Keep our antibiotics working – appropriate prescriptions matter this flu season

In March 2019, researchers from the Wits University School of Public Health and the London School of Economics, jointly reported on the results of a new study which investigated unnecessary antibiotic prescribing in primary health care in South Africa. The study found, worryingly, that 78% of patients sent to a public clinic and 67% of patients sent to a private general practitioner (GP) received antibiotics - even though antibiotics were not clinically indicated for these patients.

The Wits study highlighted that previous research in South Africa has focused on antibiotic use in hospitals. However, there is a need to look at primary care, because data from other countries showed that the majority of antibiotics are usually prescribed in primary care. "Respiratory tract infections (RTIs) such as the common cold and acute bronchitis are one of the main problem areas because primary care providers prescribe antibiotics for these infections even though they are caused by viruses rather than bacteria," the researchers report.

The Wits study is one of the first to document the extent of antibiotic prescribing for RTIs in primary healthcare, in the country. Researchers found that: "The very high rates of antibiotic use by both public nurses and private GPs are a concern." There were, "some significant gaps in the knowledge of providers, particularly in relation to the recommended management of acute bronchitis." The simple knowledge that antibiotics were not recommended for treating acute bronchitis meant healthcare practitioners were less likely to have prescribed an antibiotic.

Antibiotics are very important and have served as a cornerstone of modern medicine. But the persistent overuse and misuse of antibiotics in human and animal health has led to widespread resistance to these medicines, rending many of our best antibiotics useless - with very few new antibiotics on the market to replace them," says Dr Roshini Moodley Naidoo, Head of Risk Management and Quality of Care at Discovery Health.

"Misuse of antibiotics allows the bacteria that cause illness to become resistant to the antibiotic drugs used to treat them. By misuse, I mean cases where antibiotics are dispensed to people with viral infections like colds and flu - as happens every flu season. It also happens when they are given as growth promoters in animals or used to prevent diseases in healthy animals."

The link between unnecessary antibiotic prescribing and the development of Antibiotic Resistance (ABR) is well documented, and ABR has now reached critical status in South Africa and the rest of the world, making common infections much more difficult to treat. The country’s high burden of infectious diseases combined with the highest rates of ABR in the world are a ticking time bomb. This trajectory means that routinely treating wounds and performing Caesarean sections could cease because there would be no defense against infection, as bacteria becomes resistant to antibiotics. But you as a medical practitioner know this. Here’s what to do about it.

Vaccination - patients' and providers' best protection against the flu

"Vaccination against influenza should be patients’ first defense against the virus – not antibiotics," says Dr Noluthando Nematswerani, Head of the Centre for Clinical Policy at Discovery Health.

"All of us are advised to get vaccinated as soon as possible, to drop our risk of catching influenza. High risk members and their families are priority on the list of who should be vaccinated - and this should happen before the start of the influenza season." Healthcare practitioners and workers fall under this high risk group due to their daily exposure to sick people.

Published evidence shows that the influenza vaccine is 60% effective in preventing related hospitalisations, and up to 89% effective in preventing particularly severe cases of influenza.

"Discovery Health encourages practitioners to explain the need for an annual flu vaccine to patients, especially to high risk members and their families, going a long way to keeping your patients healthy and saving lives," says Dr Moodley Naidoo.

The National Institute of Communicable Diseases (NICD) and the World Health Organization (WHO) recommend that people older than 65 years and those with certain chronic medical conditions have a seasonal flu vaccination.

Discovery Health defines high risk members as those who are 65 years or older, pregnant or who are registered on the Chronic Illness Benefit for one of the following chronic conditions:

• Asthma
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disease
• Chronic renal disease
• Coronary artery disease
• Diabetes (types 1 and 2)
• HIV

"The viruses that cause this illness are anything but predictable, and it's up to primary care healthcare practitioners to advise high risk members in particular of the need for vaccination each year, to keep up with latest flu strains" says Dr Nematswerani. "While flu causes mild illness in most people, it can cause severe and life-threatening illness in more vulnerable groups who might see their flu develop into bronchitis or pneumonia or other such complications,” explains Dr Nematswerani. "Otherwise healthy people will recover from the flu in a week or two. But those more vulnerable to flu could be sick for an extended period, require hospitalisation or even die."

Patience in the face of patient demands

Dr Dena van den Bergh, Honorary Lecturer at the Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape town, adds: "Our studies have shown that 76% of private sector patients mistakenly think that ABR refers to the human body becoming resistant to antibiotics, not understating that it's in fact the bacteria that cause illness, that become resistant. We also found 32% of patients went to the doctor specifically to obtain an antibiotic – before they even knew that they had a bacterial infection. And, 43% of patients thought new antibiotics would be discovered soon, so even if we overuse the ones we have now, they will be replaced. That's a very alarming and incorrect perception – especially as we approach the 2019 flu season."

Another fascinating study published in Sept 2018, by the University of Cape Town, surveyed a sample of 264 South African primary care providers - like GPs - and found that 96% believed resistance to antibiotics was a huge problem and that these drugs are overused. Yet, 67% felt pressure from their patients to prescribe antibiotics - to meet a patient’s expectations, even when these drugs are unnecessary, to maintain a good relationship with patients, prevent malpractice claims or because a doctor suspects there could be a bacterial infection without being sure. Doctors with greater awareness of the harm that incorrect use of antibiotics can cause, went to greater lengths to explain this to patients.

Dr Moodley Naidoo adds, "It is fundamental that South Africans understand when an antibiotic is really necessary to take, if it is necessary, and how it should be taken. It's no longer simply a case of patients taking antibiotics and hoping for the best. The survival of the human race depends on our understanding when and where antibiotics are appropriate - and that they cannot treat the flu and other viral infections."

The Discovery Health Medical Scheme is an independent non-profit entity governed by the Medical Schemes Act, and regulated by the Council for Medical Schemes. It is administered by a separate company, Discovery Health (Pty) Ltd, an authorised financial services provider.