Curing the antibiotics 'disease'

One of modern medicine's greatest discoveries, antibiotics have added an average of 20 years to each person's lifespan.

Today, they are one of the most frequently prescribed medications, helping the body fight infections, making transplant and appendix operations possible.

But the way in which these medicines have been used is also causing concern worldwide, including in Singapore.

Misuse and overuse of antibiotics have caused germs to develop resistance to them.

The Straits Times reported in December that a national antimicrobial resistance plan is in the works.

The effort will involve the Health Ministry, the Agri-Food and Veterinary Authority, and the National Environment Agency as well as the National University of Singapore.

The Straits Times understands that the plan is likely to stick closely to recommendations made by the World Health Organisation to tackle antimicrobial resistance (a broader term which includes antibiotic resistance).

This could include educating the public on which illnesses should or should not be treated with antibiotics, and stepping up the monitoring of their use.

The need for such a plan was highlighted by results of a new study here which showed that many patients of GPs are poorly informed about what antibiotics should be used for.

WRONGLY SEEN AS CURE-ALL 

While the problem of antibiotic resistance cannot be attributed to just one sector alone, general practitioners play a key role as they prescribe first-line antibiotics.

If the study findings are anything to go by, awareness on how antibiotics should be used is still lacking among patients of GPs.

The study was published last year by students from the Yong Loo Lin School of Medicine at the National University of Singapore, with public health experts from the National University Health System (NUHS).

It found that one-third of patients expect antibiotics to be prescribed by their GPs for common ailments like cough, sore throat, runny nose and blocked nose.

These are mainly caused by viruses, and not bacteria.

Many of the patients were not aware that antibiotics are useless against viruses.

The Straits Times reported the findings in November.

The study, which involved 914 adult patients from 24 GP clinics across Singapore, also found that half of those expecting antibiotics would ask their doctors to prescribe the medication or would see another doctor if antibiotics were not prescribed.

"GPs may often be under pressure by anxious parents and patients to prescribe antibiotics," said Associate Professor Lee Kheng Hock, president of the College of Family Physicians Singapore.

"Better communication is needed to convince many such patients that antibiotics are not needed."

TESTS FOR GREATER CERTAINTY 

Part of the problem is that it is tricky for a doctor himself to distinguish between a bacterial and a viral infection.

It requires not just knowledge, but also experience, doctors say.

For example, when a patient is down with a throat infection, it is a viral infection most of the time.

But an observation of symptoms alone may not be enough for doctors to be sure if antibiotics are needed.

Point-of-care test kits, such as those which test for influenza A or B, could help doctors to make a more informed decision.

Both influenza A and B are caused by viruses. All that is needed is a nose swab and the results can be out in five minutes.

While these tests are already available, the take-up rate seems slow.

The tests do cost $35 each, but Dr Jason Pang, who has been a GP for more than 20 years and runs a clinic in Siglap, said that most patients there do not mind paying for it.

"Such kits, together with a good history-taking of presenting symptoms and meticulous clinical examination, potentially could reduce the use of unnecessary antibiotics," added Dr Pang.

However, Dr Winston Ho, medical director of Parkway Shenton, which has 55 clinics, said that additional trained staff might be required to do these tests and in a busy GP clinic, this could be challenging.

Generally, the accuracy of these tests is only 70-75 per cent, he added.

Still, test results, when taken into consideration with symptoms presented by the patient, could help provide peace of mind in terms of whether to prescribe antibiotics or not.

Infectious diseases specialist Leong Hoe Nam, from Mt Elizabeth Novena Hospital, said: "I expect test kits to get more popular with better and improving accuracy and (hopefully) lower prices. Antibiotics are not needed more than 90 per cent of the time. Such kits can help determine the diagnosis."

Indeed, studies have shown the use of point-of-care kits to be effective in bringing down the number of antibiotic prescriptions without compromising patients' health.

According to a study published in 2014 in science journal Therapeutic Advances In Drug Safety, diagnostic kits which helped to rule out serious respiratory tract infections have helped reduce the prescription of antibiotics by more than 50 per cent in the Netherlands.

The major contribution of such tests seems to be that of decreasing doctors' uncertainty, adding useful information that helps to identify who to treat or not with antibiotics, noted the study.

Infectious diseases specialist Paul Tambyah said that in Singapore, the widespread use of tests for dengue has allowed early recognition when symptoms are non-specific, so appropriate referrals can be made, blood tests ordered and complications avoided.

Singapore's dengue mortality rate has plummeted despite large numbers of cases, largely through the efforts of GPs, he said.

"Until we can accurately distinguish viral from bacterial infections in the clinic, there is always going to be the fear of missing a serious bacterial infection," added Professor Tambyah.

He noted: "This is exacerbated by a system which does not mandate a fixed GP who can follow up on a patient to see if there is improvement (which one would expect for a viral illness) or progression (of the infection)."

Associate Professor Goh Lee Gan, a senior consultant at the National University Hospital under NUHS, said that "doctor-hopping" makes it difficult for GPs to have a good understanding of a patient's condition.

Fortunately, doctor-hopping is taking place less frequently and patients are better at telling what medications they have received, he said.

"At end of the day, society and doctors need to work together. Asking patients whether they are feeling better or feeling worse often gives a handle to the problem," added Prof Goh, who was a GP for seven years.

"Acting rather than watchful waiting is a judgment call and the more inputs the doctor receives, the more accurate he will be in deciding if he should prescribe antibiotics."

WHAT ABOUT A PAYMENT INCENTIVE? 

In Britain, GPs are paid by the National Health System to reduce their antibiotic prescriptions.

While results have proven effective - with prescriptions for all types of antibiotics down by more than 2.6 million in 2015 compared with the previous year - questions have been raised about whether doctors should be paid for doing something that is essentially part of their job.

Other suggestions such as separating drug dispensing from prescription have also been mooted, but this could increase GPs' consultation fees and lead to more hassle for patients who would have to collect their drugs separately.

On Britain's policy, Associate Professor Hsu Li Yang, programme leader of the antimicrobial resistance programme at the Saw Swee Hock School of Public Health at the National University of Singapore, agreed that some doctors may be uncomfortable with getting paid for what should be part of their job.

However, he noted: "There is no question that it takes time to explain to patients why they should not be getting antibiotics, something which is financially unrewarding under traditional compensation schemes."

GPs may offer test kits, but that is just one part of the picture, with Prof Hsu saying the key to tackling the situation would be to create a culture where people with upper respiratory tract infections and other viral illnesses do not ask doctors for antibiotics.

And also, where doctors are not penalised when they advise patients to "tough it out" without antibiotics.

EDUCATION IS KEY 

There is no single magic bullet to tackle the problem of antibiotic resistance.

GPs can do only so much in providing the right prescriptions and diagnosis of a patient's illness.

As noted by Prof Hsu, the lack of awareness that patients have in thinking that antibiotics are effective against illnesses caused by viruses can be reinforced by mere anecdotal experience.

This happens when someone with a viral upper respiratory tract infection asks for, and gets prescribed, antibiotics from the GP, and then recovers.

The recovery happens because of their immune systems fighting off the viruses.

Attributing the recovery to antibiotics, however, creates a vicious circle.

"They end up repeatedly requesting from their doctors antibiotics whenever they themselves or their children come down with a cough or runny nose," added Prof Hsu.

Public awareness and education campaigns will take a while to bear fruit, but their importance cannot be understated.

In Europe, pharmacists provide a guide that gives advice on when patients should seek medical help, as most cold and flu symptoms can be treated without going to the GP.

While the Pharmaceutical Society of Singapore does have a guide on antibiotic resistance and what can be done to prevent it, it doesn't seem as detailed as the European one.

Europe also has a European Antibiotic Awareness Day, on Nov 18. Members of the public can sign up as an "Antibiotic Guardian" and pledge to take antibiotics exactly as they are prescribed, and not share them with others.

Singapore does observe the World Health Organisation's Antibiotic Awareness Week in November.

At past awareness weeks, several local hospitals organised events to educate healthcare staff about antibiotics and antibiotic resistance.

In terms of including the public, and not just healthcare staff, there were information books at libraries and experts discussed the issue in the media.

But there was nothing like an "Antibiotic Guardian" pledge that involves people at the individual level.

In 1945, Sir Alexander Fleming, who won the Nobel prize for discovering the antibiotic penicillin, warned about antimicrobial resistance.

He said: "The thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism."

Deaths due to antibiotic resistance are already occurring in various parts of the world.

Clearly, education is key, whether it is a GP searching for a way to make a more accurate diagnosis, or a healthcare worker deciding how the drug should be prescribed judiciously.

But most importantly, the public, as patients, need to be weaned off the mistaken idea of antibiotics as a cure-all.

As users of the drug, we all have the responsibility to use them responsibly.

kcarolyn@sph.com.sg

This article was first published on Feb 02, 2017.
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