Shorter courses will help reduce unnecessary use of antibiotics

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

Abstract

Objective
To evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations.

Design
Cross sectional study.

Setting
General practices contributing to The Health Improvement Network database, 2013-15.

Participants
931 015 consultations that resulted in an antibiotic prescription for one of several indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis.

Main outcome measures
The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication.

Results
The most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines.

Conclusion
For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.

Public health disaster on the cards if pharmaceutical pollution is left unchecked

Pollution from pharmaceutical plants is harming ecosystems and leading to the development of antimicrobial resistance (AMR) which could see more and more people dying from previously treatable diseases

Dear
Mr Timmermans,

We write in relation to the risks to human health and the environment posed by releases of pharmaceuticals into the environment. In particular, we are very concerned about how these releases affect ecosystems and are contributing to the development of antimicrobial resistance (AMR), one of the major threats to human health today. We would like to discuss with you the opportunities that the Commission has in the coming months to spearhead action against the global rise of drug resistance, including within the framework of its Proposal for a Regulation on veterinary medicinal products and its upcoming Strategic Approach to Pharmaceuticals in the Environment.

In its report on Frontiers 2017: Emerging Issues of Environmental Concern, UN Environment identifies growing AMR linked to the discharge of drugs and particular chemicals into the environment as one of the most worrying health threats today. Indeed, experts view the promotion of antibiotic resistant bacteria as “by far the greatest human health risk” posed by the presence of pharmaceutical residues in the environment and note that, in addition to fostering the spread of resistant pathogens, antibiotic residues can also turn harmless environmental bacteria into carriers of resistance.

Europe’s AMR burden in terms of lives lost, morbidity, healthcare costs and productivity losses is much greater than currently available statistics suggest. Recent projections estimate a 15-fold increase in morbidity in Europe due to AMR by 2050, with 390,000 deaths every year as a result of drug-resistant infections. The use of antibiotics in intensive livestock farming promotes the development of resistant bacterial strains and the environment plays not only an important role in the spread of those, but also wildlife organisms and ecosystem services are at risk.

We are concerned that the pharmaceutical industry is currently excluded from any kind of environmental legislation, which is untenable in the light of the risk that pharmaceutical pollution poses to the environment and to human health. We expect legislative action from the Commission to tackle this issue, similar to the regulation of the chemical industry through REACH.

Since AMR is a quintessential cross-border issue, it is important that the EU-One Health Action Plan against AMR is supported by policy measures and legislation in other areas, along the lines with those proposed in our recent briefing on policy options to be considered in the context of the Strategic Approach to Pharmaceuticals in the Environment and the proposal for a Regulation on veterinary medicinal products to ensure that we tackle the problem in a comprehensive way.

We would therefore like to request a meeting with you to discuss the main policy measures available to successfully tackle this problem.

References

  • European Environmental Bureau, joint letter, 10 April 2018.
    Public health disaster on the cards if pharmaceutical pollution left unchecked say campaigners, metamag, 12 Apr 2018.
  • Policy options for regulating pharmaceuticals in the environment, eeb, Feb 2018.
  • Prevention is better than cure: Europe’s chance to act on AMR is now, epha, May 8, 2017.
  • Ecological Impacts of Veterinary Pharmaceuticals: More Transparency-Better Protection of the Environment, pan-germany.
  • Antibiotics in Livestock Farming. What can be done to reduce environmental threats and avoid the development of antibiotic
    resistance? pan-germany.
  • Antimicrobial resistance from environmental pollution among biggest emerging health threats, says UN Environment, unenvironment, dec 2017.
    Improving environmental risk assessment of human pharmaceutical, American Chemical Society, 2015.
  • Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations, amr-review, 2014.
  • Image credit oceancrusaders.

La ténacité des rumeurs et des conventions médicales

Soyons encore et toujours plus vigilants ; la médecine ne doit pas s’endormir sur ses lauriers

Publié par Luc Perino, médecin généraliste, humeur du 18/09/2017

… Dans le monde de la médecine, les rumeurs et les conventions sont parfois plus tenaces, car nul ne souhaite changer l’image de sa philanthropie conventionnelle.

  • La saignée a tué des milliers de patients qui auraient guéri sans soins.
  • On a longtemps langé les nourrissons avant de s’apercevoir que cela leur luxait les hanches, on les a longtemps couchés sur le ventre avant de dénombrer les morts dus à cette position.
  • Les médecins ont extrait des millions d’amygdales, de végétations, de verrues, d’appendices, de thyroïdes, d’utérus et d’ovaires sans aucune autre raison que la force de l’habitude.
  • On continue à prescrire des antibiotiques dans les angines banales parce que la croyance en des complications rhumatismales révolues persiste envers et contre tout.
  • On continue à prescrire du fer aux femmes enceintes, car on est toujours convaincu qu’elles en ont besoin.
  • On continue à se persuader que la pilule n’est pas un perturbateur endocrinien.
  • On refuse le stérilet aux nullipares, car l’anecdote du risque infectieux fait le tour des tables de médecins.
  • Les médicaments dont les risques sont supérieurs aux bénéfices continuent à se vendre par tonnes.
  • On continue à penser que les déclenchements facilitent les accouchements sans voir qu’ils en sont l’une des sources de complications.

Et tant d’autres exemples auxquels des médecins continueront longtemps à réagir, parfois violemment, car de tels propos bousculent les conventions.

Loin de dénigrer la médecine, je pense qu’elle mérite tous ses lauriers, mais il ne faut pas la laisser s’endormir dessus, tout particulièrement en notre époque où l’information n’a jamais été aussi puissamment biaisée. Il serait dommageable de la laisser insinuer son infaillibilité au seul prétexte qu’elle ne veut que notre bien. Soyons encore et toujours plus vigilants et sachons dépister les rumeurs de caste avant que les carottes et les huîtres ne soient trop cuites.

En Savoir Plus

Antibiotic resistance genes traced from manure to soil and water on Finnish farms

Influence of Manure Application on the Environmental Resistome under Finnish Agricultural Practice with Restricted Antibiotic Use

A recent study has investigated the movement of antibiotic resistance genes between farm animals, soil and water in Finland. The results show that many of these genes are spread from animals to the soil through manure application; however, these genes do not appear to persist in soil. The study suggests that practices that minimise the use of antibiotics, as used in Finland, may lead to lower levels of clinically relevant resistance genes in agricultural soils.

2017 Study Abstract

The co-occurrence of antibiotic-resistance genes (ARGs) and mobile genetic elements (MGEs) in farm environments can potentially foster the development of antibiotic-resistant pathogens. We studied the resistome of Finnish dairy and swine farms where use of antibiotics is limited to treating bacterial infections and manure is only applied from April to September. The resistome of manure, soil, and tile drainage water from the ditch was investigated from the beginning of the growing season until forage harvest. The relative ARG and MGE abundance was measured using a qPCR array with 363 primer pairs. Manure samples had the highest abundance of ARGs and MGEs, which increased during storage. Immediately following land application, the ARGs abundant in manure were detected in soil, but their abundance decreased over time with many becoming undetectable. This suggests that increases in ARG abundances after fertilizing are temporary and occur annually under agricultural practices that restrict antibiotic use. A few of the ARGs were detected in the ditch water, but most of them were undetected in the manure. Our results document the dissipation and dissemination off farm of ARGs under Finnish limited antibiotic use and suggest that such practices could help reduce the load of antibiotic-resistance genes in the environment.

Sources

  • Antibiotic resistance genes traced from manure to soil and water on Finnish farms, ec.europa.eu, 08 February 2018.
  • Influence of Manure Application on the Environmental Resistome under Finnish Agricultural Practice with Restricted Antibiotic Use, Environmental Science & Technology, April 28, 2017.

Ask McDonald’s to Hold the Antibiotics

Advocacy group calls on McDonald’s to remove antibiotics from beef, pork

“If we want to save our antibiotics, we need to stop the overuse of antibiotics by all large industrial farms. So we’re focussed on getting the restaurant chain cited as the country’s biggest purchaser of beef and a major pork buyer, McDonald’s, to “Hold the Antibiotics.”

McDonald’s no longer serves chicken raised with medically important antibiotics in the U.S., and when they make a similar commitment to phase routine antibiotic use out of their pork and beef supply chains, it will signal a massive shift that could transform the way we raise meat in our country, and more importantly help preserve the effectiveness of antibiotics, protecting public health, and saving lives.

McDonald’s has signaled that they want to move in this direction. The question is how fast, and how strong a commitment are they be willing to make? This could result in an industry-wide shift away from misusing our life-saving medicines to produce meat.”

U.S. PIRG
TELL MCDONALD’S: HOLD THE ANTIBIOTICS
Stands up to powerful interests whenever they threaten our health, our financial security, or our right to fully participate in our democracy“.

More Information

  • Hold The Antibiotics McDonald’s, uspirg.org.
  • NEW CAMPAIGN CALLS ON MCDONALD’S TO HOLD THE ANTIBIOTICS FROM THEIR MEAT SUPPLY CHAIN, uspirg, JANUARY 25, 2018.
  • MCDONALD’S CHANGES MEAT SUPPLY GUIDELINES TO STEM SPREAD OF ANTIBIOTIC-RESISTANT BACTERIA, uspirg, AUGUST 23, 2017.
  • STATEMENT ON MCDONALD’S SHAREHOLDER RESOLUTION TO ELIMINATE THE ROUTINE USE OF MEDICALLY IMPORTANT ANTIBIOTICS FROM THE COMPANY’S MEAT SUPPLY CHAIN, uspirg, MAY 24, 2017.

Abus d’antibiotiques : une catastrophe annoncée

Bactéries résistantes, la guerre est déclarée – Enquête de santé le documentaire

Les antibiotiques sont l’arme la plus puissante contre les infections bactériennes. Mais à force d’en abuser, ces médicaments ont perdu de leur efficacité et les bactéries ont appris à s’en défendre.

A force d’abuser des antibiotiques, les bactéries ont appris à se défendre. Les médicaments ont perdu de leur efficacité. En France, chaque année, près de 12 500 personnes meurent des suites d’une infection causée par ces formes mutantes. Martelée depuis 2002, cette résistance pousse les plus pessimistes à envisager le pire pour les années à venir. D’autant que cette surconsommation se retrouve également chez les animaux d’élevage dont les bacilles résistantes peuvent se transmettre par la chaîne alimentaire.

The world is running out of antibiotics, WHO report confirms

Too few antibiotics in pipeline to tackle global drug-resistance crisis, WHO warns

A new report, Antibacterial agents in clinical development – an analysis of the antibacterial clinical development pipeline, including tuberculosis, launched this week by WHO shows a serious lack of new antibiotics under development to combat the growing threat of antimicrobial resistance.

Most of the drugs currently in the clinical pipeline are modifications of existing classes of antibiotics and are only short-term solutions. The report found very few potential treatment options for those antibiotic-resistant infections identified by WHO as posing the greatest threat to health, including drug-resistant tuberculosis which kills around 250 000 people each year.

“Antimicrobial resistance is a global health emergency that will seriously jeopardize progress in modern medicine,”
“There is an urgent need for more investment in research and development for antibiotic-resistant infections including TB, otherwise we will be forced back to a time when people feared common infections and risked their lives from minor surgery.”

says Dr Tedros Adhanom Ghebreyesus, Director-General of WHO.

In addition to multidrug-resistant tuberculosis, WHO has identified 12 classes of priority pathogens – some of them causing common infections such as pneumonia or urinary tract infections – that are increasingly resistant to existing antibiotics and urgently in need of new treatments.

The report identifies 51 new antibiotics and biologicals in clinical development to treat priority antibiotic-resistant pathogens, as well as tuberculosis and the sometimes deadly diarrhoeal infection Clostridium difficile.

Among all these candidate medicines, however, only 8 are classed by WHO as innovative treatments that will add value to the current antibiotic treatment arsenal.

There is a serious lack of treatment options for multidrug- and extensively drug-resistant M. tuberculosis and gram-negative pathogens, including Acinetobacter and Enterobacteriaceae (such as Klebsiella and E.coli) which can cause severe and often deadly infections that pose a particular threat in hospitals and nursing homes.

There are also very few oral antibiotics in the pipeline, yet these are essential formulations for treating infections outside hospitals or in resource-limited settings.

“Pharmaceutical companies and researchers must urgently focus on new antibiotics against certain types of extremely serious infections that can kill patients in a matter of days because we have no line of defence,”

says Dr Suzanne Hill, Director of the Department of Essential Medicines at WHO.

To counter this threat, WHO and the Drugs for Neglected Diseases Initiative (DNDi) set up the Global Antibiotic Research and Development Partnership (known as GARDP). On 4 September 2017, Germany, Luxembourg, the Netherlands, South Africa, Switzerland and the United Kingdom of Great Britain and Northern Ireland and the Wellcome Trust pledged more than €56 million for this work.

“Research for tuberculosis is seriously underfunded, with only two new antibiotics for treatment of drug-resistant tuberculosis having reached the market in over 70 years,”
“If we are to end tuberculosis, more than US$ 800 million per year is urgently needed to fund research for new antituberculosis medicines”.

says Dr Mario Raviglione, Director of the WHO Global Tuberculosis Programme.

New treatments alone, however, will not be sufficient to combat the threat of antimicrobial resistance. WHO works with countries and partners to improve infection prevention and control and to foster appropriate use of existing and future antibiotics. WHO is also developing guidance for the responsible use of antibiotics in the human, animal and agricultural sectors.

Why Our Misuse of Antibiotics Could Mean the End of Modern Medicine

Adam Ruins The Hospital – Season 2 | Ep 203, 2017

Adam Conover starts explaining that the reckless prescription of antibiotics is making them worthless – abstract from Adam Ruins The Hospital.

Use of antibiotics during pregnancy and the risk of major congenital malformations

Clindamycin, doxycycline, quinolones, macrolides and phenoxymethylpenicillin in utero exposure were linked to major congenital malformations

2017 Study Abstract

Introduction
Few studies have investigated the link between individual antibiotics and major congenital malformations (MCMs) including specific malformations owing to small sample size. We aimed – population based cohort study, British Pharmacological Society, 19 July 2017 – to quantify the association between exposure to gestational antibiotic and the risk of MCMs.

Methods
Using the Quebec pregnancy cohort (1998 -2008), we included a total of 139,938 liveborn singleton alive whose mothers were covered by the “Régie de l’assurance maladie du Québec” drug plan for at least 12 months before and during pregnancy. Antibiotics exposure was assessed in the first trimester and MCMs were identified within the first year of life.

Results
After adjusting for potential confounders, clindamycin exposure was associated with an increased risk of MCMs (aOR 1.34, 95%CI, 1.02-1.77, 60 exposed cases), musculoskeletal system malformations (aOR 1.67, 95%CI, 1.12-2.48, 29 exposed cases) and ventricular/atrial septal defect (aOR 1.81, 95%CI, 1.04-3.16, 13 exposed cases).

Doxycycline exposure increased the risk of circulatory system malformation, cardiac malformations and ventricular/atrial septal defect (aOR 2.38, 95%CI ,1.21-4.67, 9 exposed cases; aOR 2.46, 95%CI, 1.21-4.99, 8 exposed cases; aOR 3.19, 95%CI, 1.57-6.48, 8 exposed cases, respectively). Additional associations were seen with quinolone (1 defect), moxifloxacin (1 defect), ofloxacin (1 defect), macrolide (1 defect), erythromycin (1 defect) and phenoxymethylpenicillin (1 defect). No link was observed with amoxicillin, cephalosporins and nitrofurantoin. Similar results were found when penicillins were used as the comparator group.

Conclusions

  • Clindamycin, doxycycline, quinolones, macrolides and phenoxymethylpenicillin in utero exposure were linked to organ specific malformations.
  • Amoxicillin, cephalosporins and nitrofurantoin were not associated with MCMs.

Assessment of the biodegradability of selected sulfa drugs in two polluted rivers in Poland

Effects of seasonal variations, accidental contamination, turbidity and salinity

Up to 90% of consumed drugs enter the environment. This may have negative effects on wildlife, especially when the drugs take long periods to break down. This study assessed the breakdown of sulphonamides — a class of antibacterials — in samples from two rivers in Poland. The results showed that sulphamethoxazole, a common veterinary antibiotic, was the most persistent and that various factors inhibit degradation, including low temperatures, heavy metal pollution and low pH.

Highlights

  • Biodegradation rate of sulfonamides (SNs) in river water is variable.
  • Biodegradability of SNs depends on the growing season.
  • High concentration of salts in river water inhibits the SNs biodegradation.
  • Sulfamethoxazole could be classified as Persistent Organic Pollutant (POP).

Abstract

Which factors make drugs persistent? A look at sulphonamides in Polish rivers, Science for Environment Policy, 12 January 2017.

Assessment of the biodegradability of selected sulfa drugs in two polluted rivers in Poland: Effects of seasonal variations, accidental contamination, turbidity and salinity, science direct, August 2016.

Image credit Janusz Nowak.

The aim of our study was to assess the aerobic biodegradation of four selected sulfonamides (sulfanilamide, sulfamethoxazole, sulfadiazine and sulfathiazole) using water samples drawn from highly polluted rivers. Additionally, we aimed to identify the factors that have a significant effect on the process efficiency.

The 19 water samples were collected from Brynica and Czarna Przemsza rivers (in Poland) at the same location at approximately monthly intervals. A characteristic feature of the results is the presence of significant differences between the rates of sulfonamides biodegradation in particular samples.

The sulfonamide most resistant to biodegradation was sulfamethoxazole, whereas sulfathiazole was most biodegradable. Seasonal variations and related microbial population changes had the most significant effects on sulfonamides biodegradation, e.g., the studied process was highly inhibited during wintertime. A decrease in the biodegradation rate in the river water could be caused by an accidental water pollution by industrial wastewater with heavy metals, an increase in salinity and a decrease in pH, and turbidity.