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Commentary"Antibiotic Prescribing Revisited"
It is well recognised that antibiotic-resistant strains of bacteria are increasing and concerted action is needed if the problem is to be controlled. For an effective outcome to take place, there is a need for both the doctor and the patient to play a part.
Professionally, the problem lies not only with the general practitioner but the hospital doctor as well(1). There are common denominators. Most hospital clinicians would prefer to either choose an antibiotic with the widest spectrum, or institute multiple antibiotics so as to hopefully obtain a favourable outcome while waiting for bacteriological culture results. For the general practitioner, there is a tendency to prescribe the widest spectrum of drugs or the latest antibiotic in the hope of achieving a "definite" cure. In both instances, there are too many antibiotics available and new ones are continuously being added to the market. It is difficult for doctors to have a complete knowledge of the pharmacology of many of these drugs. The patient has a potent influence on the doctor, particularly in the general practice setting. A qualitative study of 21 GPs and 17 of their patients on their perceptions of antibiotics for sore throats was reported in the BMJ(2). The key messages of this study are: doctors know that antibiotics do not help in most sore throat sufferers but try not to jeopardise relationships with patients over this issue; a third of the patients had clear expectations for antibiotics; mothers were more likely to accept non-antibiotic treatment for their children than for themselves; satisfaction was not necessarily related to receiving antibiotics, information and reassurance were sometimes more important. What is the way ahead? Several strategies have been described. In the outpatient setting, the authors of the qualitative study said that consulting techniques that make expectations explicit, preserve relationships and facilitate acceptable management are important(1). Emphasising risks to individuals of unnecessary antibiotics rather than trial evidence for marginal benefits of antibiotics was more acceptable. It is of course important for the doctor to remind the patient to complete the course of antibiotics prescribed. Doctors need to keep up-to-date on the duration of antibiotics recommended for various conditions and the antibiotics of choice. Reading of journals and participation in continuing medical educational programmes organised by recognised academic institutions remain an important measure(2). Dr Ling Moi Ling, writing in Medicine Digest described several practical strategies for the hospital setting. A common practice is to select a particular agent to represent a class of antibiotics and not allow other agents of the same class to be available. It is not advantageous to allow clinicians to order whatever antibiotics they desire. Audit of the use of antibiotics is an effective measure in assessing the prescribing habits of the clinician and the department: it serves to evaluate the success of implementation of various policies. Continuing surveillance has been demonstrated to lead to a more appropriate use of antibiotics. Antibiogram charts are also useful guides to empirical therapy. The most useful educational approach is one-to-one instruction or group consultation with a drug utilisation expert(2).Finally, efforts to help patients understand the place of antibiotics in their illnesses will modulate inappropriate demands. The mass media can certainly run talk shows and documentaries to discuss this rather important aspect of care. We will be returning to the pre-antibiotic era if we do not take steps to avoid the "Tragedy of the Commons". Everyone has a role to play.
REFERENCES
1. Ling ML. Changing trends in antimicrobial resistance. Medicine Digest Feb 1998;16:2:5-8.
2. Butler CC et al. Understanding the culture of prescribing: the qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 5 Sep 1998;317:673-642.
A/PROF GOH LEE GAN