Antibiotic misuse

Antibiotic misuse, (sometimes called antibiotic abuse or antibiotic overuse) refers to the misuse and overuse of antibiotics which has serious effects on public health. Antibiotic resistant bacteria is a growing threat and becoming increasingly common. This overuse creates multi-antibiotic resistant life threatening infections by "super bugs", sometimes out of relatively harmless bacteria.^[1] Antibiotic abuse also places the patient at unnecessary risk of adverse effects of antibiotics.

Epidemiology

A recent study concerning the proper use of this class in the emergency room revealed that 99% of these prescriptions were in error. Out of the 100 total patients studied, 81 received a fluoroquinolone for an inappropriate indication. Out of these cases, 43 (53%) were judged to be inappropriate because another agent was considered first line, 27 (33%) because there was no evidence of a bacterial infection to begin with (based on the documented evaluation) and 11 (14%) because of the need for such therapy was questionable. Out of the 19 patients who received a fluoroquinolone for an appropriate indication, only one patient out of 100 received both the correct dose and duration of therapy.^[2]

Within a 1994 study, it was found that 75% of the fluoroquinolone prescription issued within a long term care setting were judged to be inappropriate . In more than 50% of the cases reviewed, the fluoroquinolone used were not considered to be a first line agent.^[3]

Social and economic impact

See also: adverse effects of fluoroquinolones

Increased hospitalizations attributed to adverse drug reactions alone account for billions of dollars of expenses each year within the US healthcare system. Severe reactions do occur with antibiotics and can add significantly to the cost of care. Antibacterial adverse effects account for nearly 25% of all adverse drug reactions amongst hospitalized patients.^[4] Adverse drug reactions to fluoroquinolones are easily misdiagnosed as seizure disorder or regular CNS or psychiatric symptoms. The diagnosis of quinolone toxicity or adverse reaction are also missed.^[5] Adverse event reporting in Italy by doctors showed fluoroquinolones among the top 3 prescribed drugs for adverse neurological and psychiatric adverse effects. These neuropsychiatric effects included: tremor, confusion, anxiety, insomnia, agitation and in severe cases psychosis. Moxifloxacin had the worst effect amongst the quinolones for causing CNS toxicity. The central nervous system is an important target for fluoroquinolone mediated neurotoxicity.^[6]

Antibiotic resistance

Main article: Antibiotic resistance

Though antibiotics are considered to be a very important and necessary drugs required to treat severe and life threatening bacterial infections, antibiotic abuse has contributed to the problem of bacterial resistance. The overuse of antibiotics by children suffering from otitis media and others has given rise to a breed of super bacteria that is resistant to antibiotics entirely.^[7]

The overuse of fluoroquinolone and other antibiotics will eventually result in them becoming useless for treating antibiotic-resistant infections, which broad-spectrum antibiotics are supposed to be reserved.^[8][9]

The over-prescribing and inappropriate use of antibiotics is fueling antibiotic resistance in bacteria. For example the inappropriate widespread use of fluoroquinolones as first line antibiotics is leading to decreased bacterial sensitivity, which has important implications for certain serious bacterial infections such as those associated with cystic fibrosis where quinolones are among the few available antibiotics.^[10][11][12]

Inappropriate use

Only about 5-10% of bronchitis cases are caused by a bacterial infection. Antibiotics have no effect upon viral infections such as the common head cold. Most cases of bronchitis are caused by a viral infection and are "self-limited" and resolve themselves in a few weeks. The use of antibiotics such as ofloxacin to treat bronchitis is to be considered unnecessary and as such exposes the patient to an unacceptable risk of suffering a severe adverse reaction.^[13] Nor does antibiotic treatment help sore throats.^[14] Prescribing antibiotics for sore throats encourages increased visits to the doctor. As most cases of sore throats are viral and are self limiting it has been recommended that antibiotic treatment is delayed in most cases.^[15] Nevertheless, for severe forms of community-acquired pneumonia the fluoroquinolones seem to be associated with improved treatment rates, but with no differences found in mortality between antibiotic regimens.^[16] In spite of this caveat, the use of the fluoroquinolone to treat community acquired pneumonia (CAP) increased by >50%, from 25% to 39% of all prescriptions. This increase was at the expense of the macrolide class of antimicrobial drugs, the use of which declined 20% during the study period.^[17]

As with other fluoroquinolones their use as first line agents is not generally recommended. They are usually reserved for use in patients who are seriously ill and may soon require immediate hospitalization.^[18] Though considered to be a very important and necessary drug required to treat severe and life threatening bacterial infections, the associated overprescribing of fluoroquinolones remains unchecked, which has contributed to the problem of bacterial resistance.^[19] The overuse of antibiotics such as happens with children suffering from otitis media has given rise to a breed of super bacteria which are resistant to antibiotics entirely.^[7] “Fluoroquinolone resistance is an increasing problem not only in the U.S. but also worldwide, potentially due to the widespread misuse of this class of antimicrobials.”^[20] For example the use of the fuoroquinolones had increased three-fold in an emergency room environment in the United States between 1995 and 2002, while the use of safer alternatives such as macrolides declined significantly.^[17][21]

Chronic pelvic pain (category IIIB) is often misdiagnosed as chronic prostatitis and needlessly treated with a fluoroquinolone drug. Within a Bulgarian study, where by definition all patients had negative microbiological results, 65% of patients experienced an adverse drug reaction who were treated with a fluoroquinolone in comparison to a 9% rate for the placebo patients. This was combined with a higher cure rate (69% v 53%) found within the placebo group. The authors stated that “The results of our study show that antibiotics have an unacceptably high rate of adverse side effects as well as a statistically insignificant improvement over placebo...”^[22] Prostatitis has been termed "the waste basket of clinical ignorance" by prominent Stanford University Urologist Dr. Thomas Stamey. Campbell's Urology, the urologist's most authoritative reference text, identifies only about 5% of all patients with prostatitis as having bacterial prostatitis which can be "cured" at least in the short term by antibiotics. In other words, 95% of men with prostatitis have little hope for a cure with antibiotics alone since they don't actually have any identifiable bacterial infection.^[23]

There are limited indications for ciprofloxacin as a first-line therapy within long term care facilities.^[24] Within a 1994 study it was found that 75% of the prescriptions for fluoroquinolones issued within a long term care setting were judged to be inappropriate by the authors. In more than fifty percent of the cases reviewed fluoroquinolones were not considered to be a first line agent.^[3]

Another widespread example of antibiotics overuse or abuse is the partial adherence of the dental practitioners^[25] and dental patients^[26] to the previous (1997) guidelines of the American Heart Association for the prevention of infective endocarditis rather than the current (2007) guidelines which dictate a more restricted antibiotic use.^[27]

References

1. ^ Harrison JW, Svec TA (April 1998). "The beginning of the end of the antibiotic era? Part II. Proposed solutions to antibiotic abuse". Quintessence International 29 (4): 223–9. PMID 9643260. 
2. ^ Lautenbach E, Larosa LA, Kasbekar N, Peng HP, Maniglia RJ, Fishman NO (March 2003). "Fluoroquinolone utilization in the emergency departments of academic medical centers: prevalence of, and risk factors for, inappropriate use". Archives of Internal Medicine 163 (5): 601–5. doi:10.1001/archinte.163.5.601. PMID 12622607. http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12622607. 
3. ^ ^{a b} Pickering TD, Gurwitz JH, Zaleznik D, Noonan JP, Avorn J (January 1994). "The appropriateness of oral fluoroquinolone-prescribing in the long-term care setting". Journal of the American Geriatrics Society 42 (1): 28–32. PMID 8277111. 
4. ^ Beringer PM, Wong-Beringer A, Rho JP (January 1998). "Economic aspects of antibacterial adverse effects". PharmacoEconomics 13 (1 Pt 1): 35–49. doi:10.2165/00019053-199813010-00004. PMID 10175984. 
5. ^ James R. Roberts (October 2008). "Adverse Reactions to Fluoroquinolones". Emergency Medicine News (Emergency Medicine News) 30 (10): 16–18. doi:10.1097/01.EEM.0000338244.41795.9c (inactive 2010-03-01). http://journals.lww.com/em-news/Fulltext/2008/10000/Adverse_Reactions_to_Fluoroquinolones_.23.aspx. 
6. ^ Galatti L, Giustini SE, Sessa A, et al. (March 2005). "Neuropsychiatric reactions to drugs: an analysis of spontaneous reports from general practitioners in Italy". Pharmacological Research 51 (3): 211–6. doi:10.1016/j.phrs.2004.08.003. PMID 15661570. 
7. ^ ^{a b} Froom J, Culpepper L, Jacobs M, et al. (July 1997). "Antimicrobials for acute otitis media? A review from the International Primary Care Network". BMJ 315 (7100): 98–102. PMC 2127061. PMID 9240050. http://bmj.com/cgi/pmidlookup?view=long&pmid=9240050. 
8. ^ Neuhauser MM, Weinstein RA, Rydman R, Danziger LH, Karam G, Quinn JP (February 2003). "Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use". JAMA 289 (7): 885–8. doi:10.1001/jama.289.7.885. PMID 12588273. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12588273. 
9. ^ "Studies examine prescribing of antibiotics for respiratory infections in hospital emergency departments". USA: U.S. Department of Health and Human Services. http://www.ahrq.gov/research/nov07/1107RA29.htm. "From 1995 to 2002, inappropriate antibiotic prescribing for acute respiratory infections, which are usually caused by viruses and thus are not responsive to antibiotics, declined from 61% to 49%. However, the use of broad-spectrum antibiotics such as the fluoroquinolones, jumped from 41% to 77% from 1995 to 2001. Overuse of these antibiotics will eventually render them useless for treating antibiotic-resistant infections, for which broad-spectrum antibiotics are supposed to be reserved." 
10. ^ "Cipro, Related Antibiotics Over-Prescribed, Fueling Microbe Resistance". USA: University Of California. 1 October 2002. http://www.universityofcalifornia.edu/news/article/4786. Retrieved 13 August 2009. 
11. ^ K. Bassett; B. Mintzes V. Musini T.L. Perry Jr M. Wong J.M. Wright (November 2002). "Therapeutics Letter" (PDF). Canadian Family Physician 48. http://www.cfpc.ca/cfp/2002/Nov/_pdf/vol48-nov-critical-2.pdf. "Gatifloxacin and moxifloxacin have no proven clinical advantages over other fluoroquinolones, macrolides, or amoxicillin. Based on cost, they are not first-choice drugs for their approved indications." 
12. ^ Ziganshina LE, Squire SB (2008). Ziganshina, Lilia E. ed. "Fluoroquinolones for treating tuberculosis". Cochrane Database of Systematic Reviews (1): CD004795. doi:10.1002/14651858.CD004795.pub3. PMID 18254061. 
13. ^ Hueston WJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". The Journal of Family Practice 44 (3): 261–5. PMID 9071245. 
14. ^ Majeed A, Harris T (August 1997). "Acute otitis media in children". BMJ 315 (7104): 321–2. PMC 2127258. PMID 9270442. http://bmj.com/cgi/pmidlookup?view=long&pmid=9270442. 
15. ^ Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (August 1997). "Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics". BMJ 315 (7104): 350–2. PMC 2127265. PMID 9270458. http://bmj.com/cgi/pmidlookup?view=long&pmid=9270458. 
16. ^ Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME (December 2008). "Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials". CMAJ 179 (12): 1269–77. doi:10.1503/cmaj.080358. PMC 2585120. PMID 19047608. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2585120. 
17. ^ ^{a b} MacDougall C, Guglielmo BJ, Maselli J, Gonzales R (March 2005). "Antimicrobial drug prescribing for pneumonia in ambulatory care". Emerging Infectious Diseases 11 (3): 380–4. PMID 15757551. http://www.cdc.gov/ncidod/EID/vol11no03/04-0819.htm. 
18. ^ Terry K. Babb, Michael Boothe, Heidi Brainerd,Richard E. Brodsky, Kelly C. Conright, Traci Gale, Arthur S. Hansen, R. Duane Hopson, Thomas C. Hunt, Diane Liljegren, Ronald J. Miller, Gregory R. Polston, Richard C. Reem, Janice L. Stables, Alexander H. vonHafften, Trish D. White,Dave Campana, Sandy Kapur, Dr. Jeffrey Demain (19 March 2004). "ALASKA MEDICAID PHARMACY AND THERAPEUTICS COMMITTEE" (PDF). Alaska, USA. http://www.hss.state.ak.us/dhcs/PDL/minutes_meetings_pdl/minutes_031904_pdl.pdf. Retrieved 12 August 2009. 
19. ^ "Fluoroquinolone Resistance and Tuberculosis Treatment". USA: The New York City Department of Health and Mental Hygiene. http://www.nyc.gov/html/doh/html/tb/tb4a.shtml. 
20. ^ LaTiffany C. Epps; Paul D. Walker (20 October 2006). "Fluoroquinolone Consumption and Emerging Resistance". USA. http://econnect.uspharmacist.com/econnect/Default.aspx?tabid=53&page=publish/content/8_1868.htm. 
21. ^ Linder JA, Huang ES, Steinman MA, Gonzales R, Stafford RS (March 2005). "Fluoroquinolone prescribing in the United States: 1995 to 2002". The American Journal of Medicine 118 (3): 259–68. doi:10.1016/j.amjmed.2004.09.015. PMID 15745724. 
22. ^ J. Dimitrakov; J. Tchitalov, T. Zlatanov, D. Dikov. "A Prospective, Randomized, Double-Blind, Placebo-Controlled Study Of Antibiotics For The Treatment Of Category Iiib Chronic Pelvic Pain Syndrome In Men". Third International Chronic Prostatitis Network. http://www.prostatitis.org/a92000.html. Retrieved 4 September 2009. 
23. ^ Wein, Alan J.; Kavoussi, Louis R.; Novick, Andrew C.; Partin, Alan W.; Peters, Craig A. (19 March 2007). Campbell-Walsh Urology Review Manual (Ninth ed.). Saunders. ISBN 978-1416031550. http://books.google.com/?id=KGVqAAAAMAAJ. 
24. ^ Nicolle LE, Bentley DW, Garibaldi R, Neuhaus EG, Smith PW (August 2000). "Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee". Infection Control and Hospital Epidemiology 21 (8): 537–45. doi:10.1086/501798. PMID 10968724. 
25. ^ Zadik Y, Findler M, Livne S, et al. (December 2008). "Dentists' knowledge and implementation of the 2007 American Heart Association guidelines for the prevention of infective endocarditis". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106 (6): e16-9. doi:10.1016/j.tripleo.2008.08.009. PMID 19000604. http://www.ooooe.net/article/S1079-2104(08)00597-0/abstract. 
26. ^ Elad S, Binenfeld-Alon E, Zadik Y, Aharoni M, Findler M. (March 2011). of acceptance of the 2007 American Heart Association Guidelines for the prevention of infective endocarditis: A pilot study "Survey of acceptance of the 2007 American Heart Association guidelines for the prevention of infective endocarditis: a pilot study". Quintessence Int 42 (3): 243–51. PMID 21465012. http://www.quintpub.com/journals/qi/abstract.php?iss2_id=919&article_id=10528&article=9&title=Survey of acceptance of the 2007 American Heart Association Guidelines for the prevention of infective endocarditis: A pilot study. 
27. ^ Wilson W, Taubert KA, Gewitz M, et al. (October 2007). "Prevention of infective endocarditis: guidelines from the American Heart Association". Circulation 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442. http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=17446442.