The Impact on Resistance of Antibiotic Availability to the Public

THE  IMPACT  ON  RESISTANCE  OF  ANTIBIOTIC AVAILABILITY  TO  THE  PUBLIC

The ease of availability of antibiotics to the general public varies throughout the world. In Europe the Council of the European Union recommended in 2001 that member states should support the prudent use of antibiotics by restricting systemic antibacterial agents to prescriptiononly availability. In many other countries, though, antibiotics are supplied without a prescription—either because the practice is not illegal, or because the law is not enforced. Even in the USA this is so: in its testimony to Congress referred to in the first sentence of this chapter the IDSA posed the question ‘Antibiotics’ true value: “precious resource” or a “giveaway marketing tool”?’ They were referring to the practice ‘where grocery stores and pharmacies give prescribed antibiotics away for free as a marketing ploy to lure customers into their stores’. Self-medication with antibiotics (obtained via the internet or simply by patients using left-over antibiotics prescribed at an earlier date for unrelated infections) is another practice that contributes to uncontrolled and often inappropriate antibiotic use and so contributes to the resistance problem.

In the UK there has been a slow movement of topical anti-infective agents from prescription-only medicine (POM) to pharmacy-only (P) status; thus, clotrimazole, chloramphenicol and aciclovir creams, and others, have all undergone this reclassification, but in late 2008 azithromycin became the first systemic antibiotic available in pharmacies without prescription, albeit for the defined purpose of treating chlamydial infection. This change in policy by the UK Medicines and Healthcare products Regulatory Agency (MHRA) received a mixed reception. It was welcomed by some as a step towards the desirable objectives of increasing patient choice and encouraging patients to take responsibility for their own healthcare, but executive officers of the British Society of Antimicrobial Chemotherapy strongly criticized the change as a retrograde step that is likely to lead to increased use without professional advice and, as a consequence, increased resistance. The situation was exacerbated by proposals for similar reclassification of other antibiotics, e.g. trimethoprim and nitrofurantoin, both for the treatment of cystitis, but in March 2010 the UK government stepped in to halt MHRA reconsideration of the trimethoprim application.

Apart from the likely increase in use leading to increased resistance, one of the strongest arguments against the availability of antibiotics without prescription is that it would even remove the means by which the consumption of a particular antibiotic could be monitored and correlated with any resistance trends— prescriptions can be counted, but sales are not! The ability to operate such surveillance systems is an integral component of stewardship programmes, so any change in the legal status of systemic antibiotics to make them available without prescription would not only flout the EU recommendation but undermine the government’s stated support for prudent antibiotic use. It would seem that the decision to halt MHRA consideration of the proposal to reclassify trimethoprim means that the UK government has heeded the warnings that can be summarized in the following quotation from the Chief Medical Officer’s report for 2008:

The potency of one of the key weapons in the medical armoury is being eroded. The harm caused by each unnecessary prescription is not visible at the time, and so society fails to take action that is necessary to stop the problem worsening. Correcting this situation will require a paradigm shift in thinking. The effectiveness of antibiotics should be seen as a common and collective public good. Every antibiotic expected by a patient, every unnecessary prescription written by a doctor, every uncompleted course of antibiotics, and every inappropriate or unnecessary use in animals or agriculture is potentially signing a death warrant for a future patient.