The discovery of Penicillin in 1928 was a crucial breakthrough for medicine and health care. Penicillin also then championed as “the Miracle drug” had the unique ability to rapidly control infectious bacteria without harming the patient. “Antibiotics” was the term coined for such naturally occurring substances of the microbial world that killed bacteria (Stuart B. Levy). Antibiotics became an important weapon for mankind’s fight against bacterial infections. However, the overuse and misuse of antibiotics led to the infection causing bacteria to develop antibacterial Resistance (ABR) hence rendering the medicine ineffective and the infection untreated (WHO). This resistance is a result of a genetic mutation in the bacteria. The genetically resistant bacteria once created starts to multiply and replace the once-sensitive bacteria (Bull). These new bacteria also called “superbugs” are now free to spread to others hence putting public health at grave risk. The risk of ABR was flagged as early as 1945 by the British bacteriologist Alexander Fleming who had discovered Penicillin. He had expressed his concern in an interview with The New York Times regarding the spread of Penicillin-resistant bacteria as a consequence of self-medication (Stuart B. Levy). A report commissioned by the U.K. Government in 2016 warned that superbugs could by 2050 cause the death of 10 million people a year worldwide if major steps weren’t taken to combat the threat (Marcus).
To examine the causes of the misuse of antibiotics, it is important to identify the key agents of misuse. These include Physicians/healthcare workers, livestock farmers and the public. The causes of the behavior of the 3 groups are seen to be a mixture of lack of knowledge and perverse incentives.
Inappropriate prescribing by physicians /healthcare workers
Physicians around the world have been reported to be prescribing antibiotics incorrectly. Inaccurate diagnosis appears to be partially responsible for this. Studies in the U.S. have reported that the treatment indication, choice of compound and duration of treatment were incorrect in 30% - 50% of the cases (C. Lee Ventola). In addition, another U.S. study revealed that close to 30% of the outpatient antibiotic prescriptions are unnecessary (The PEW Charitable Trusts). Excessive use of antibiotics in hospitals and clinics are responsible for escalating the rates of resistance (Iruka N. Okeke).
Most studies have focused on ancillary data related to over-prescription but it is not entirely clear what the motivations and causes are for such behavior in physicians. A study on developing countries dating back to 1999 noted that lack of continuing medical education and high number of pharmaceutical sales representatives had adversely affected prescription habits (Iruka N. Okeke).
Regarding healthcare workers, it has been observed that less skilled healthcare staff aren’t well versed with the knowledge of ABR. In a survey conducted on Australian nursing homes, it was found that around 22% of the cases where antibiotics were prescribed showed no symptoms of an infection. And for the cases where symptoms were recorded, two-thirds of the prescriptions of antibiotics were deemed inappropriate (Meredith Griffiths). Similarly, community health workers, pharmacy technicians and traditional healers in developing countries are known to prescribe antibiotics inappropriately (Iruka N. Okeke).
Agricultural use
A major portion (50-80%) of antibiotics sold in developed countries are consumed by livestock. The rationale for this is compelling. Antibiotics increase yield in livestock and also prevent infections (C. Lee Ventola). There is a clear financial incentive for the livestock farmers. However, this poses a grave risk to public health. Humans ingest these antibiotics via meat products. Also, 90% of the antibiotics fed to livestock are excreted in urine and stool. This again spreads widely through fertilizer, groundwater and surface runoff. Interestingly, Denmark has witnessed continued high productivity despite banning antibiotics used for growth promotion (Cully).
Misuse of antibiotics by patients
Patients are arguably the most important piece of the puzzle as they are the final point of contact for antibiotics. Studies have suggested that patients often prefer to be prescribed antibiotics regardless of the nature of their illness and they also tend to value the potential benefit of antibiotics more than the harmful side-effects that may manifest (McSweeney). However, once prescribed antibiotics, patients seem to find it difficult to adhere to the full course due to improved health, forgetfulness and negative side-effects. Moreover, a study investigating patients understanding of ABR pointed out a major misconception that confused resistant bacteria for "resistant human body" (McSweeney). Significantly, patient's expectations for antibiotics have shown to increase the physician's intention to prescribe even when it is not warranted clinically which may explain some of the excessive prescription by doctors (Marion E. Davis).
Evidence suggests that the cause for such detrimental behavior is a significant lack of knowledge about antibiotics and its appropriate use. For example, a recent U.S. survey found that 53% erroneously believed that antibiotics could be used to treat viral infections (Marion E. Davis). It has also been surveyed that a majority of patients (58%) are unaware of the dangers of antibiotics misuse (Jodi Vanden Eng). Furthermore, a research studying the relationship between patient education and adherence to antibiotic regimens found that adherent patients had displayed a better understanding of science topics (McSweeney).
Conclusion
When antibiotics shifted from intravenous therapy to oral consumption in the 1940’s, the ease of use and autonomy led to a microbial environment that was difficult to regulate or control. Nevertheless, in the current circumstances it is crucial that mankind devise a way to control the emergence and spread of superbugs which could potentially destroy us. On examining the causes and motivations of the relevant stakeholders, the lack of knowledge about antibiotics and ABR seems to be the most dominant theme across the board. Bad incentives amongst Doctors and livestock farmers have also played their role in escalating the issue. A careful understanding of the causes lay the foundation for the next crucial step – Solutions.
Works Cited
Bull, Jim J. "Evolutionary Biology: Technology for the 21st century." Action Bioscience. Florida: University of Central Florida, 2000.
C. Lee Ventola, MS. "The Antibiotic Resistance Crisis: Part 1 - Causes and Threats." Pharmacy and Therapeutics (2015).
Cully, Megan. "Public health: The politics of antibiotics." Nature: International Journal of Science (2014): 16-17.
Iruka N. Okeke, Adebayo Lamikanra, Robert Edelman. "Socioeconomic and Behavioral Factors Leading to Acquired Bacterial Resistance to Antibiotics in Developing Countries." Emerging Infectious Diseases (1999): 19.
Jodi Vanden Eng, Ruthanne Marcus, James L. Hadler, Beth Imhoff, Duc J. Vugia, Paul R. Cieslak, Elizabeth Zell, Valerie Deneen, Katherine Gibbs McCombs, Shelley M. Zansky, Marguerite A. Hawkins, Richard E. Besser. "Consumer Attitudes and Use of Antibiotics." Emerging Infectious Diseases (2003): 1128-1135.
Marcus, Mary Brophy. "Superbugs could kell more people than cancer, report warns." 19 May 2016. https://www.cbsnews.com/news/superbugs-could-kill-more-people-than-cancer-report-warns/.
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Marion E. Davis, Tsai-Ling Liu, Yhenneko J. Taylor, Lisa Davidson, Monica Schmid, Traci Yates, Janice Scotton, Melanie D. Spencer. "Exploring Patient Awareness and Perceptions of the Appropriate Use of Antibiotics: A Mixed - Methods Study." Antibiotics (Basel) (2017).
McSweeney, Morgan. "The Relationship Between Patient Education and Adherence to Antibiotic Regimens: Exploring Profiles of Adherent Groups." Showcase of Text, Archives, Research and Scholarship 2015.
Meredith Griffiths, Sophi Scott. "Antibiotics being incorrectly prescribed in Australian nursing homes, prompting superbug fears." 10 June 2016. http://www.abc.net.au/news/2016-06-10/superbug-fears-over-antibiotic-use-in-australian-nursing-homes/7497664.
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Stuart B. Levy, M.D. The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle. Springer Science+Business Media, LLC, 1992.
The PEW Charitable Trusts. "Antibiotic Use in Outpatient Settings." Secondary Survey report. 2016.
WHO, Antimicrobial Resistance: Global Report on Surveillance)WHO. "Antimicrobial resistance." January 2018. http://www.who.int/mediacentre/factsheets/fs194/en/.
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