EXAMINING ANTIBIOTIC RESISTENCE IN RESPIRATORY TRACT INFECTIONS

Causes for antibiotic resistance

Antibiotic resistance has several causes. First of all, inappropriate prescribing is the most significant. Recent research shows that only 49% of antibiotic prescribing is appropriate, and antibiotics are often prescribed for viral infections, like the common cold, and the flu. Second, antibiotics are often prescribed in doses too low, or for durations too short, to completely eradicate a bacterial cause for infections. Third, our more potent antibiotics, such as Cipro, are used by clinicians for less serious infections. This practice encourages organisms to become resistant to our more potent treatment options, potentially resulting in an ineffective drug for more severe infections. This practice also increases the cost of care, since newer antibiotics, like Cipro, are generally more expensive. Fourth, our more potent antibiotics (like Cipro), which should be reserved for treatment failures, are used as first line therapy. Treatment failure means having taken a prescribed antibiotic correctly, yet the illness persists. First line therapy refers to our first selection for antibiotic prescribing. Yet, medical practitioners aren’t only to blame. Patients need to accept a lot of the responsibility also. Patients frequently insist on receiving antibiotics, even where not indicated (i.e. viral infections, like the common cold). They often fail to finish or take as directed their prescription (skipped doses). Most concerning is patients self medicating without consulting a medical provider first. This practice is more common here in Honduras, where most antibiotics are over-the-counter and don’t require a medical practitioner’s prescription. In addition, pharmacy staff aren’t necessarily trained in pharmacology, and are therefore unable to correctly advise patients on the appropriateness of antibiotic therapy.

Antibiotics used for Respiratory Tract Infections

The major classes of antibiotics used for a bacterial etiology in Respiratory Tract Infections are: penicillins (Amoxicillin, Augmentin), cephalosporins (Ceftin, Ceclor, Lorabid), quinolones (Cipro, Zagam), and macrolides (Erythromycin, Zithromax, and Biaxin). The site of infection is an important consideration regarding appropriate use of antibiotics. Generally, an antibiotic will reach a higher concentration in the alveoli (within the lung tissue), than in the middle ear, or sinuses. As a result, longer durations of antibiotic treatment are generally indicated for ear infections (otitis) and sinus infections (sinusitis). Frequently, patients will be given a short course of treatment, when 10-14 days may be indicated.

Patient compliance

Patient compliance is a key component in preventing the rise in antibiotic resistance, and the development of more convenient dosing regimens is a priority for clinicians. For example Biaxin (clarithromycin) now comes in a once daily, extended release form. This newer version has an improved side effect profile (less incidence of stomach upset and unpleasant taste) and a once daily dosing schedule is much more convenient for patients. Augmentin can now be taken twice a day, at higher doses, rather than the customary three times a day scheduling. This also provides more convenience for patients, and subsequently greater compliance rates.

Viral versus Bacterial

Distinguishing between a viral versus bacterial etiology for Respiratory Tract Infections can be challenging for both patient and medical provider.

Typically, the signs and symptoms suggestive of a viral cause are: low-grade fever; thin, clear sputum; clear nasal drainage; mild to moderate nasal congestion; scratchy throat with minimal to moderate discomfort; sneezing with post-nasal drip; mild headache with general aches and pains; mild dry cough with minimal chest wall discomfort. Typically, viral infections last 7-10 days. When viral, patients generally start feeling better by the end of the first week.

If, however, the trend is for persistent/worsening symptoms, then a bacterial etiology needs to be considered. Bacterial infections, on the other hand, present with: high fever and chills; more severe pain (ear, sinus pressure, throat); purulent nasal discharge or sputum production; painful throat with significant redness and exudates on the tonsils and posterior pharynx; more pronounced chest wall pain with coughing; chest tightness with difficulty breathing.

Certain patient populations are more susceptible to bacterial infections and include: smokers, advanced age, infants, immunocompromised state (history of HIV/Aids, cancer), those with chronic diseases (diabetes, asthma, chronic obstructive lung disease), and substance abusers. When to seek medical attention It is advisable to seek medical attention whenever symptoms persist or become worse; whenever underlying chronic illness is present; when bacterial infection is suggested; if symptoms persist beyond 7-10 days.

Conclusion

Antibiotic resistance in Respiratory Tract Infections is a concern for the medical practitioner and the patient. With improved prescribing practices, and patient understanding, this potentially serious problem can be prevented. Salient points for the patient to remember are:

• Seek medical attention when necessary.

• Respect the clinical judgement of the practitioner (don’t pressure the clinician to prescribe antibiotics if not clinically indicated).

• Take as prescribed your medication, in particular avoid skipping doses, and finish the treatment as indicated.

• Don’t self medicate. This practice is unsafe since the potential also exists for untoward effects of the medication when taken incorrectly.

Further information

For additional information, please feel free to contact me, Angela, at the Sante Wellness Centre, Day Spa and Retreat, Parrot Tree Plantation, Roatan, Bay Islands, Honduras.

References:

1. Therapeutic Spotlight, Respiratory Tract Infections, Exploring Efficacy Rates and Resistance Patterns, Supplement to Clinician Reviews, February 2002.

2. Lawrence, M., Tierny, Jr., McPhee,S., Papadakis, M. Current Medical Diagnosis and Treatment. Appleton & Lange.

3. Uphold, C., Graham, M. Clinical Guidelines in Family Practice. Barmarrae Books.

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