13. 10. 2022
The increasing resistance of bacteria to the effects of antibiotics is responsible for more deaths than traffic accidents. Statistics also say that in 2019, 1.27 million people died worldwide as a result of contracting antibiotic-resistant bacteria. People with associated infections after injuries or heart attacks also die from it. Surveys show that education of the general and professional public can reverse this negative trend.
About a hundred years ago, antibiotics were discovered. They were life-saving drugs. Later, we came to see them as disease-shortening drugs. The layman’s view today is that they help protect our comfort. We have come to think of them as a tool that is available whenever it is – and even when it is not – needed. And that’s the problem. Both overuse and misuse of antibiotics make bacteria more resistant to their effects. And this is not a negligible problem because it affects the whole world. Antibiotic resistance is causing increasing difficulties in treating various types of disease, often resulting in the death of the patient.
“Unfortunately, the situation in the Czech Republic is not ideal. In terms of monitoring the prevalence of resistance in selected bacteria, we are often closer to the countries of Eastern and Southern Europe than to the developed countries of Western or Northern Europe. Even in our country, we are already encountering bacteria that are so resistant that treatment of the infections they cause is difficult or even impossible. I believe that we should take inspiration from the Scandinavian countries in particular, where the situation is significantly better thanks to a very good antibiotic policy,” explains Milan Trojánek, MD, PhD, Head of the Department of Infectious Diseases and Travel Medicine at the University Hospital in Motol.
Infections caused by resistant bacteria are difficult to treat. Antibiotic resistance leads to longer hospital stays, increased risk of patient death and higher treatment costs.
We use mostly inappropriate broad-spectrum antibiotics
One of the factors that contribute to the development of antibiotic resistance is the use of broad-spectrum antibiotics. For common and usually minor infections, it is advisable to use antibiotics with the narrowest possible spectrum of action. This is to target the most likely or proven infectious agents and to protect the natural microflora of the human body.
“There are no antibiotics like antibiotics. They differ, for example, in the quantity and quality of adverse effects, have different mechanisms of action and therefore a different spectrum of efficacy. Even their therapeutic effect occurs at different times. We often have a choice of several options. But it is certainly not true that the best antibiotic is the one that works on the most bacteria and is taken as little as possible in a day to be convenient. On the contrary, this ‘cannon fodder’ approach is one of the causes of our current troubles. Moreover, a large proportion of common infections are viral in origin and antibiotics are of no use for them. However, even some bacterial infections, such as bronchitis or some intestinal infections, do not need to be treated with antibiotics; the body can cope with them just as well. Antibiotics should rather be a scalpel, which is used to solve problems that cannot be solved otherwise,” says Jan Strojil, MD, PhD, physician and clinical pharmacologist at the Olomouc University Hospital.
Trends and quality of antibiotic prescription are monitored by the portal of quality indicators of health services covered by health insurance. One of the indicators monitored is the ratio of prescriptions with narrow-spectrum penicillin antibiotic prescriptions to the total number of prescriptions with antibiotic prescriptions. The lower threshold is defined at 11%.
“Current data indicates that the national average is 7.14%, which unfortunately falls far short of the minimum threshold of 11%. The worst performing regions are Moravian-Silesian (only 5.14%!), Zlín, Olomouc and Hradec Kralove, where the most unwanted broad-spectrum antibiotics are prescribed. The Vysočina region is the best (11.72%) followed by the Pilsen region (9.73%). The attached table shows that the tendency to prescribe narrow-spectrum antibiotics is unfortunately decreasing everywhere,” continues J. Strojil.
The solution is also to shorten antibiotic treatment
An effective tool that can lead to a reduction in the incidence of resistant bacteria is to shorten the length of antibiotic therapy for certain infections, taking inspiration from northern and western Europe.
“More and more studies are showing that we can reduce the length of antibiotic treatment for more common infections, such as urinary or respiratory infections. It is also important to eliminate the prescription of less appropriate antibiotics, including the so-called three-day antibiotics, which have many negative characteristics and also induce resistance to a large extent. They are particularly overused in respiratory infections. Our aim is to increase the use of lower-risk and more environmentally friendly antibiotics, including, for example, common penicillin or antibiotics of the penicillin series,” adds M. Trojánek.
What helps doctors decide on antibiotic therapy?
Most antibiotics are prescribed by primary care physicians. They have several methods and tools at their disposal when deciding whether to start antibiotic therapy, and in many situations, antibiotic deployment is not necessary. Most respiratory infections are viral in origin and are so-called self-limiting.
“My diagnosis is based primarily on the clinical examination of the patient in the office, knowledge of their chronic diseases, general health, temporal context and epidemiological situation. We have point-of-care methods available, the result of which is available within 15 minutes, such as CRP determination, streptococcal antigen test, SARS-CoV-2 antigen test, as well as the possibility of laboratory testing. However, all these methods are auxiliary and the conclusion is not always unambiguous, a comprehensive assessment and communication with the patient is important,” says general practitioner Ludmila Bezdíčková.
The decision-making process of whether or not to prescribe antibiotics, or which ones to choose, how to dose them and how long to take them, has been facilitated for a few months now by clinical recommendations on the Antibiotic Resistance.cz project website. Doctors are also newly helped by the tool for monitoring antibiotic prescription created by the Health Insurance Office. For the first time, adult and paediatric practitioners can compare their practice not only with the recommended thresholds but also with aggregate reference values in their region and across the country.
Looking forward to better times? Czechs have a better understanding of antibiotics
By 2020, the Czech Republic has seen a decline in resistance for almost all hospital pathogens. Ironically, the COVID-19 pandemic may be the explanation, as contact between populations and thus the spread of viruses and bacteria has been reduced. However, effective prevention of the emergence and spread of resistant bacteria lies rather in the education of the population, which is the aim of the Antibiotic Resistance.cz project.
“Several worrying facts emerged from the surveys we conducted before the launch of the awareness campaign. I would mention the two most important ones. Almost 18% of the respondents took antibiotics without consulting a doctor and 37% of the respondents mistakenly believed that antibiotics can speed up the treatment of colds. We checked the knowledge of the Czechs with another survey 7 months later, after the end of the first phase of the campaign, and the results showed a noticeable improvement. We believe that we will be able to reduce the prescription of antibiotics at least as much as in France, where thanks to the awareness campaign it was reduced by a quarter,” mentions doc. MUDr. Helena Žemličková, Ph.D., head of the National Reference Laboratory for Antibiotics of the National Institute of Health and the expert guarantor of the Antibiotic Resistance.cz project.
The second part of the survey monitoring the knowledge of Czechs in the use of antibiotics, conducted by Remmark and Engage Hill, revealed, among others, that 82% of people in the Czech Republic already know that antibiotics do not cure viruses.
“We are honoured that as the State Institute of Health we have the opportunity to sponsor interdisciplinary activities aimed at improving the situation with antibiotic resistance in the Czech Republic and at raising people’s awareness of the existence and severity of the problem. We are addressing the issue not only within the framework of this project, but also in the long term, through the cooperation of all actors within the Ministry of Health and inter-ministerial cooperation on the implementation of the Action Plan of the National Antibiotic Programme,” adds Barbora Macková, M.D., Director of the National Health Institute and Chair of the Central Coordination Group of the National Antibiotic Programme (CKS NAP).
The State Institute of Health is the implementer of the project Prevention of Antibiotic Resistance. The project Prevention of Antibiotic Resistance (ZD-PDP2-001) was supported by a grant from the EEA Grants 2014-2021 under the Health Programme. www.eeagrants.cz