacterial infectionsamounted to 55% (22.6 million) of all antibioticsprescribed for acute respiratory tract infections at a cost ofapproximately $726 million.13 Third, injudicious use ofantibiotics clearly influences the ecosystem. Antibiotic usein humans and animals has been shown to change themicrobial flora of the gut and the ecosystem. Finally,ongoing antibiotic misuse perpetuates a culture ofinjudicious use where every contributor to this

undesirable practice makes it more difficult to change thehabit. Of all the reasons cited above, the possibility ofavoidable side effects and unnecessary cost would mostlikely appeal to individuals while reducing antibioticresistance, minimizing the detrimental impact on theecosystem and reversing the evolving culture of antibioticmisuse should motivate the physician community,governments and policy makers.

UNDERSTANDING THE PATHOGENESIS OFINJUDICIOUS USE OF ANTIBIOTICS

There are numerous factors varying by geographicalregion, social circumstances and existing health caresystems that influence antibiotic use and misuse invarious parts of the world. In this productivity drivensociety, patients may seek a fast fix to every illness andfind waiting for the natural evolution of a viral illnessunacceptable. Doctors may experience real or perceivedpressure from their patients to prescribe an antibiotic pressure that is compounded by fear of losing a patient toanother provider or fear of the possibility of medico legalimplications if they failed to catch something treatableearly. Economic pressures that influence patients andphysicians to antibiotic overuse are often talked about butless well studied. The pharmaceutical industry may feelthe pressure to sell their product to realize the costs of theinvestments made and in doing so may reach out to itsclients including both patients and physicians inquestionable ways. Under such circumstances it is awasted effort to identify the sinner because no one isinnocent, but it is appropriate to accept that regardless ofthe reasons that drive injudicious use of antibiotics everyperson who contributes to the problem by being aparticipant perpetuates this deep rooted practice.

Various patient and provider characteristics that areassociated with antibiotic use and misuse are summarizedbelow. The nontherapeutic use of antibiotics in animalagriculture has recently been reviewed elsewhere.14

PROVIDER CHARACTERISTICS

Provider experience. Numerous studies have shownwidespread unnecessary use of antimicrobials in patientswith viral upper respiratory tract infections.15,16

Interestingly, we recently found that antibioticprescribing in the context of an outpatient visit for adiagnosis suggestive of a viral respiratory tract illnessoccurs more commonly among staff physicians thantrainees, and among staff physicians, more commonly innon-teaching compared to teaching institutions.15 Thisstudy used data collected from ambulatory clinicsassociated with hospitals in the United States as part ofthe National Hospital Ambulatory Care Survey from 1995to 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 andperceive less medico-legal risk when withholdingantibiotics in specific clinical situations compared topracticing clinicians in hospital based outpatientdepartments. Additionally our findings may represent acohort effect; trainees may be more familiar withrecently administered guidelines and may be morecomfortable with antibiotic restraint than providers whotrained and practiced prior to the dissemination of theseguidelines. Mainous et al using information from theKentucky Medicaid database, reported that the highprescribers of antibiotics for children with upperrespiratory tract infections were significantly more yearsfrom medical school graduation (27 vs 19 years) than lowprescribers.17 In a study reported by Steinke et al, non-training practices in Tayside, UK were in general found toprescribe significantly more antibiotics as well as a higherproportion of broad spectrum penicillins, a higherproportion of newer antibiotics and a greater number ofdifferent antibiotics per doctor compared to trainingpractices.18 We and others have shown that non-pediatricians prescribe antibiotics more often to childrenwith colds, bronchitis and upper respiratory tractinfections (URI) than pediatricians.15,16

Time spent with the patient. Physician time constraint isa factor that is frequently mentioned as a hypothesis forantibiotic overuse.19 However, few studies have examinedthis hypothesis. Surrogate measures for shorter visit timesas measured by number of patients seen in a week or typeof remuneration (fee-for-service) have been associatedwith higher antibiotic prescription rates. The presumptionis that the necessity of shorter patient-visit times leadsphysicians to prescribe antibiotics rather than take thetime to explain why an antibiotic is not indicated.However, our findings in a study examining therelationship between physician visit time and antibioticprescribing in the context of other factors that may play arole in antibiotic prescribing for viral respiratory tractinfections, do not support the contention that it takeslonger not to prescribe antibiotics in ambulatory caresettings.20

Inadequate information among various antibioticproviders. Lack of knowledge contributes toinappropriate antimicrobial use. In many countries,including India, antibiotics are dispensed not only byphysicians but a host of other providers with variabletraining backgrounds including those with no medicaltraining. A study from China provides a good example ofthe magnitude of the problem and the challenge ofproviding adequate information.21 Through multistagestratified sampling, 100 of the 1508 Heath Care Workers(HCWs)s working in a county in China were selected forobservation of their management of acute respiratory tractinfections (ARI). Assessment of diagnostic standards,antibiotic abuse and appropriateness of antibiotic use wasbased on the WHO definition. There were three categoriesof HCWs in the county: (1) doctors who after a

Bachelors degree and a competitive entranceexamination, have undergone 4 to 6 years of training at anUniversity; (2) HCWs who after middle or high schoolhave undergone 3 years of training in a secondarymedical or nursing school (this category includespractitioners of traditional Chinese medicine); (3) villageworkers who have only 6 to 24 months of training on thelocal level. Not sampled but present in the county weretraditional 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); andlincomycin. Before the parents sought medical care, 47%of children in the county hospitals, 25% of those in thetownships and 18% of those in the villages had alreadyreceived antibiotics available without prescription.Among the HCWs, antibiotic abuse (antibiotics forpresumably viral disease) was detected in the treatment of97% of cases, and severe abuse (such as prescription oftwo incompatible antibiotics) was detected in 37%. Most(197 of 200) patients with bacterial disease receivedantibiotics, but inappropriate antibiotic treatment (dose ortype) was observed in 63% of these cases. HCWs withUniversity training and those with higher test scores onknowledge and attitude prescribed antibiotics morejudiciously than those lacking those attributes. Thissituation is not unique to this county in China andsymbolizes the problems with the health careinfrastructure of many countries. Contributing to this lackof knowledge of appropriate choice of antimicrobials maybe factors such as limited access to updated, unbiasedinformation especially regarding local antibiotic resistancepatterns, and the availability of treatment guidelines thatprovide a cost-effective approach to common clinicalsyndromes using available antibiotics. It is not uncommonfor drug company sales representatives and thecommercially oriented publications they provide to be themain sources of information for many prescribers.22

Real time monitoring of antimicrobial resistance andongoing feedback to the prescribers in a community isvery important. Medical care costs and lack of affordableculture and sensitivity tests often limits the availability ofpatient specific information. Under such circumstancesempiric therapy of real or perceived treatable infectionswith broad spectrum agents is common. Additionally,prescribing just to be safe increases when there isdiagnostic uncertainty, lack of prescriber knowledgeregarding optimal diagnostic approaches, lack ofopportunity for patient follow-up, and/or fear of possiblelitigation.19,23 Diagnostic uncertainty can be viewed ashaving two components an uncertainty of whether apatient has a bacterial infection or not and/or if abacterial infection, the uncertainty of what antibiotic touse. It is important to acknowledge that even in the handsof the best clinician there will be patient case scenariosassociated with a diagnostic uncertainty and in

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situations where the potential consequences ofmisdiagnosis are great such as a patient with suspectedmeningitis, empiric antibiotic use is unavoidable andunderstandable. In sharp contrast is the diagnosticuncertainty of an otitis media where the consequencesof a delayed diagnosis are minimal.

Cultural and Economic factors. In some cultural settings,antimicrobials given by injection are considered moreefficacious than oral formulations. This tends to beassociated with the over prescribing of broad-spectruminjectable agents when a narrow spectrum oral agentwould be more appropriate. Gumodoka et al reported thatone in four patients in their medical districts receivedantimicrobials by injection and that approximately 70% ofthese injections were unnecessary.24 Prescribers may fearthe potential loss of future patients and revenue if they donot respond to perceived demands for antimicrobials.25 Infocus group studies, prescribers expressed concern that, ifthey did not prescribe antimicrobials, patients would seekother sources of care where they could obtainantimicrobials. Furthermore, in some countries,prescribers profit from both prescribing and dispensingantimicrobials, so that it is in their financial interest toprescribe antimicrobials even when they are not clinicallyindicated. Additional profit is sometimes gained byrecommending newer and more expensive antimicrobialsin preference to older and cheaper agents. In countrieswhere physicians are poorly paid, pharmaceuticalcompanies have been known to pay commissions toprescribers who use their products.26

PATIENT CHARACTERISTICS

When a parent or child has received an antibioticprescription for an illness in the past, that experienceengenders expectations that the same therapy is requiredshould such symptoms recur.27 Parental expectation isoften cited as a reason for antibiotic prescriptions.28

However, at least one study shows that physiciansperceptions of parents expectations are not alwayscorrect.29 In this study while physicians were significantlymore likely to inappropriately prescribe if they believed aparent desired antimicrobials, there was poor agreementbetween actual pre-visit expectations reported by parentsand physician-perceived expectations. Actual parentalexpectations did not have an effect on the decision toprescribe after controlling for covariates. Of interest, thisstudy found that when physicians thought a parentwanted an antimicrobial, otitis media and sinusitis wereboth significantly more likely to be diagnosed.Additionally, studies have also shown thatmisconceptions regarding antibiotic use are widespreadamong patients and parents.30-32

In a study by Macfarlane et al the authors assessedpatients views and expectations when they consult theirgeneral practitioners in the UK with acute lower

respiratory symptoms and the influence these have onmanagement.33 They found that most patients think theirsymptoms are caused by infection, think an antibiotic willhelp, and want antibiotics. Three quarters of previouslywell adults in this study consulting with the symptoms ofan acute lower respiratory tract illness received antibioticseven though their general practitioners assessed thatantibiotics were definitely indicated in only a fifth of suchcases. Patients expectations and views and doctorsconcern that the patient may otherwise reconsult had apowerful effect on doctors decision to prescribe. Patientswho did not receive an antibiotic that they wanted weremore likely to be dissatisfied and reconsulted twice asfrequently. In a survey of 3610 patients conducted byBranthwaite and Pechre,34 over 50% of intervieweesbelieved that antimicrobials should be prescribed for allrespiratory tract infections with the exception of thecommon cold. It was noted that 81% of patients expectedto see a definite improvement in their respiratorysymptoms after three days and that 87% believed thatfeeling better was a good reason for cessation ofantimicrobial therapy. Most of these patients also believedthat any remaining antimicrobials could be saved for useat a later time.

These and other patient misconceptions combinedwith access to antimicrobials without a prescription inmany countries creates the perfect environment forinjudicious use of antibiotics. In a Brazilian study, it wasdetermined that the three most common types ofmedication used by villagers were antimicrobials,analgesics and vitamins. The majority of antimicrobialswere prescribed by a pharmacy attendant or werepurchased by the patient without prescription35 despitehaving prescription-only legal status. In addition toobvious uncertainty as to whether the patient has anillness that will benefit from antimicrobial treatment, self-medicated antimicrobials are often inadequately dosed36

or may not contain adequate amounts of active drug,especially if they are counterfeit drugs.37 Patients mayshop by brand name of antibiotics not realizing thatdifferent brand name products may contain the sameantibiotic. Specific patient demand caused one pharmacyin South India to stock more than 25 of the 100 or sobrands of co-trimoxazole.38 In countries with such freeaccess to antibiotics there is often unregulated growth ofcompanies that manufacture these products. This raisesconcern about the quality of many antibiotic products andultimately the impact this would have on the problem ofantimicrobial resistance.

Direct-to-consumer advertising allows pharmaceuticalmanufacturers to market medicines directly to the publicvia television, radio, print media and the Internet. Wherepermitted, this practice has the potential to stimulatedemand by playing on the consumers relative lack ofsophistication about the evidence supporting the use ofone treatment over another.39

Poor adherence to medication doses and duration of

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therapy is a well recognized cause of resistance. This isespecially so with illness requiring long term therapy suchas tuberculosis and HIV. Adding to the complexity of theproblem is the fact that in many countries most of thepatients pay out of pocket for medical treatment. It is notunusual for patients to buy aliquots of medicationsbased on what they can afford and to skip doses or takeinadequate doses when feeling well or when short onmoney.

INTERVENTIONS TO PROMOTE JUDICIOUS USE OFANTIBIOTICS

A number of interventions have been tried to promotejudicious use of antibiotics around the world. Theapplicability of these interventions differs not only basedon the clinical setting of antibiotic use i.e. management ofacute infections in an outpatient setting vs. inpatientsetting vs. treatment of chronic infections, but also on anumber of other factors such as site characteristics(private practice vs. academic setting), available resources(such as electronic data management and electronicprescriptions) and patient characteristics (literacy, culturalbeliefs, socio-economic status). No single intervention islikely to have a significant impact by itself and acombined approach using multiple interventions isnecessary. Additionally, while the enormity of theproblem and the degree to which it has become pervasivein society, especially in some countries may be daunting,every effort that is made to promote judicious antibioticuse will have some benefit. A list of ideas andinterventions is provided below realizing that not all ofthem may be practical or applicable to every country orclinic setting. This list includes some recommendationsmade as part of the WHO Global strategy for containmentof antimicrobial resistance (http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf), areview of interventions reported successful in variousstudies and authors opinion. The WHO Global strategyfor containment of antimicrobial resistance is acomprehensive source of information regarding judiciousantibiotic use and other measures to address the problemof antimicrobial resistance. Readers are encouraged tobrowse the cited WHO Global Strategy link to getcomplete details on this topic. Based on existing resources,feasible options should be considered.Interventions directed to patients and the non-medicalcommunity:

1. Education: Physicians have cited patient/parentpressure as one of the factors that influences theirantibiotic prescribing practice. For this and otherreasons educating patients and the general public iscritical to the efforts to promote judicious antibioticuse. Educational messages should be directed on thefollowing themes:a. Education regarding common diseases and the

role of antibiotics (where they work and wherethey do not)

b. Efforts to increase awareness of antibioticresistance and its impact on individuals and thesociety.

c. Education to discourage self-initiation oftreatment and encourage appropriate andinformed health care seeking behavior.Education on suitable alternatives toantimicrobials for relief of symptoms should beprovided where applicable.

d. Education to promote adherence to theprescribed treatment.

As with any other public health related interventioncreative use of locally available and applicable resourcesthat take into account patient literacy should be done toeffectively impart education related to the abovementioned themes. These messages can be delivered bythe media, in clinic waiting rooms,40 during prescriber-patient interaction and during dispenser-patientinteraction. Based on patient literacy, information leafletscan be provided.41 A number of websites provide patienteducation material and evidence based recommendationson antibiotic use. Examples of such resources from USbased organizations are the Center for Disease Controland Prevention (www.cdc.org) and Alliance for thePrudent Use of Antibiotics (http://www.tufts.edu/med/apua/). Among other things the CDC website providesthe template for a prescription pad that can be used inpatients with a viral illness. Such information can be usedto create patient information material in regionallanguages with the message modified where necessary tofit the local culture and beliefs. Some drug resistantbacteria i.e. super bugs have caught the media attentionand this limelight should be used to present informationregarding judicious antibiotic use to the community. Inaddition to the media, information can be provided atcommunity health events and through local communityleaders as part of other public health messages thatincrease overall health awareness in the community.

2. Incentives and reassurance: Patients seek reassurance,symptomatic relief (often a quick fix) and especiallywhen paying out of pocket for the medical servicesthey expect something concrete out of the visit tojustify the money or time they have spent to accesscare. Keeping this in mind, some interventions thatcan be considered, include:a. The use of delayed prescribing techniques.19 A

strategy of providing the patient with aprescription for an antibiotic but asking that theprescription not be filled unless symptoms donot get better within a few days has beensuccessfully used in one study.41

b. Some physicians say that they promise a freereturn visit if the patient feels that a re-consultation is necessary because they did notreceive antimicrobials.19 Another approach (if the

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resources are available) is to arrange for theoffice staff such as a nurse to make a follow-upphone call to the patient. This can potentiallydecrease the insecurity felt by a patient/parentwhen leaving the clinic without an antibioticprescription.

c. Suitable alternatives to antimicrobials for relief ofsymptoms should be provided where applicable.

d. From acute care to comprehensive care: Forpatients with poor access to health care, visits foracute illnesses are the window of opportunity forthe physician to provide health-relatededucation, immunizations, and treatment ofcommon illnesses such as anemia andhelminthiasis.

Interventions directed to the prescribers anddispensers of antibiotics:

1. Education: While the need for ongoing education ofall clinical care providers regarding judicious use ofantibiotics is widely accepted the question of whoshould do it and how should it be done inpreferably an evidence based manner needs to beanswered based on local health care and politicalinfrastructure. While it is important to provide thisinformation as part of all clinical provider trainingprograms (medical schools, pharmacy schools etc),based on information we presented earlier the valueof continuing medical education for practicingphysicians cannot be over emphasized. As withpatient education, multiple avenues to disseminateinformation have to be identified. These includeprinted materials (journals, periodicals, newsletters),continuing medical education (CME) activities(meetings, conferences, online access), and point ofcare services (pop up prompts triggered by electronicprescribing).42 Previous studies have shown thatdidactic sessions alone do not help.43-45 Educationaloutreach or academic detailing, which consists ofbrief, targeted, face-to-face educational visits toclinicians by specially trained staff,44;46 is successfulbut may not be practical or cost-effective in manycountries. Engaging local opinion leaders in theprocess of disseminating targeted educationalmessages to their peer group has been shown to beanother successful strategy.40,47

2. Affordable, reliable microbiology laboratory services:Reliable culture and antimicrobial susceptibilitystudies are critical to optimizing antimicrobial use inthe hospitals and the community. Access to suchservices is often unaffordable or under utilized indeveloping countries. Diagnostic uncertainty asdescribed before (does the patient have a bacterialinfection and if so what empiric antibiotic to use) isoften cited as a reason for over prescribing andbroad-spectrum antibiotic use. Availability of lowcost microbiology facilities for individual patient care

is desirable but in many countries is not alwaysfeasible. Especially in such settings, systematiccollection of reliable and comparable antimicrobialresistance data by regional government and privatelaboratories and dissemination of this information ona regular basis to prescribers in the community isvery important.

3. Clinical care guidelines: Clinical care guidelines canaddress both forms of diagnostic uncertainty. Accessto updated regionally appropriate treatmentguidelines for common infections facilitates evidencebased standard of care.48 These guidelines should bebased on existing antibiotic resistance patterns. In1998 the CDC and the American Academy ofPediatrics published evidence based principles todefine judicious antimicrobial use for pediatric upperrespiratory tract infections that account for majorityof outpatient antimicrobial use in the United States.49

Dissemination of such guidelines using multiplemethods including CME activities, academicdetailing, local opinion leaders and others willoptimize the impact of these guidelines.

4. Education for other clinical care providers: In manycountries including India the presence of non-physician providers with no formal training whocontinue to provide health care services to a largesection of society is well recognized. These providerspersist because of cultural, financial or lack ofaffordable alternative reasons. Recognizing thelogistical difficulties of removing such non-traditional providers and dispensers, taking steps toprovide them with drug and disease relatededucation, including judicious antibiotic use mayreduce antibiotic misuse.

5. Hospital therapeutic committees and antibioticaudits: While the major contributor to the overallvolume of antimicrobial overuse may be outpatientprescribing, measures to address judicious antibioticuse in the hospitals are also important. Besides theoverall benefits of promoting judicious antibiotic use,hospital based interventions may affect theprescribing habits of not only trainees but communityphysicians with admitting privileges. The beneficialrole of hospital therapeutic committees in thepromotion of rational prescribing habits, monitoringof drug usage and cost containment is wellestablished in developed countries.50 There is paucityof literature about the feasibility and effectiveness ofsuch committees in developing nations. Suchcommittees are responsible for development ofwritten policies and guidelines for appropriateantimicrobial usage in the hospital, based on localresistance surveillance data. They assist in selectionand provision of appropriate antimicrobials in thepharmacy after consideration of local clinical needs.Additionally they define an antimicrobial utilizationreview program, with audit and feedback on a

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regular basis to providers, and promotion of activesurveillance of the nature and amount ofantimicrobial use in the hospital. Despite thelogistical challenges of creating and empoweringsuch committees in hospitals where a culture ofcomplete physician autonomy exists the potentialbenefits of having such a self regulating committeeshould be explored.

Interventions directed to Governments and otherpolicy makers: It is beyond the scope of this article to gointo the nuances of some of the suggested interventionsand how they would be applied based on the uniquepolitical healthcare infrastructure and societalcircumstances of each country. For example, a crackdownon antibiotic dispensing to make these available only witha prescription without looking into the feasibility ofpatients to access a prescription provider or the abilityto authenticate the credentials of the person who writesthe prescription is unlikely to be effective and may haveother undesirable ripple effects including breedingcorruption. In many countries overall or region specific(for e.g. in rural areas) lack of trained health careproviders combined with poverty, low literacy rate andout of pocket expenses for medical care have alloweduntrained prescribers of antibiotics to flourish. It is alsonot unheard of for the drug dispensers and pharmacies tooffer free medical advice including suggestions aboutantimicrobials. Understanding these problems andsuggesting a remedy to them is not easy and requiresgovernment initiative and policy changes.

The importance of taking the essence of each of therecommendations and distilling them into practical,regionally appropriate actions cannot be overemphasized.

1. Governments and physician organizations shouldprovide funding and resources to educate patients,prescribers and dispensers as delineated in theprevious paragraphs.

2. Governments should develop and enforce regulationslimiting over-the-counter purchase of antimicrobials.

3. Governments should develop and enforce regulationsto ensure the quality of antibiotics that are available inthe market.

4. Governments and physician organizations shouldlink professional registration requirements forprescribers and dispensers to requirements fortraining and continuing education.

5. Government schemes should subsidize the creation ofaffordable microbiology laboratory services.

6. Governments and physician organizations shouldprovide funding and collaboration to optimizeantimicrobial resistance surveillance.

7. Government schemes should subsidize the cost ofcertain preferred antimicrobials and/or provide freeaccess to them through specific centers. This isespecially important for medications used for chronicillnesses such as tuberculosis and HIV.

8. Governments should control and monitorpharmaceutical company promotional activities anddirect-to-consumer advertising and limit these to onlythose that have educational benefit.

CONCLUSION

Many parts of the world have witnessed a change insocietys views about smoking, diet and obesity asimilar level of awareness and motivation is needed inregards to antibiotic use. Measures to improve the use ofantibiotics are not limited to addressing this problemalone but are far overreaching. In a way the interventionsdiscussed earlier go towards creating a society ofinformed consumers who receive rationale health care.While the goal is far from being reached, a reader whomakes it to the end of this review article is encouraged topause for a moment, reflect on his practice and decidewhat he as an individual can do to address this problem.

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Judicious Use of Antibiotics 1