WA News Letters In Defence of Antibiotics
In Defence of Antibiotics
Written by Adj/Prof John Yovich
Wednesday, 28 June 2017

Dear Editor,

I am perplexed about the editorial in the Medical Journal of Australia (17 April 2017) concerning antimicrobial resistance (AMR) and the lopsided viewpoint it presented. In particular it implies that controlling AMR in Australia requires, among other strategies, addressing the “unrestrained use of antibiotics”.

As a 72-year-old gynaecologist enjoying good health I thank three aspects for my blessed life:

  1. As a child of the 1940s and ’50s, whenever I was too unwell to attend school, my mother took me to one of our local GPs in Midland Junction who, upon seeing my red throat and noting tender neck glands, gave me a penicillin needle “in the bum” and prescribed some oral penicillin.
  2. As an RMO of the early 1970s, I faced 25% pelvic infection rates post-hysterectomy; particularly vaginal hysterectomy, hence I eagerly embraced the new concept of prophylactic antibiotics, providing a more relaxed medical career than my mentors (and totally avoiding mortalities as well as major morbidities).
  3. To this day, I cover every gynaecological and fertility-related invasive operation (including male andrological surgeries) with prophylactic antibiotics; using penicillin or the related ß-lactam cephalosporins.

I am concerned by the ‘heavy teaching’ of medical students and vulnerable young medical practitioners who pass their examinations by indicating they only prescribe antibiotics when there is proven microbial infection, unresponsive to an observational period.

As a Medical Director I face numerous accreditation processes in two Australian states each year (covering laboratory, day-hospital and clinical assisted reproductive technology services) and have to justify my use of antibiotics in a process known as AMS – antibiotic microbial stewardship.

So far I have been allowed to continue this practice as I have been able to present personal horror stories from the 1970s and ’80s explaining my pro-antibiotic bias. I certainly do not support the low-value intervention promoted in the recent edition of MJA, particularly when it relates to young people and pregnant women.

Newer medical graduates have been ‘born into’ a blissful period of reduced septicaemia, unstimulated to develop my depth of passion in defence of a pro-antibiotic approach. Is this why I face stories of young people losing limbs or dying from those dreadful scourges, Group A streptococcus (Strep pyogenes), Pneumococcus pneumonia and Meningococcus (Neisseria meningitides)?

As I understand it, these organisms have mostly remained quite sensitive to penicillin or the related cephalosporins and the real problem of antibiotic resistance is more associated with chronic infections – aged care, prolonged hospitalisation and debilitation.

The current young doctors may have been oversold the idea they should withhold antibiotics until there is a proven need. Previously healthy young people will continue to lose limbs and even die from this widely promoted policy of delay.

Adj/Prof John Yovich, West Leederville

 


 

This letter is a good demonstration of the complexity of managing the antimicrobial resistance problem. As mentioned by Dr John Yovich, antibiotics have revolutionised the outcome of infections and, together with immunisation and infections control, antibiotics are the single medical intervention which has reduced crude mortality rates over the years.

However, what is also clear is the association between the use of antimicrobials and the rise in antimicrobial resistance. Today, resistance to antibiotics is unfortunately common not only within our hospitals but also in the community. Although in Australia we are fortunate to still have therapeutic options – unlike the case of septic shock due to a K. pneumoniae reported by Chen et al in the US – it is well documented that infections due to resistant organisms have a worse outcome, increase cost and length of stay compared to similar infections due to susceptible pathogens.

The Australian Government has released its first National Antimicrobial Resistance Strategy 2015-2019 and one of its key features is the implementation of effective antimicrobial stewardship (AMS) to reduce inappropriate antimicrobial use, improve patient’s outcome and reduce adverse consequences including resistance, toxicity and unnecessary costs.

The number of publications supporting AMS has significantly increased in the past five years, from 50 in 2009 to over 500 in 2016. For example, at a community level, a national campaign to reduce unnecessary prescriptions was associated with a 36% reduction in outpatient antibiotic use and a significant reduction in penicillin resistance in Streptococcus pneumoniae.

In the healthcare setting, a meta-analysis showed that AMS reduced antimicrobial resistance by 34%. Similarly, AMS was associated with a reduction in infection due to resistant organisms such as MRSA, ESBL Klebsiella spp or carbapenem-resistant Pseudomonas aeruginosa.

Furthermore, AMS has been associated with reduction in Clostridium difficile infection, mortality, length of hospital stay and cost. Importantly, many publications have demonstrated that the measures implemented to reduce antimicrobial use did not cause harm or have unintended consequences.

While it is well recognised that in the severely infected patient such as those in septic shock, early appropriate antimicrobial 27062017-Robinson-Owen-Dr Jun17-2therapy improves lives, systematic antibiotics for a red throat or a cough, prolonged antimicrobial prophylaxis after surgery are things of the past.

AMS is now part of the accreditation standards in all medium to large hospitals and is being implemented in most other healthcare settings. It must continue if we do not want to go back to a pre-antibiotic era.

References on request

Dr Owen Robinson, Infectious Diseases Consultant, RPH & FSH