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Too much of a good thing

MagazineJune 1991 (Vol. 2 Issue 3)Too much of a good thing

Antibiotics, the wonder drugs of the Fifties, are responsible for many aillnesses in the Nineties

Antibiotics, the wonder drugs of the Fifties, are responsible for many aillnesses in the Nineties.

I owe my life to antibiotics.In l942, when my mother was 24, her dentist unwisely extracted a tooth while she had the flu. Within days, her neck ballooned with a streptococcus infection, and she was rushed to hospital. My father, then her fiance, wept helplessly at her bedside while priests filed past him after administering last rites.

And then the wonder drug arrived; as a last resort, my mother was given penicillin, still in experimental use then. Within a day or two, the swelling that had almost obscured her face simply melted away. My ordinarily doubting father rushed off to church and humbly knelt before the altar, convinced that he had witnessed a miracle.

In those days, antibiotics were being tested to combat deadly bacterial infections. As a result of the work of Alexander Fleming and others, penicillin began to be used gingerly during the war, against such life threatening illnesses as septicemia, meningitis or pneumonia. There is perhaps no other family of drugs that has so revolutionized health care.

Nevertheless, 50 years on, this century's wonder drug has become one of the most abused substances in modern medicine. What was once reserved for life threatening illnesses like lobar pneumonia is routinely handed out at the surgery for athlete's foot or colds anytime a benign infection is suspected, or even suspected of one day developing. The problem is that up until now, an unnecessary antibiotic was only thought to cause a tummy upset or a reaction in the approximately 5 per cent of those truly allergic to them. But a growing body of opinion believes that repeated courses of antibiotics can so disturb a person's internal ecology that it begins a process of disease that could end in ME or even cancer.

Study after study in the medical literature of the last decade points to massive and incorrect overuse of antibiotics. A l98l audit of antibiotic use in the States, published in the Review of Infectious Diseases, claimed that in half of all cases where antibiotics were prescribed, the medical condition didn't warrant them or the prescribing doctor prescribed the wrong drug, the wrong dosage or duration. In Britain, these prescribing habits were paralleled in two studies published in The Wrong Kind of Medicine? by Charles Medawar, director of consumer organization Social Audit, which showed that antibiotic use in two British and one Scottish hospitals was inappropriate in about two thirds of cases. Similarly, a l988 study of antibiotic use in a paediatric teaching hospital in Kuwait found that of 7l6 prescriptions given to children, about 40 per cent were judged to be inappropriate.

In the overwhelming majority of cases antibiotics are prescribed for conditions they cannot treat. Health writer Geoffrey Cannon, who has investigated antibiotics misuse for his forthcoming book Superbug, says that in 97 per cent of cases, antibiotics are given for ear, nose and throat problems or for what is assumed to be cystitis conditions, in most cases, that don't respond to antibiotics. In the doctor's surgery, reckons allergy specialist Dr John Mansfield, in "three out of four instances", antibiotics are used as "placebos": to "cure" such things as colds. But as any medical student knows, viral infections, the cause of colds and flu, do not respond to antibiotics.

An "unholy alliance" between doctor and patient, claims Mansfield, is at the root of this deliberate misdiagnosis. Even if doctors remember that colds don't respond to antibiotics, this generation of patients has grown accustomed to expecting indeed, demanding the magic bullet approach.

In a shocking number of cases, the doctor himself doesn't know that penicillin won't cure a cold or flu. In the Kuwaiti study, 68 per cent of the mistakes and nearly one quarter of the children were given antibiotics for a respiratory infection. In the States, says the Health Research Group, in l983, "more than 5l per cent of the more than 32 million patients who saw doctors for treatmentof the common cold were unnecessarily given a prescription for an antibiotic."

Besides colds and flu, the next most common use of antibiotics (about a quarter) is for childhood middle ear infections. Although these infections (referred to as otitis media) are usually self resolving, the rationale has always been to use the antibiotics as a just in case measure in case meningitis or mastoiditis develops.

According to an excellent recent issue of The Doctor's People, the Robert Mendelsohn founded newsletter in the States, antibiotic prescriptions to children under l0 more than doubled from l977 to l986, and now account for around half of all antibiotic paediatric prescriptions.

This meteoric rise in prescriptions for ear infections has paralleled a similar rise in the number of cases of ear infections for children under three (more than two thirds of all American children will suffer one or more bouts of middle ear infection). In other words, despite the wholesale attack on these infections with antibiotics, the incidence of them is rising. And one large scale Danish study in l98l failed to show that antibiotics did any good; in another study that same year, almost one third of cases diagnosed as otitis media had no bacteria present.

Anyone doubting that doctors are participating in this "unholy alliance" with childhood ear infections should take a peek at the cover of the l Feb l99l for doctors only MIMS magazine, whose cover line blares out: "Otitis Media: Can You Stop Prescribing for the Mother?"

In the inside pages, one David Grieg, a Taunton GP, writes : " . . . we often need a placebo. Yes, I really do mean need. Any mother who has sat up half the night with a crying child needs something to placate her. Any child whose excruciating earache has caused all this fuss needs a let out. Especially if it magically disappears as they reach the doctor's surgery. Finally the doctor does not want to discourage mothers from bringing children with earache, because it is still likely that a minority can be helped by antibiotics. I have no idea how to identify that minority and I am uncertain as to which antibiotic is most often going to be effective. I still use penicillin but now try hard not to use it except for really florid cases. If in doubt, I do not prescribe."

In other words, he's not sure whether the kid needs a drug or which drug to give him, but he'll give it to calm a hysterical mother or to help the kid save face if he's already got better.

The argument always given in favour of antibiotics for ear infections is, "But suppose it were your child who were screaming and in pain?" But antibiotics are not painkillers. It makes far more sense to give a child in pain a decongestant and a mild pain reliever like child's paracetamol. Or better yet some non drug solution (see box). Geoffrey Cannon and others confirm that meningitis and mastoiditis resulting from otitis media are very rare indeed.

Even if a doctor believes an antibiotic is truly necessary, he usually prescribes it before he knows for sure. In most instances, the GP might take a lab sample of the suspected infection, but he'll also hand the patient a course of antibiotics to start immediately. The patient could be halfway through the course before he discovers he's taken the wrong drug or a drug for no reason.

This makes sense in life threatening cases where a patient might be dead in the 36 or 72 hours required to get results back from the lab, but not with more benign problems, particularly when clinical diagnoses so often are wrong.

In only half of all so called cases of cystitis, for instance, are E coli bacteria, the cause of true cystitis, actually present, says Professor Ian Phillips, a microbiologist at London's St Thomas Hospital.

In most cases when doctors aren't sure which bug they're treating, they'll resort to the scatter gun approach with a broad spectrum antibiotic. Unlike the narrow spectrum variety, broad spectrum antibiotics blast out all manner of bacteria, even the friendly kind. Imipenem, for instance, a recently introduced broad spectrum antibiotic, has been applauded in some medical circles because it kills 98 per cent of all germs that cause infections about twice as many as penicillin does.

Hospitals also tend to overuse antibiotics as a just in case measure for surgical patients "in case" they develop infections during surgery. "For instance, it's known that antibiotics are helpful during surgery of the large bowel to prevent infection," says Phillips.

"This gets extrapolated into completely clean surgery like hysterectomies or appendectomies where there is no clear indication." Hospitals even routinely administer antibiotics to premature newborns, "just in case" they fall prey to bacteria.

Up till now, doctors haven't worried about over prescribing because they figured the drugs do little harm to patients other than perhaps a little tummy upset. Only five per cent of the population was thought to be seriously allergic to penicillin.

But a glance at the British National Formulary reveals many potentially crippling side effects of antibiotics: prolonged use of neomycin to treat liver disease can cause the liver to malfunction: tetracycline can permanently stain a child's teeth yellow; chloromycetin can interfere with the bone marrow's production of red blood cells, and chloramphenicol can cause irreversible, potentially fatal bone marrow depression.

Even more worrisome, repeated courses of antibiotics appear to seriously disturb our immune systems in ways that medicine doesn't yet understand. Geoffrey Cannon refers to the current use of antibiotics as the "Domestos theory of human health if there are bacteria present in the gut then they must be blasted out." Dr Mansfield, who regularly treats immune system disorders like candida albicans, believes that "undoubtedly the most common cause is the broad spectrum antibiotic. Three or four courses can often push a patient over the precipice into chronic illness."

Once the good bacteria in the gut are eliminated, candida or one or another opportunistic yeasts or moulds in the gut can overpopulate. The toxins they send out can inhibit T-lymphocytes, the main search and destroy cell in the immune system. This in turn can weaken the body, he says, leaving it open for more serious problems: gastrointestinal or hormonal disorders, severe allergies, psoriasis or even multiple sclerosis. Many such cases can be treated with dietary and medical management. But even if a patient is lucky enough to find a sympathetic and knowledgeable doctor, there is no guarantee that his immune system won't be permanently damaged.

There are even some speculative arguments that continually stripping off the friendly bacteria and mucosa in the gut could lead to Crohn's disease and irritable bowel syndrome.

We also don't know the long term effects on this generation of children, who receive many courses of antibiotics before they even reach their teens. Sally Bunday, of the Hyperactive Children's Support Group, claims her group sees a definite correlation between antibiotic use and hyperactivity among children a correlation borne out by the findings of American allergist Dr William Crook in Solving the Puzzle of Your Hard to Raise Child (Random House). In Sally's own case, her son was given four years of courses of antibiotics by their GP to cure persistent catarrh. "And he was 5 before we had a decent night's sleep and the problem was diagnosed."

Repeated courses of antibiotics only encourage the development of supergerms in your body which will resist treatment from the antibiotics, so that when you really need the drug, it won't work. Many people feel that repeated courses of antibiotics for, say, middle ear infections, are responsible for the child developing repeated ear infections the same for cystitis. "People so disturb their natural defences that they get on a chemical treadmill," says Geoffrey Cannon. "It ends up that they have to use more and more drugs to keep ahead of infection."

This kind of "transfer resistance" can also affect the population at large, as it has with gonorrhoea and staphylococcus infections. A moderate course of penicillin used to easily cure both diseases. Now it takes two giant doses of penicillin, often in combination with another antibiotic, to do the job. In some parts of Africa, and the Phillipines, penicillin won't work at all.

The February l988 Journal of Hospital Infections reported that resistance rates of staph isolated in hospitals in Athens, where antibiotics are enthusiastically prescribed, had increased in a single year by about 50 per cent with all drugs but penicillin, where resistance was already at 80 per cent.

The problem with wonder drugs is that they breed in the public mind a sense that medicine can and always should work miracles, even with benign problems. What gets forgotten is the price we always pay by tampering so totally with mother nature.

If you are prescribed an antibiotic, spend time discussing with your doctor (presumably a doctor you respect and trust) why he thinks you need it. Unless your situation is life threatening, insist on a test to prove that your problem is bacterial. Again, unless your situation is life threatening, try to let your own body's defence mechanisms wipe out the infection. Many benign infections will clear up by themselves. When my daughter was small, I suffered from a couple of bouts of severe mastitis. I phoned my hospital and convinced my doctor, who usually treats the problem with antibiotics, that I wanted to wait 24 hours to see what happened. During that time (and subsequent ones) I bathed the affected breasts with heat. My daughter, as if sensing my problem, nursed more than usual on the affected breast. A day later I was back to normal.

Antibiotics are life saving drugs. Geoffrey Cannon echoes the view of many that antibiotics should be used once or twice in a lifetime against life threatening illnesses. In my mother's case, the benefits were clearly worth the risks. But I'm part of the antibiotic generation. I'm going to wait until I've got a life saving reason before taking another course of them.

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