Growing levels of antibiotic use in the Republic are contributing to unacceptably high levels of antibiotic resistance, writes Eithne Donnellan, Health Correspondent
In 1922 when Alexander Fleming discovered penicillin, our first effective antibiotic, he warned that if it were used inappropriately, the bugs it was meant to destroy would develop resistance to it.
His words of wisdom went unheeded however, and now almost 100 years on we are seeing growing levels of antibiotic resistance around the world.
Not alone have some conditions become resistant to one antibiotic, they have become resistant to a number of antibiotics, limiting the range of treatments that are available to sick patients to perhaps more costly and more toxic drugs.
"And there are few new antibiotics in the pipeline. We are running out of options," warns Dr Robert Cunney, a consultant microbiologist with the national Health Protection Surveillance Centre (HPSC).
The World Health Organisation (WHO) has cautioned that the bacterial infections which contribute most to human disease across the globe are also those in which emerging and microbial resistance is most evident: diarrhoeal diseases, respiratory tract infections, meningitis, sexually transmitted infections, and hospital-acquired infections. Some important examples of hospital-acquired infections which the WHO mentions include MRSA or methicillin-resistant Staphylococcus aureus, and VRE or vancomycin-resistant Enterococci.
Irish hospitals reported almost 600 cases of MRSA bloodstream infections last year and figures released under the Freedom of Information Act earlier this year showed that some 452 patients tested positive in 22 hospitals for VRE in 2005.
While factors including hygiene, lack of isolation facilities and a shortage of infection-control staff contribute to the numbers of patients in the Republic picking up these infections, our overuse of antibiotics and the emergence of antibiotic resistance is also a factor.
This includes overuse of them in hospitals and in the community.
And while in some countries they are also overused in the agricultural sector, stringent EU-driven controls being enforced here mean the level of antibiotic residues found in Irish-produced food is low and has continued to fall in recent years.
But data from the HPSC shows overall consumption of antibiotics by people outside hospital settings here continued to rise in 2005. It monitors consumption in terms of defined daily doses per 1,000 inhabitants per day (DID) and in a recent report it noted "antibiotic usage has been rising steadily [ in this sector] from 16.2 DID in 1993 to 21.8 DID in 2005, and was 23.8 DID for the last quarter of 2005".
Furthermore, it said outpatient antibiotic usage in some counties was higher than in others which could reflect differences in prescribing practices, socio-economic factors or marketing by pharmaceutical companies.
Cunney says that overall there is far more antibiotic use in the community than in hospitals. But he says antibiotic usage in both areas needs to be tackled if resistance levels are to be taken down.
The use of antibiotics in Irish hospitals is "quite high", increasing, and "well above the European average", he reveals.
In 2005 there were 81.5 DDD (defined daily doses) of antibiotics per 100 bed days in Irish hospitals compared with 78.2 the previous year. In Scandinavian countries the level would be 40-50, Cunney says.
However, he stresses that some hospitals here, through the appointment of clinical pharmacists and microbiologists, are managing to address the issue. The introduction of antibiotic guidelines have also been shown to help in hospitals such as Naas General.
In terms of how we compare with other European countries on outpatient antibiotic use, we would be "in the middle", Cunney says. Countries with low levels of usage such as Denmark, Sweden and the Netherlands also have lower levels of antibiotic resistance.
"Our level should be lower and one cause for concern has been the fact that our level of use has been increasing steadily over the past 10 years while some countries like Belgium have been bringing theirs down," he says.
"The second cause for concern is the types of antibiotic we use. We tend to use more broad spectrum antibiotics and our level of use of broad spectrum antibiotics [ those are antibiotics that cover a vast range of bacteria] has also increased over the past 10 years," he adds.
Furthermore, he points to seasonal variations in antibiotic use here with more used in winter.
"In countries with low levels of resistance, there is much less variation between levels of use in summer and winter. Here the levels of use are much higher in the winter. That implies a lot of antibiotics are used to treat colds, flus and viral infections here in the winter months for which they have no benefit whatsoever," he says.
So why do doctors prescribe them then? Prof Hilary Humphreys, professor of microbiology at the Royal College of Surgeons in Ireland and a consultant microbiologist at Dublin's Beaumont Hospital, says that doctors, particularly GPs, are often in a difficult position.
"They have a patient, they think the patient has infection, they are not absolutely sure. They may not have ready access to radiology or laboratories . . . and they have to make a decision. And they have to make a decision primarily in the best interests of the patient. That will sometimes mean that the individual GP will sometimes prescribe more antibiotics than he or she would ideally like," he says.
"So what we really need in some instances is to provide more support for GPs in the community, to provide them with more rapid diagnostic tests so that they can make decisions quickly about whether antibiotics are used or not," he says.
Furthermore, he says, doctors may be deciding to "err on the side of caution" in situations when they are not sure. "That's actually good practice but what it does mean is that in some instances patients are receiving antibiotics who ideally do not need them."
In addition, he says it is very difficult sometimes for patients, particularly those who are paying to see their GP, to accept it is good practice for a doctor to let them go home without a prescription.
There is also an element perhaps in modern society that people haven't time to wait to get better, Humphreys suggests. "We don't have the patience. We want to go back to work and want to go back to school. We are not prepared to put up with a snuffy cold or a bit of a headache, maybe in the way that our ancestors would," he says.
Cunney advises people attending their GP to ask if they or their child really need an antibiotic. "In some cases the answer will be yes, but in a lot of cases the answer will be no."
Our level of antibiotic resistance is "unacceptably high", he says, and levels of resistance here to a number of types of bacteria are increasing at a worrying rate. For example, in 2002 just over 5 per cent of E.coli were quinalone (a group of antibiotics) resistant whereas in the first quarter of this year it had gone up to over 20 per cent, a fourfold increase in the space of just four years.
Antibiotic resistance poses "a genuine serious threat that needs to be tackled" he stresses. "It causes unnecessary illness and unnecessary death," he says.
"A lot of resources have gone into it but we still have a long way to go."
A strategy for the control of antimicrobial resistance was published in 2001 and it said, among other things, that the public must be educated to understand that antibiotics are not always the answer for sore throats, colds and flu.
Only now is the HSE thinking of putting such an education campaign in place.
It also hopes a project piloted in Cork and aimed at improving prescribing practices among GPs can be rolled out nationally next year. Cunney stresses that both the prescribers, whether they are doctors or dentists, as well as the public, need to be targeted to reduce levels of antibiotic use. A public education campaign has helped bring down levels of antibiotic use in Belgium over a number of years since 1997.
"And they have shown that the direct savings to the healthcare system in antibiotic costs were actually 10 times higher than the cost of the education programme," he says.
A survey in Northern Ireland last year after a public education campaign there on the correct use of antibiotics showed the percentage of the population who had been "prescribed antibiotics in the last year" dropped from 42 per cent in 2003 before the campaign to 38 per cent in 2005 after it.
It also found a drop in the percentage of the population who would expect their GP to prescribe antibiotics for flu, fever and bad colds after the advertising campaign.
However, Humphreys believes some of the increase in antibiotic use here is appropriate and is due to the fact that we now have many older patients and many sicker patients.
"If we have older patients, if we have more sick patients in our hospitals or in the community, it's likely that they are going to need antibiotics so we are using more antibiotics. Some of it is inappropriate and that's what we have to deal with but some of it is appropriate," he says.
A more difficult issue to address but one which also poses a threat is the possibility of growing numbers of people self-medicating with antibiotics bought over the internet and then taking the medication only for a few days until they feel better, which may occur before the pathogen has been eliminated, thereby also encouraging antibiotic resistance.
Humphreys warns that people need to be aware that antibiotics are different from most other drugs.
"If you give a drug for treatment of high blood pressure and there's an adverse consequence, it's toxic or whatever, it's only the patient who is affected. Antibiotics are different. If I prescribe an antibiotic to you inappropriately, not only may you suffer an adverse event but because I prescribed an antibiotic to you and you live in the community, there can be consequences for the community in terms of the emergence of antibiotic resistance.
"So there is a greater onus not just for prescribing antibiotics appropriately for the welfare and safety and effective treatment of the individual patient but also to ensure that you don't damage the population's health."