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15.11.2019

Approaching doctors first

Resistant bacteria are on the rise worldwide. And the overprescription or misprescription of antibiotics by doctors is part of the problem.

10 million dead per year as of 2050 because of antibiotic resistance, resulting in costs of up to 100 billion US dollars. Such forecasts are unprofessional, overblown and ultimately counterproductive says infectiologist and NRP 72 researcher Benedikt Huttner of Geneva University Hospital. But this should not hide the fact that the rising number of resistant bacteria poses a real problem.

South-East Asia, South America, Africa and the Mediterranean region are the most badly affected. "At the same time, hundreds of thousands of children still die each year because they don't have access to antibiotics," Benedikt Huttner says. "Resistance is one side of the coin, generated by people taking too many antibiotics that they don't need. The other side is patients who badly need antibiotics, but don't get them."

Irrational use undermines efficacy

The most important weapon in the fight against bacterial infections can itself become a threat. This has a lot to do with what in professional circles is termed "irrational use": the practice of prescribing antibiotics unnecessarily, in the wrong dose, for the wrong duration, or even if not medically indicated. At this year's Conference on Prevention & Infection Control in Geneva, Benedikt Huttner talked about the various reasons for this irrational prescription practice and how they could be overcome.

In his opinion, patients' misconceptions or lack of knowledge play a subordinate role in Switzerland. Therefore he has his doubts about the effectiveness of awareness-raising campaigns. His view is corroborated by data obtained in studies, which show that the success of antibiotics campaigns is linked to the amount of antibiotics used in the country in question. But even in countries with high usage levels, the impact of targeted informational measures is relatively small.

"Truth amnesia" – wasn't there something...?

In France, for example, the health authorities have for years tried in vain to reduce the amount of antibiotics used, which is still twice or three times as high as in Switzerland. "Providing patients with information isn't enough," Huttner says, pointing out that raising awareness can even have the opposite effect where complex public health issues are concerned. An Italian study (1) showed that, at the end of a campaign pushing the message "Antibiotics fight bacteria, but they have no effect on viruses", people were even more confused than before.

This phenomenon is called "truth amnesia": people vaguely remember that there was talk of viruses, bacteria and antibiotics, but the message as a whole is lost. And it is not always possible to package efficient measures as generally valid statements. For instance, the rule of thumb "go on taking antibiotics till the treatment is over" is still applied resolutely in fighting tuberculosis, but precisely the opposite approach is required in other cases: taking antibiotics for too long can lead to the development and spread of resistance, particularly if antibiotics - see above - are prescribed unnecessarily or without being indicated in specific cases..

Not always consistent

Huttner thinks that talking to doctors might be a more successful approach in Switzerland. Because they, too, are miles away from a rational use of antibiotics - one of the measures best able to curb the development and spread of resistant germs. Sometimes this can be attributed to a lack of knowledge or, more generally, to the long time it took till the relevant guidelines for Switzerland were published.

However, even doctors who know the risks do not always act consistently. As they apparently find it difficult to tell what their patients expect of them, they often wrongly prescribe antibiotics in spite of knowing better, for example in cases of virally induced coughs and sneezes. Fear is another bad motivator: "Those who have ever seen a bad middle-ear infection turn into life-threatening meningitis will prefer to err on the side of caution and overprescribe rather than underprescribe antibiotics, even though such complications are very rare," Huttner says.

Prescribing instead of explaining

In addition, time constraints can impede communication between doctor and patient. And sometimes it is simply much easier to prescribe an antibiotic than to explain the alternatives at length. There are another two, specifically Swiss, practices that thwart the rational use of antibiotics: in Switzerland, patients are usually given the full package rather than the precise number of tablets needed for the treatment, with the surplus pills presenting a temptation to self-medicate at a later date. And in German-speaking cantons, where doctors with their own practice have the right to dispense medicines at their own discretion, financial considerations might conceivably get in the way of rational use.

In support of improved prescription practices

With his two NRP 72 projects, Benedikt Huttner wants to contribute to a more rational use of antibiotics in hospitals - where resistant germs are at their most dangerous given the concentration of seriously ill patients on the same site. In one of the projects, a tool integrated into the patient's electronic file makes clinicians more conscious of how they use antibiotics and helps them to continually evaluate their own prescription practices. In the other project, an app sends doctors updated guidelines in real time and verifies whether this can influence for the better how they prescribe medication.

(1) https://www.bmj.com/content/347/bmj.f5391

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Dr Benedikt Huttner Chef de clinique avec FMH Service des Maladies Infectieuses Département de Médecine Interne Hôpital Cantonal - HUG Rue Gabrielle-Perret-Gentil 4 1211 Genève 14 +41 79 553 33 99 huttner.benedikt@gmail.com