Time for statutory restriction on antibiotic prescribing

A Finnish study following up people returning home from travelling abroad found that more than nine out of 10 people who take fluoroquinolone antibiotics for traveller’s diarrhoea while abroad return with multiresistant strains of bacteria.¹

It is known from previous research that people who contract the common problem of diarrhoea while abroad have an increased risk of acquiring antibiotic resistant intestinal bacteria, with the highest risk being in people visiting south and southeast Asia and Latin America. However, information on patterns of this resistance is limited.

Inappropriate and unnecessary use of antibiotics has been identified as a major threat to public health. We are now entering an era when some infections will be untreatable due to antimicrobial resistance. Furthermore, there seems little prospect of the development of completely new classes of antibiotics. Unfortunately the adverse effects of excess antibiotic use relate not to the primary user but to other people who may contract a resistant organism. Thus healthy adults with community-acquired infections, often not bacterial, suffer no adverse effect from their own inappropriate antibiotic use. It is rather older people or immunocompromised patients who become colonised with resistant organisms from others that are at most disadvantage.

This study is important, therefore, because it demonstrates a distinct disadvantage of antibiotic abuse for the primary user – in this case those developing diarrhoea while visiting developing countries. The research invited 430 people to give stool samples before and after travelling abroad in 2009-2010. Of these, 90 were found to have contracted extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae and nearly all of these (95%) had taken fluoroquinolone antibiotics while abroad. Only 37% of people not taking these antibiotics had ESBL (p = 0.001).

The researchers said: “While recent data show that destination, age, traveller’s diarrhoea and antibiotic use all predispose to colonisation by ESBL-producing Enterobacteriaceae, our data reveal that the menace posed by antimicrobials is even worse. Not only do antibiotic users contract higher rates of ESBL-producing Enterobacteriaceae, but the acquisition process is selective, favouring strains resistant to many beta-lactams but also some clinically important non-beta-lactam antibiotics.”

Colonisation with multiresistant organisms such as ESBL is recognised as a common feature of hospitalised patients, especially those with a history of frequent admissions or institutional care. This study demonstrates remarkably high rates of colonisation in healthy adults based in the community and is yet another example of the detrimental effect of casual non-evidence-based use of antibiotics in normal healthy people. The recognition of that danger of undiagnosed sepsis in hospital settings, together with the application of the Early Warning Score algorithms, may be saving some lives but it is almost certainly leading to even further lowering of the threshold for antibiotic prescribing. 

As the medical profession has failed to educate the general population about abuse of antibiotics and seems unable to resist requests for unnecessary prescriptions, the time must surely be approaching for statutory restriction on antibiotic prescribing.

Reference 

1. Kantele A, Mero S, Kirveskari J, Lääveri T. Fluoroquinolone antibiotic users select fluoroquinolone-resistant ESBL-producing Enterobacteriaceae (ESBL-PE) – data of prospective traveller study. Travel Med Infect Dis 2017   doi: 10.1016/j.tmaid.2017.01.003