Wednesday, February 11, 2009

Indonesia must be smarter in handing out antibiotics

Since 1999 I have had the pleasure of collaborating with several schools of medicine in Indonesia in the framework of the Science Program Indonesia Netherlands (SPIN). As a collaborative program shared by the Indonesian and Dutch Academies of Sciences, SPIN aims to improve the role of science in Indonesian society by fostering long-term research and by building scientific expertise for Indonesia.
Together with the Airlangga University in Surabaya and the Diponegoro University in Semarang, we recently concluded a study on the use of antibiotics in Indonesia and the problem of antibiotic resistance. It is now well known antibiotic use has several negative effects. Approximately 10 percent of people given antibiotics will experience some types of side effect, including nausea, dizziness, skin rashes and even shock. Some people die from such complications.

Further, antibiotics create resistant bacteria. And the more antibiotics taken, the greater the risk of building resistance. Bacteria that is resistant to many antibiotics has now emerged worldwide as a consequence of multiple course of antibiotics. Antibiotic resistant bacteria cause infections that are much more difficult to treat; patients may not respond to treatment and can die from such resistant bacteria. In the United States, where many antibiotics are used, multi-resistant strains of Staphylococcus aureus (MRSA) infect and kill 17,500 people every year, and in the United Kingdom these same MRSA cause blood poisoning in approximately 8,000 people every year -- and many die from these infections. Antibiotics are not harmless drugs, they should only be prescribed when a bacterial infection is proven to be present or highly likely to be present. Such problems are particularly high in countries that use too many antibiotics. In our studies, we measured antibiotic use by 4,000 patients and their relatives in Semarang and Surabaya and found that most of the antibiotics were prescribed without proper indication.

Antibiotic use and misuse was particularly high in hospitals where doctors treat many patients without any indication of infection or suspected infection.
Newborn babies are routinely given a cephalosporin antibiotic when born in hospital even though they are perfectly healthy. Also, patients admitted to intensive care units are given antibiotics routinely without any evidence of infection. My fellow Indonesian doctors said they fear infection and so start antibiotics early in the belief this will prevent infections. Also, doctors routinely prescribe antibiotics to patients that clearly suffer from an infection caused by a virus (like dengue or influenza or even the common cold) although they know antibiotics only kill bacteria and not viruses. Again, they seem to think they will prevent bacterial infection in these cases. There is no scientific evidence antibiotics used in this manner will prevent infection. It has been proven too many antibiotics see many patients infected with difficult-totreat bacteria.

During my tour to nine university medical centers in Medan, Padang, Palembang, Jakarta, Bandung, Yogyakarta, Surakarta, Surabaya and Denpasar, I visited many clinical wards of class A and B state hospitals. I discussed patients admitted to these wards with my Indonesian colleagues. It is perhaps not polite to be critical of my hosts but in the large majority of the cases presented to me antibiotics were used irrationally. Most of the time there was no proven infection nor any circumstantial evidence supporting bacterial infection. So, no indication to prescribe an antibiotic at all.

My Indonesian colleagues seem not to be aware of the hazardous consequences of overuse and misuse of antibiotics in their patients. In many cases, patients were treated without proper microbiological diagnosis, so the attending doctor did not really know what the cause of the patient's illness was. He was using antibiotics blindly -- which can be compared to a surgeon performing an operation blindfolded. Also, in many cases that did have an indication for antibiotic use, the choice of antibiotic was wrong. There are many different types of antibiotics and doctors in general have only marginal knowledge about antibiotics.

What are the consequences of antibiotic overuse and resistance? First of all, antibiotics are relatively expensive drugs that constitute a large proportion of the hospital budget. Indonesia has approximately 110 class A and B state hospitals, each with an operational budget of approximately Rp 200 million per year, of which approximately Rp 30 million is spent on antibiotic treatments. The hospitals spend approximately Rp 3.3 trillion on antibiotics alone every year. If doctors would only prescribe antibiotics when indicated, this would easily save the hospitals and the Indonesian government at least Rp 1 trillion annually. Reducing the amount of antibiotics used will also decrease the risk of resistant microorganism from emerging and causing hospital-acquired infections, and, therefore, save many Indonesian lives. How to improve doctors' prescription of antibiotics? First, doctors should be given proper information and support from true experts in the field of infectious diseases -- especially clinical microbiologists and infectious diseases clinicians. They need advice on a daily basis to help them make correct diagnoses of infections and to help them make more rational choices regarding when and how to use antibiotics.

In addition, clinical microbiological diagnostic facilities and expertise should be expanded in these hospitals so that clinical decisions are more often based on laboratory evidence. Finally, Indonesian patients would benefit so much more if in each hospital doctors were willing to follow agreed-to guidelines on how to use antibiotics rationally. These guidelines should, of course, be evidence-based and not dictated by other forces including the pharmaceutical industry. Why not use some of the trillion rupiahs saved to invest in proper training of infectious diseases clinicians and clinical microbiological experts, and to improve the diagnostics facilities for infections in hospitals. In the end, patients' safety will improve, there will be less infections with resistant organisms and the government will save money. The writer chairs the department of medical microbiology and infectious diseases at Erasmus University Medical Center Rotterdam, the Netherlands. He recently completed a 30-day tour lecturing on infectious diseases management at nine Indonesian university medical centers.

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