Original Post on 23 Nov 2007 (Edited)

I have spoken on this issue a few times with my professional friends and colleagues. It is something that causes concern to me and colleagues.

The issue is Drug Abuse! Not the type that we most commonly hear about. This is different but nonetheless deeply worrying and potentially dangerous and in extreme cases potentially life threatening.

I am referring to abuse of non-narcotic prescription drugs. No, not by the person who is using it, but rather by the person who is prescribing it!

Let me take Antibiotics, the group of drugs used to fight off bacterial infections, for the sake of demonstrating my case.

The amount of Antibiotic prescriptions and its use has not been studied in the Maldives, EVER! However, speak to any pharmacist and you’ll hear from them that they sell plenty more of this group of drugs than they would expect. Talk to medical practitioners and you will hear from them that antibiotics are many a time prescribed unnecessarily and irrationally; a situation that amounts to “drug abuse”!

Antibiotics are the most important weapons in modern medicine in fighting off infection when an infection is established. Its use and abuse dictates over a period of time, how effective and useful it would remain in the future in fighting deadly infectious diseases. Antibiotics have no effect on Viruses, hence it has no role in the treatment of exclusive viral infections.

Antibiotics work by inhibiting the replication of bacteria, causing dysfunction in their life cycle and incurring fatal damage to its structure and functioning. These effects result in the death of the bacteria and assist an infected patient in overcoming the illness. Different antibiotics work by different mechanisms, targeting different events in the life cycle of the bug or damaging different structures of the bug that are essential for its own survival. This means that, although classified into a single group, antibiotics among themselves are very different, sometimes even uniquely so. These differences in the way different antibiotics work causes some to be effective against some bugs and virtually useless against some other bugs. The bugs themselves can over time acquire characteristics that make them “immune” to the effect of an antibiotic that previously was able to kill them: development of resistance to antibiotic.

Over years of testing and clinical use, data has been gathered and analysed to get a better understanding of which antibiotics are effective against which kinds of bugs. Armed with this collective knowledge, medical practitioners can prescribe appropriate empirical antibiotics for bacterial infections. With antibiotic resistance increasing, the collective knowledge on BUG vs ANTIBIOTICS, continues to change. Some bugs have over years acquired such effective capabilities of overcoming antibiotic assault that new SUPER BUGS, resistant to a multitude of antibiotics, have now emerged. MRSA: Methicillin Resistant Staphylococcal Aureus has been making headlines all over the world.

The drug abuse in relation to inappropriate and irrational antibiotic prescription is one that worries infectious disease specialists and international authorities and regulatory bodies.

My personal experience is that several patients are prescribed antibiotics for no justifiable medical reason and against collective good practice guidelines based on evidence based medicine. For instance, use of antibiotics – sometimes multiple antibiotics, for treating clinically and laboratory diagnosed viral diarrhea is unjustified and potentially dangerous. This is however a common practice even among some senior doctors.

Reputable and internationally acclaimed journals, organisations and medical associations have come up with guidelines on management of diarrhoealdiseases in children. All of them unanimously agree that routine use of antibiotics for diarrhoea is irrational and potentially harmful. Those who do use antibiotics in ALL cases of diarrhoea claim that they are doing so to ensure that all potential causes of diarrhoea are addressed in treatment; a technique called SHOT GUN THERAPY. {A shot gun fires multiple pellet projectiles in a “spray” ensuring a “hit” even when the gun is not exactly aimed at the target}. Shot gun therapy is irrational, is against good medical practice and reflects poorly on the grasp of medical knowledge by the one who uses it.

Increasing number of antibiotics are heading towards becoming utterly useless and obsolete because of their abuse. In our small community, bacterial resistance to antibiotics is already a huge concern. Microbiology culture reports (blood culture reports, urine culture reports and swab culture reports) are increasingly demonstrating the emergence of multi-resistant potential SUPER BUGS.

Allowing irrational antibiotic use, one that I would call as “drug abuse”, to continue will almost certainly make treatment of life-threatening infections more difficult than they already are. We, like the rest of the world, are heading toward an inevitable SUPER BUG crisis unless we rationalise antibiotic use and stamp out the abuse.

It is my plea to medical practitioners in Maldives, both local and expatriates, to give this some thought, keep themselves up-to-date on medical knowledge and make an effort to minimise their contribution to this growing problem. Let the collective experience of the larger international medical and scientific community ( evidence based medicine: derived from systemic reviews and other high level evidence) guide you, rather than sticking to personal observations and experiences (anecdotal evidence) when they differ. That would be the right choice for you, your patient and the future of medical success.