WA News News & Reports Antibiotic Resistance Myths?
Antibiotic Resistance Myths?
Written by Dr Rob McEvoy
Wednesday, 30 November 2016

The Prof of Clinical Medicine at the University of Southern California, Brad Spellberg MD, has raised some interesting points about antibiotic resistance on a website posting. He says:

  • Bacterial antibiotic resistance is an inevitable part of Nature.
  • Yes, avoid prescribing antibiotics unnecessarily. When they are appropriate, prescribe the narrowest-spectrum agent and the shortest duration possible.
  • Do not tell patients to take every dose prescribed. Be available to coach patients, encouraging them to stop antibiotics early when symptoms resolve.
  • Prescribed antibiotics select for resistance in the patient's microbiome.
  • When choosing antibiotics, cidal vs static is largely irrelevant.201612-Antibiotic sensitvity and resistance

His expanded comments say genetic analysis indicates that bacteria invented antibiotics about 2 billion years ago – killing each other with these weapons, and using resistance mechanisms to protect themselves. Resistance to modern antibiotics, including multi-drug resistance, was found in bacteria in a New Mexico cave that had no previous exposure to mankind.
Antibiotic use causes selective pressure by killing off bacteria, whether prescribing is appropriate or inappropriate. The difference is that inappropriate use offers no benefit. Eliminating inappropriate antibiotic use may slow the emergence of resistance (but does not cause resistance per se).
There are no data to support the idea that continuing antibiotics past resolution of signs and symptoms of infection reduces the emergence of resistance. Every randomised clinical trial that has ever compared short-course therapy with longer-course therapy, across multiple types of acute bacterial infections, has found shorter-course therapies are just as effective. In acute infections, if patients feel substantially better, with resolution of symptoms of infection, they can stop antibiotics early.
In most cases, resistance emerges not at the site of infection during therapy, but rather among bacteria in the gut or on the skin as a result of genetic sharing of pre-existing resistance mechanisms (e.g. plasmids, transposons, phages, naked DNA). Resistant strains can cause future infections, or spread to others in communities or hospitals.
Contrary to common belief, bacteriostatic ("static") antibiotics do kill bacteria; they just require a higher concentration to do it. We define a bactericidal ("cidal") antibiotic based on laboratory conventions, not on specific scientific principles. There is no clinical trial evidence of benefit of cidal agents over static agents (more to the contrary in fact!).
By Dr Rob McEvoy

While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork.

The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners.

The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix.

Is there a problem, Houston?

It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent.

In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience.

If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-in-the-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

What Fair Doctors Want

Talking to doctors, they appear to want an apolitical system of investigation that is fair and timely. They want to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those with a political bent in the medical profession could influence what the Medical Board did.

While this is a very difficult area for us to investigate, with arguments and counter-arguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement (and we don’t think AMA members have been polled on this issue.)

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