Antibiotic only kills bacteria.

Killing bacteria might result in a cure, or expedited recovery, or help an injury recover: but the antibiotic only kills bacteria or in some cases, cause horrible side effects. This might be rather obvious to some of you, but believe me there are some strange beliefs out there. When I first started work in a hospital in Uganda, an injection of streptomycin and penicillin was given to every patient after surgery “to make the wound heal”. When I didn’t prescribe the magic needle, the patients begged the nurse for the injection that healed the scar, fully convinced that if they didn’t get it, then when the sutures were removed the wound would burst.

I have heard tourists asking for antibiotics for coughs, I have seen pharmacists give Amoxyl syrup as cough syrup. I have seen people with twisted ankles given antibiotics: it’s hot painful and swollen it must be an infection, right?

This is not a third-world problem.

Not long ago an official health spokesman for the E.U. said that 80% of prescriptions for antibiotics in the E.U. for respiratory infections were not necessary. There was a long discussion on an international medical education site asking why doctors in USA prescribed azythromycin for upper respiratory tract infections: basically, for viral common colds. They said that patients demanded their “z-pac”. It was advertised direct to the consumer for “respiratory infections” with claims that most respiratory organisms were resistant to other antibiotics: actually true of course, because no antibiotic is of any use in a viral infection. If the doctors didn’t prescribe it, they went to another doctor who would, and then complained to the insurance. Those complaints meant the doctors lost customers. The result is that the best, realistically the only effective, treatment for dysentery, cholera, typhoid and some std’s is now facing increasing antibiotic resistance because it’s prescribed for coughs and sore throats.

So, when are antibiotics needed?

Katyama syndrome or conversion fever. After wriggling through the skin the cercaria lose their tail and become schistosomules. Somehow they get to the liver, and the boys and girls meet. No one knows how. One theory is they whistle and burp. Or they meet in intrahepatic discotheques. That’s why the Nile river rafting guides hold parties that play very loud music after rafting, in an attempt to confuse the schistosomes and prevent them meeting. They spend 3 to 6 weeks in the liver, they grow to about 2 cms long. The male has muscles (don’t we all?) the female is just a long egg laying tube (no comment). He wraps himself round his lady and they spend the next 15 years in permanent copulation. No wonder we feel tired.

Across Europe there are big differences in the rate of prescriptions, the Dutch prescribe the least and some of the southern countries the most. If the Dutch prescribe 4 x fewer antibiotics than the Italians do, does that mean that thousands of Dutch die from untreated infections? Or does it mean the Spanish are swallowing a lot of unnecessary antibiotics? In Kampala a few years ago before I retired, a colleague doing research in this area told me that in Uganda country wide on average 80% o of patients got a prescription for antibiotics. So, I looked at our practice in The Surgery. Our rate was 20% if we included Aminosidine for amoeba. If we excluded Aminosidine it was about 8%. Personally, I had a tooth infection a few years back and I took a course of penicillin V. It was my only antibiotic apart from Aminosidine for giardia for about 20 years.

Antibiotics can even make infections worse.

They kill bacteria. If you have a viral respiratory infection, your throat is red and sore with damaged cells and increased mucous. Mucous is an excellent growth medium for some bacteria. The bacteria that live in your throat, the harmless commensals on the surface that cannot replicate and invade any further because you are immune to them, will grow in that mucous. A swab will detect them. They are probably resistant to most penicillin’s, hence the adverts that claim to prove that most upper respiratory bacteria are resistant to common antibiotics: So you need z-pack. These commensal bacteria are not only harmless they are beneficial. Many bacteria practice ethnic cleansing, they don’t let other bacteria grow in their backyard. Some actually produce a substance that kills other bacteria, essentially an antibiotic. If you kill the commensals something more virulent, invasive and immune resistant might grow in its place. Vacuums are filled, there are no microorganism deserts on our surfaces. If you have a viral infection, it’s best to keep your commensals. In the same way our intestines are teeming with bacteria: almost all of them harmless or beneficial. And we all know about lactobacillus keeping the vagina free from unpleasant infections. We are colonised or infected with countless bacteria that we should not disturb or try and eradicate. An antibiotic is indiscriminate, rather like using a flame thrower in a farm yard to get rid of ants. It works but kills the chickens so you get a plague of cockroaches instead. Learn to live in peace with our microbes: don’t disturb them then they don’t disturb us.

So how do you know if an antibiotic is essential or unnecessary?

Realistically only by proper training, experience and a commitment to a low antibiotic prescribing practice. When essential, using narrow spectrum drugs that target specifically the harmful bacteria you want to kill. Of course, it’s primarily a problem for the medical profession, but society can help. Can you influence prescribing? Yes. See my first story. US doctors admitted to giving in to patients’ demands. It’s no different in other countries, so don’t demand an antibiotic. If you are prescribed one and you don’t think you need one then ask why?

Lastly beware of Doctors who simply want to impress by prescribing exotic, expensive unavailable drugs to make themselves look important. When an antibiotic is prescribed the simplest, cheapest most available drug might be the most appropriate. Example penicillin is still the most appropriate drug for most bacterial sore throats, the streptococcus is still sensitive to penicillin and is the most likely bacteria to cause severe disease or complications. A report on urine cultures across Europe showed nitrofurantoin top of the table for least likely that the infection was resistant. I remember a lady deciding to see a surgeon for a urine infection and getting a prescription for intravenous gentamicin. I refused to dispense or provide it: suggested she go back to the doctor who prescribed it. Surely if it was so important for her life that she got that drug I’m sure he would open his office twice a day over the weekend to give it.