Volume 1

Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology.

  • Great Britain. Parliament. House of Lords. Science and Technology Committee.
Date:
1998
Catalogue details

Licence: Open Government Licence

Credit: Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology. Source: Wellcome Collection.

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    eee EEeEEEEEESSSSSSFSSSFSFFsese CHAPTER 2 PRUDENT USE IN HUMAN MEDICINE 2.1 The evidence set out above suggests that one way to tackle drug resistance in the short term is to work towards appropriate and prudent usage of the drugs themselves. In the longer term there may be new drugs and vaccines (see Chapters 6 and 7); but every doctor, dentist and veterinary surgeon can, it seems, affect the situation for better or worse from day to day by more or less appropriate prescribing. 2.2 It must be recognised at once that, even without the issue of resistance, use of medicines is a three-cornered battlefield. Doctors want the freedom to do the best for their patients; those who pay for health care, whether governments or insurers or the patients themselves, want good care at low cost; and pharmaceutical manufacturers want to maximise the return to their shareholders. Discussion of the impact of usage on resistance cannot be divorced from this context. Present use in the United Kingdom 2.3. Inthe United Kingdom, most antimicrobials used in human medicine are prescribed by GPs (general practitioners, or family doctors). The Association of Medical Microbiologists (AMM - QQ 45-52, p 9) told us that in England alone, GPs prescribe 270m defined daily doses each year—*“enough antibiotics to treat every man, woman and child in England for five days a year”. This is much more than is administered in hospitals (though data do not permit a precise comparison, and even if they did one would not be comparing like with like). This figure is derived from Prescription Pricing Authority (PPA) data for 1992-94; the same data show an annual increase in prescribing of 5 per cent over the previous three years, with no simultaneous increase in infectious disease to explain it. They also show atendency to prescribe newer drugs instead of older ones. However the AMM believe around 80 per cent of antimicrobial prescribing in United Kingdom general practice to be “fully justified” (Q 45). 2.4 The Association of the British Pharmaceutical Industry (ABPID) gave us a different set of figures. In 1996, United Kingdom GPs wrote 51m antibiotic prescriptions, which, though a lot, was 2.5m fewer than the previous year. They conclude, “The message about not prescribing antibiotics in diseases that are probably viral appears to be getting through” (p 177). 2.5 The Department of Health produce yet more figures, and analyse them in detail (p 343). Between 1991 and 1996 in England, the number of prescription items for antibacterials increased by only 7 per cent, and the net ingredient cost by only 4 per cent, both much less than the figures for all drugs; between 1995 and 1996 both figures went down, as noted by the ABPI. However there were wide variations from drug to drug. The group which gives “most cause for concern” is the fluoroquinolones: over the five years, use rose by 48 per cent, and cost by 81 per cent. “Ciprofloxacin is the market leader in a group of drugs which is heavily promoted”. Use of penicillins rose by 13 per cent; the Department find this “disappointing”, though they suggest possible innocent explanations.'* Use of macrolides rose only marginally, but their cost rose by 58 per cent, probably because erythromycin, the original macrolide, lost market share to newer and more expensive macrolides with additional applications (e.g. azithromycin). “The newer macrolides are heavily promoted”. The Department produce further figures to show that antibiotic prescribing varies widely between health authorities. 2.6 From his experience in Oxfordshire, Dr Richard Mayon-White, a Consultant in Communicable Disease Control, considers the antibiotic prescribing of United Kingdom GPs to be “conservative” (p 110). However local monitoring has revealed “wide variations” in prescribing of expensive drugs such as ciprofloxacin. Dr Hugh McGavock, Director of the Drug Utilisation Research Unit at The Queen’s University of Belfast, detects a bell-curve (Q 660): “some doctors 'S What we have to say about doctors should be taken to apply mutatis mutandis to dentists. Veterinary practice is discussed separately in the next chapter. Demographic factors, or an increase in repeat treatments due to rising resistance.