Irrational use of magic bullets: reasons, consequences, solutions
ANTIBIOTICS, termed as magic bullets, have modernized healthcare since their discovery in 1928.
The use of antibiotics in bacterial infections has significantly reduced the morbidity and mortality in humans as well as in animals.
Life-saving antibiotics are core components of the Essential Medicines List of every country and are, therefore, readily available. However, the flipside of availability is the irrational use of these lifesaving medicines.
Incorrect dose, frequency and/or duration, overuse of broad-spectrum (powerful) antibiotics, use of antibiotics for non-bacterial infections and self-medication are some of the key examples of irrational use of antibiotics.
According to the WHO irrational use of antibiotics often leads to several adverse outcomes, including development of antibiotic resistance.
Despite this well-known fact, the magnitude of antibiotic consumption has increased drastically over time, worldwide. As a result, the world is getting short of effective antibiotics.
Pakistan is ranked third highest consumer of antibiotics after India and China. Overtime, the use of broad-spectrum antibiotics as compared to bacteria specific (narrow-spectrum) antibiotics has increased in Pakistan.
This is concerning because broad-spectrum antibiotics are likely to increase the risk of drug-resistant infections.
Furthermore, there is evidence that antibiotics are often used inappropriately in minor ailments, for example, in upper respiratory tract infections, which are mainly of viral origin where antibiotics confer little or no clinical benefit.
Moreover, prophylactic use of antibiotics is high in Pakistan. The consequences of irrational use of antibiotics have been borne out in the form of higher risk of adverse drug events, antibiotic resistance, and increased treatment costs.
Other reported consequences of inappropriate use of antibiotics include, long lasting infections, therapeutic failure, amplified risk of super-infections, prolonged hospital stay, limited treatment options and increased mortality rates due to “hard to kill” bacteria.
The irrational use of antibiotics is attributed to a number of intertwined healthcare system, provider and patient related factors.
Irrational antibiotic prescribing practices of physicians are linked to lack of culture sensitivity tests, limited compliance to clinical guidelines, and incentives given by pharmaceutical companies.
Apart from the irrational prescribing, the irrational dispensing/sale of antibiotics at drug retail outlets is considerably contributing to irrational use of antibiotics and spread of antibiotic resistance.
Even though, Pakistani government is making tangible efforts to ensure access to healthcare services, and physician to patient ratio (i.e., 1 physician per 963 person population) is within the WHO recommended ratio (i.e., 1 physician per 1000 person population), but the access to physicians is still meagre because of imbalance in their distribution across the country.
More than 60% of the Pakistani population reside in rural areas. These areas do not only have poor healthcare infrastructure, but physicians also show least interest to serve in these areas.
Moreover, patients’ practice of consulting physicians is low due to poor health literacy, carelessness driven self-medication practices and busy work schedule and high consultation fee of physicians.
Because of the aforementioned reasons, drug retail outlets (ie, pharmacies and medical stores) are the first port of call for the management of common ailments, such as cough, cold, flu and other infections.
Consequently, over-the-counter sale of antibiotics in drug retail outlets is increasing and has become a major driver of irrational use of antibiotics.
Strict enforcement of regulations to limit over-the-counter sale of antibiotics is not practicable in view of patients who cannot afford to consult the physicians.
This exacerbates the irrational sale of antibiotics, which is further complicated by wide variability in the training of pharmacy workers.
In general, the majority of the pharmacy workers at drug retail outlets have minimal formal education with little or no professional training in pharmacy or medical fields.
Pharmacy workers (non-pharmacist), in the absence of any supervision, dispense antibiotics to the patients with or without prescriptions. This is alarming because such untrained staff risk the lives of people.
Although the Pharmacy Act 1967 of Pakistan binds the proprietors of pharmacies to ensure the presence of pharmacists at their premises, yet this rule is weakly implemented. As a result, most of the pharmacies operate without the presence of a pharmacist.
The government should take immediate measures to stop the sale of antibiotics without a prescription.
There could be mass media campaigns in public and awareness seminars in schools, colleges and other workplaces to educate the public about the hazards of self-medication of antibiotics.
Drug retail outlets workers, who do not have any formal pharmacy education, should be gradually replaced with pharmacy technicians.
At the same time, the government can also launch a training program for existing non-pharmacists pharmacy staff.
Besides all measures, irrational use of antibiotics cannot stop until the presence of a pharmacist is ensured at the drug retail outlets.
The pharmacist who holds a “Doctor of Pharmacy” degree with specialization in medicines, cannot only educate the general public about the rational use of antibiotics, but can also supervise the non-pharmacist pharmacy workers at their workplace.
The government can also restrict suboptimal use of antibiotics by advising the pharmaceutical companies to supply antibiotics in a way that whole pack with a complete course of treatment could be sold, but not as a single dose or a tablet, etc.
A compulsory non-credit health literacy course should be offered to school, college and university students. This strategy can gradually improve health seeking behaviour in the general public.
In conclusion, irrational use of antibiotics at drug retail outlets is associated with several patient, provider and healthcare system related factors.
If the current trend of the surge in antibiotic resistance continues, we may have no treatment choices for some of the deadliest infectious diseases.
Immediate training of non-pharmacist pharmacy workers, presence of pharmacists at drug retail outlets, training of general public about the hazards of self-medication of antibiotics and a fully functional Antimicrobial Stewardship Program are some of the key measures that should be taken on priority basis to halt the irrational use of antibiotics at drug retail outlets in Pakistan.
—The writer is Professor of Pharmacy Practice and Chairman of the Department at the Islamia University of Bahawalpur, Pakistan.