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Antibiotic Resistance:
Are We Killing the Cures?
by Alexandre Spatuzza
Doctors who want to maintain good patient relations may prescribe antibiotics against their better judgement, particularly when they know that cheaper, often substandard drugs can be easily purchased over the counter. (Photo ©Armando Waak/PAHO) |
The social conditions of patients also contribute to inappropriate prescribing practices. According to Carvalho, many doctors prefer to prescribe wide-spectrum antibiotics for patients they assume cannot wait for a full diagnosis or are unlikely to return because of transportation time or costs. Moreover, many health workers know that if they do not prescribe a drug, the patient will likely resort to self-medication, buying cheaper over-the-counter drugs that are often substandard or insufficient for a complete treatment.
Others say the problems are exacerbated by the absence of national policies on medication for the poor. A 1998 study by Brazil's Ministry of Health showed that the wealthiest 15 percent of the population consumes 48 percent of the medication dispensed from the country's pharmacies, while the 51 percent that earns US$600 a month or less consumes only 16 percent. "This is the bottom line," says Dr. Anibal Sosa, director of APUA's Latin America Initiative. "Access to health care is precarious all over Latin America, forcing people to obtain antibiotics on the streets."
Mr. Francisco Caravante, director of the São Paulo Regional Pharmacy Council, agrees that "the lower-income population doesn't get access to proper medication." This can result from poor prescribing practices, scarcity of supply in government clinics, or lack of funds to buy medication. Whatever the cause, infected patients who are unable to get proper medication are more likely to see their health worsen to the point where they are forced to go to the hospital, where they will be exposed to the hardiest bacteria of all.
A larger problem is that infectious diseases spread more easily anyway in low-income communities-and in developing countries in general-because of their poorer hygienic conditions associated with poverty.
While most Latin American and Caribbean countries have existing legislation to control the sale of medicines, few have adequate means to enforce it. Given other pressing problems, dealing with antibiotic resistance and controlling drug sales have not been top priorities.
Moreover, according to Dr. Clara of Argentina's APUA chapter, "because of the economic problems, nobody wants to face up to pharmaceutical companies and reduce consumption of antibiotics." Doctors who don't have the time to fully inform themselves about new medicines end up using the latest drugs on the market, reducing the effectiveness of older families of antibiotics. "There is no government control, and something that should be a technical choice by the doctor becomes a commercial choice," says Caravante of São Paulo's pharmacy council.
Even if doctors do wish to educate themselves, the differences between resistant microbes in Latin America and North America can mean a lack of information on less-frequently used antimicrobial drugs. "In certain cases, we've had to take forgotten, more toxic antibiotics out of the cupboard to fight these new resistant strains, and there is no literature about their use," says Dr. Helio Sader, head of the clinical microbiology laboratory at the São Paulo Federal University in Brazil.
Such was the case in the fight to control Acinetobacter infections, which occur almost exclusively in hospital patients and which in Brazil were registering 5 percent to 10 percent resistance to antibiotics. In cases in which no other drugs were successful, doctors began to use toxic polymyxins A and E, which can result in kidney failure when administered in high doses.
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