Comments on: Free antibiotics are bad?

By: Myrtle

Myrtle — Sun, 28 Jun 2009 01:49:03 +0000

Rich brought up exactly the question that I’ve had for a long time. Why is it believed that antibiotic resistant strains originate within the US and not some other country in which antibiotics are over the counter?

By: Billy Rubin

Billy Rubin — Thu, 25 Jun 2009 12:39:02 +0000

I don't see it as disrespect for the outpatient physician. You note that "in the hospital, confronted with a sick patient, infectious disease specialists often become very liberal in antibiotic use," which is true, but that's because they're sick ! On the other hand, of the free drugs you list above, at least one of them (Cipro) has gone from being a first-line agent for gram-negative infections to, in the colorful words of one of my colleagues, a "piece-of-shit drug" due to widespread resistance (say, E. coli in UTIs among other conditions). I might not go that far but I've watched fluoroquinolone resistance go from virtually nothing when I was a trainee to about 20 or 30 percent now, and I'm not that far out of training. I don't know if opposing free abx is the answer, and your point that maybe there's a culture gap between the ID and the primary care docs is well taken. Perhaps the answer lies in getting everyone , both outpatient and inpatient docs, to curb the use of either unnecessary or broad-spectrum antibiotics. But I can tell you this from an ID doc's perspective: Dr. Gershon of the IDSA is pointing out that there's a big problem out there, and it's only getting worse.

By: AnnR

AnnR — Thu, 25 Jun 2009 11:09:00 +0000

I think Rich has a good point.

By: Rich

Rich — Wed, 24 Jun 2009 23:21:05 +0000

The US is a small part of the worldwide human-bacteria ecosystem. In the typical groupthink ranting against profligate use of antibiotics by primary care doc’s, I have never heard anyone raising concern about the fact that in Mexico, or Central America, and possibly beyone, one can purchase antibiotics from ‘la pharmacia’ without a prescription. Yet, those from south of the border don’t seem to carry resistant organisms with them to the US. So, does this ”overuse of antibiotics south of the border offer a way to compare semi-controlled prescriptions against open access??
(signed – Just a general surgeon.)

By: Clinton

Clinton — Wed, 24 Jun 2009 21:41:38 +0000

I don’t quite know how to express this, but I get bothered by the “broad-spectrum -> narrow-spectrum” antibiotic use. If you take a broad-spectrum antibiotic for just a day or two and switch it over to a more specific antibiotic for a full course of treatment…. doesn’t that mean that there is an inadequate dose of broad-spectrum antibiotic being administered and thus, other bacteria NOT targeted by the narrow-spectrum antibiotic would have been selected to develop resistance to the broad-spectrum antibiotic?

I don’t know what the solution to this theoretical problem would be.

Obviously, it makes sense from a clinical framework to start with empiric antibiotics and narrow the regimen so it is specific to the disease… but is this a myopic way to look at things when the pathogenic bacteria isn’t the only bacteria that is undergoing evolutionary pressure?

By: madhu

madhu — Wed, 24 Jun 2009 18:09:06 +0000

I had not thought of things the way you did.
I work for the VA as an outpatient internist and recently one of my patients got admitted to a community hospital with “urosepsis” and was discharged on Bactrim and Levofloxacin. The gentleman told me that Levo would cost him about $75 for about 5 doses. Since I did not have any susceptibility data so I sent off a urine m,c and s and gave him Bactrim to complete his course.
Free antibiotics are bad, if they lead people to overuse antibiotics inappropriately. And your point about antibiotics in hospital is well taken and true in my experience as an occasional in-patient attending.

By: A Skeptic

A Skeptic — Wed, 24 Jun 2009 16:30:23 +0000

I disagree with you. You need to practice in the community to realize that unfortunately free antibiotics equals antibiotics for everybody. Removing the monetary disincentive increases the expectation for antibiotics to be prescribed for every upper respiratory infection. Forget the problem of resistance. What about the unnecessary cases of C. difficile colitis or other adverse effects? Just as some of us were starting to make headway against the incessant, irrational antibiotic demands, these free antibiotic programs have put us back to square one.