Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 7, Number 1, 2002

Losing the battle?

Pharmacies in many Latin American and Caribbean countries dispense antibiotics to their costumers with or without a physician's prescription.   (Photo ©Armando Waak/PAHO)

In São Paulo's Children's Institute, one of Brazil's top pediatric hospitals, Dr. Alfio Rossi Jr., chief of the hospital infection control center, says he sometimes feels he is losing the battle against the bugs. Rossi has seen some microbes attain resistance of 60 percent to frontline antibiotics, despite his efforts to introduce special practices for keeping infections isolated.

"My impression is that resistant strains and the spread of infection are increasing," he says, citing as culprits the lack of national control policies, poor antiseptic conditions, badly trained or overworked health care workers, and a popular culture of freewheeling antibiotic use. Despite strict controls on the administration of drugs in his own wards, he frequently finds his staff treating patients who have already consumed antibiotics in other hospitals and are now serving as hosts to resistant strains.

In one of the few studies of antibiotic resistance in healthy children in a developing country, Dr. Alessandro Bartoloni found an alarmingly high level of antibiotic resistance of the common E. coli bacteria in healthy Bolivian children. What he discovered while looking for causes for this resistance was equally compelling. Sending out teams of consumers with fabricated symptoms to assess the practices of pharmacies in one community, he found that "over two-thirds of pharmacies dispensed antimicrobials without a medical prescription, and the quantity dispensed varied according to the patient's ability to pay." The pharmacies gave antibiotics inappropriately for 92 percent of adults and 40 percent of children with "watery diarrhea but no fever," indicating an absence of infection. Sixty percent gave antidiarrheal drugs to children, although none gave oral rehydration salts, the medically preferred treatment. All of the local pharmacies dispensed enough antibiotics for only two days or less, even though the recommended therapy ranged from one to five days.

Such results do not surprise Dr. Liliana Clara, an infectious disease specialist at Buenos Aires' Italian Hospital and head of the Argentine chapter of the international Alliance for the Prudent Use of Antibiotics (APUA). She often sees parents medicating children with antibiotics for virally induced runny noses or diarrhea. "There's been a law to control sales since the 1960s, but nobody cares," she says, but is quick to add: "On the one hand, people think doctors are useless, and on the other, doctors are prescribing wrongly."

A recent survey by the Brazilian Federal Council of Physicians suggests that part of the problem does lie with health professionals themselves, largely as a result of the conditions under which they work. Brazil has an estimated 183,000 doctors, one for every 1,000 inhabitants. But some 65 percent are concentrated in cities, and about 60 percent work for the private sector, creating shortages in overcrowded government hospitals. Because of low salaries (an average of US$1,300 monthly), one out of four Brazilian doctors works three jobs or more. Nursing staff have similar work patterns, increasing the possibility of transferring resistant strains from one hospital to another. "The bad conditions result in low-quality services," says Dr. Regina Parizi Carvalho, president of the São Paulo Regional Council of Physicians, pointing out that doctors in Brazil examine an average of 16 patients per shift.

Continue