Tackling emerging pathogensDecember 13, 2018
In India, the largest therapeutic group — which accounts for 15.7% of the drugs market — are antibiotics. This suggests not only that antibiotics are now available to a larger segment of needed people, but also irrational use, leading to antibiotic resistance in bugs. India and the world at large are on the verge of facing their worst healthcare crisis due to fast-emerging antibiotic-resistant pathogens. This multifaceted problem arises due to several aspects, such as non-prescription self-medication, unwarranted dosages to patients by clinics, and the lack of knowledge translation to the public.
According to the World Health Organization (WHO) definition, medicines are used ‘rationally’ (i.e., responsibly, appropriately, correctly and properly) when patients receive the medicines from responsible clinicians in appropriate doses for correct indications and meet the individual need for an adequate period of time with proper knowledge. However, these aspects are seldom practiced, leading to high expenditure on buying medicines and the ever-growing problem of resistant bacteria. The development and implementation of certain guidelines by regulatory authorities may, to some extent, help in curbing this problem.
Due to patients’ demand for instant gratification and other market issues, clinicians are forced to prescribe more than the required amount of antibiotics. It is important to note that bacteria can develop resistance in different ways, like de novo gene mutations and the import of resistance-related genetic information from other bacteria due to selective pressure on them by an overdose of antibiotics. With less antibiotic use, antibiotic effectiveness is maintained for a longer period and the chances of developing resistant bacteria are reduced.
EML for better outcomes
The inappropriate use of antibiotics can start at any of the four stages of treatment cycle, namely diagnosis, prescribing, dispensing and patient adherence. In the first stage, a wrong diagnosis can lead to the use of drugs which will be ineffective. It is very important to practice proper diagnosis and look at the possibility of using non-drug based therapies that may relieve the patient before prescribing drugs. Every country has an Essential
Medicines List (EML) based on the
needs of the populations. The concept of the EML is based on the notion that limited use of well-known and cost-effective medicines can result in better healthcare outcomes, enhanced long-term supply and sustainable access to medicines.
Prescribing is a complex process for doctors and begins with establishing the goal(s) of the therapy. Meeting the patient expectation, arriving at benefit-risk balance, availability and cost are the important considerations for clinicians. This daunting process of prescribing needs openness in engaging with the patient, which is important as it is the patient who is the ultimate recipient of any benefits of taking the medication. For most patients, transitioning into a role of someone who has to take medicines is often difficult. This is more so in cases where the benefits of the medication are not immediate and the mere presentation of the diagnosis may not be a motivator. There is an urgent need to understand this and develop better methodologies in patient adherence and reduce the irrational use of antibiotics.
Threat to progress
In the event of no proper diagnosis, incorrect or general antibiotic prescription can lead to complex and unwanted clinical outcomes. In such cases, it is important to evaluate the patient’s co-existing medical, genetic and environmental conditions. Beyond the prescription, dispensing and patient adherence are even more difficult to follow and improve. Especially in rural areas, the pharmacists almost become non-prescribing doctors in giving medicines and advice, which may not be effective. This aspect also leads to patient non-adherence in taking medications. Essential cross-checks and patient knowledge translation, empowering them for better adherence to therapy protocols, are needed.
Antibiotic development is now considered to be a global health emergency, with the average time needed to receive regulatory approvals being 7.2 years, with a very low clinical success rate of 16%. There is a need for a national-level plan to combat antibiotic resistance by driving more inter-sectoral partnerships among scientists and medical, epidemiological and diagnostic personnel. Ever since penicillin ushered in the modern era of antibiotic development, they have become the cornerstone of human lives by changing the way we live. In this post-antibiotic era, evaluation of epidemiological aspects and tailoring the use of antibiotics by proper use of scientific methods can lower the threat of ever-growing, drug-resistant bacteria.
The impact of the irrational use of antibiotics can be more far-reaching than perceived, as suggested by the Nobel Laureate Joshua Lederberg: “The future of humanity and microbes will evolve as episodes…of our wits versus their genes”. The emergence of new pathogens with antimicrobial resistance can not only be seen as a threat to the progress made in healthcare, but also as something that can make humanity go back to the pre-antibiotic era where the masses suffered and died due to untreatable infections. It is now in our hands to embrace the most logical step of stopping irrational antibiotic use at each and every step of therapy.