Monthly Archive for August, 2008

Grania: Antibiotic Over-use

Now I know you are all awaiting the stories to match the gorilla photos that Dan has posted, and you will get them here as soon as we receive the promised guest posts (hint hint Clive, Jackie, Beth!)

In the meantime I will let you know about some of the other stuff that I’ve been up to.  As the TB project has taken so long to get going, I’ve been busy filling my time with other projects – in particular establishing an antibiotic protocol at IHK.

One thing that became very obvious as soon as I got onto the wards was the Ugandan love of antibiotics. This could be summed up as:

“Any illness can be and should be treated with antibiotics and if possible antibiotics through a drip.”

On the ward I would regularly find patients with minor head injuries being observed for 24 hours on IV (intravenous) antibiotics, bruises treated with IV antibiotics – anything and everything was given antibiotics. Not only were they getting antibiotics unnecessarily, they were also getting very strong antibiotics, the logic being that as they were at the “International Hospital”, and were private paying patients, they should be receiving the “best”, regardless of need.

This is not a unique problem to Uganda – antibiotics are overused everywhere. And in the developed world this overuse has presented itself as the dreaded MRSA (methicillin resistant staph aureus). In the UK, this has resulted in a severe crackdown on antibiotic use – patients have been re-educated and doctors over-prescribing antibiotics are told-off. As a result there’s been a definite change in the use of antibiotics. Here you have all the same problems but they are slightly worse:

  • Patients –  they demand antibiotics, and if you say no, well they are paying patients so they go elsewhere to a doctor who gives them antibiotics and give their business to that doctor (and therefore their money). Giving quite a bit of power to the patient.
  • Education – There are so many other health problems that are obviously more important than antibiotic use (HIV/AIDS, child malnutrition, malaria) that there isn’t the money or the will to educate the public that antibiotics isn’t always the pill to cure all.
  • Pharmacies – Even if you can get the doctors to stop prescribing antibiotics that actually doesn’t matter as you can buy them without a prescription anyway. Any pharmacy can sell them and they sell what the patient can afford, which often means that patients buy the minimum to start to make them feel better (about two days’ worth), stop for a week or so, then take another two days’ worth a couple of days later when their symptoms come back.

Like the TB problem, there is no data on the prevalence of MRSA or other drug-resistant strains. Antibiotics is something I feel strongly about back home: I regularly go round stopping antibiotics or changing them to a weaker form (as some of my previous junior doctors know!). In Uganda this was not going to be enough to change such ingrained habits, it needed more. So a two-pronged attack was launched against the doctors at International Hospital!

Working with the IHK pharmacist, we devised a formal antibiotic protocol. This meant that doctors couldn’t use the excuse of” I didn’t know what antibiotic to use”, it was all written down for them.  We put some of the stronger antibiotics under lock and key, only allowing them to be prescribed by myself or the ITU doctor, meaning that we at least had something in reserve for the severe cases.

With the help of Augustin (the second-in-command in the TB lab who went AWOL recently), we started a culture and sensitivity study. We nagged the doctors, nurses and even the patients to send the samples of the presumed infected area for culture so that we could start gathering data about antibiotic-resistant patterns. This was initially met with much resistance (“what’s the point in culturing, we are giving them strong antibiotics via a drip”). So as what often happens, you have to lead by example. I went on a culturing frenzy – anyone in the ward that I saw got cultured. Slowly the results came back, showing multiple-resistant patterns. As a result, patients not improving were changed to antibiotics that we know would work, they got better, and eventually went home. It only needed a few of these examples for word to spread and the habit of culturing samples to grow.

This has now been in place for about six months, and I think there is a slow but steady change in behaviour. Now if I see a drug chart with Ceftriaxone iv (strong antibiotic)  on it, I track the unfortunate owner of the signature down and make them explain why they prescribed it.  I have found that this is a great way to change behaviour, just ask why! The long-term junior doctors are now my ambassadors, I have heard some of them explaining to the new doctors about the antibiotic protocol (albeit I have also heard “Don’t let Dr Price catch you prescribing ceftriaxone”!) Patients also like getting their culture results back, seeing what they have grown and that they have been on the right antibiotic (or if not, knowing that the Doctor they are seeing has the evidence now to change their treatment).

Unfortunately the culture and sensitivity study is showing what you would expect in a situation with such liberal and incorrect use of antibiotics – there is a real problem with multi drug-resistant organisms. MRSA prevalence is still low – we have only had one death so far this year from MRSA but it is likely there will be more soon.

I am not sure if the resistance pattern at IHK is particularly bad, as IHK is often the last place people come to for treatment so they may well have had three or more incorrect and incomplete courses of antibiotics, still feel bad, and then come to us. But like the TB resistance, this is something that cannot be ignored for much longer.

On Friday a drug rep came to IHK offering a new supa-dupa antibiotic – the one used as the last hope for MRSA in the UK. If we do buy it then that’s another one for the locked cupboard!