Volume 1

Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology.

  • Great Britain. Parliament. House of Lords. Science and Technology Committee.
Date:
1998
Catalogue details

Licence: Open Government Licence

Credit: Resistance to antibiotics and other antimicrobial agents / Select Committee on Science and Technology. Source: Wellcome Collection.

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    68. Dr Avorn of Harvard Medical School has also worked on education for prudent use. His approach is modelled on that of the pharmaceutical industry, and not unlike that of Dr Schwartz. He began with focus groups of physicians. These revealed two groups of doctors: some who overprescribe out of ignorance; and others who consciously overprescribe in order to satisfy their patients. For the second group, like Dr Schwartz, he provides “paper placebos”. For the first, he sends out “academic detailmen’”: pharmacists from the medical schoo] who meet physicians one-to- one, on the same basis as salesmen, to talk about prudent prescribing. He has shown that every $1 spent on these actions saves $2 on the drugs bill. His approach has been taken up in various places around the USA; similar approaches have been tried in various parts of the UK, and adopted nationwide in Australia. He acknowledged that some doctors require to be persuaded that prudent use 1S not just a euphemism for cutting costs at the expense of patient care. 69. Asa location for education of patients, Dr Avorn commended schools; so did Dr Levy. The Alliance for the Prudent Use of Antibiotics, which was set up in 1981 and now has members in 92 countries including a few in the UK, has produced material for schools. APUA also produces patient leaflets, issues a newsletter and organises conferences. It encountered initial hostility from the pharmaceutical industry, but this is wearing off. 70. The people we met over lunch in Boston disagreed as to the appropriate level of coercion. Dr Gorbach favours control, e.g. by requiring that every prescription for a drug associated with a resistance problem be accompanied by a “chit” giving the reason for prescribing. Dr Medeiros considers that this would restrict professional freedom to a degree unacceptable in the USA; he believes that, if surveillance 1s thorough and its findings are properly communicated, doctors will moderate their practice voluntarily. Dr Bennish inclines towards Dr Gorbach’s position; he considers that Dr Medeiros underestimates the power of pharmaceutical advertising, and he would like to see such advertising controlled. Length of course 71. We put it to the FDA that their policy encouraged pharmaceutical companies to specify longer courses of antibiotics than were necessary, thereby adding to the general antibiotic load. Dr Goldberger replied that the FDA has no policy on length of courses; it relies on the manufacturer to decide what length to use for the trials leading up to licensing, and licenses the the drug on that basis. Under pressure from managed care (see below) to reduce costs, manufacturers are beginning to try shorter courses as a way to gain market advantage; the FDA requires to be convinced in each case that the short course is at least as effective as the longer one. Dr Siegfried of PARMA commented that the manufacturer’s view of the ideal length of treatment often changes once a drug reaches the market. Antibiotics in old people’s homes 72. Nursing homes are big business in the USA, as in the UK. People at the Institute of Medicine said that they were under-regulated. Dr Siegfried at PhaARMA drew attention to an invisible form of “drug abuse”: informal and inappropriate pill-sharing by old people. ICARE staff at CDC told us of a case where the main source of resistant infections in a hospital turned out to be a nearby nursing home. Antibiotics for export 73. We asked the FDA about regulation of antibiotics manufactured for export. Antibiotics manufactured in the USA for export to a country with lower standards are not required to meet the high standards set by the FDA for drugs intended for use by Americans. However drugs may not be exported which have passed their “sell-by” date. Antibiotics in farming 74. “Antibiotic resistance 1s our most important issue just now,” said Dr Stephen Sundlof, Director of the FDA Center for Veterinary Medicine; and its importance in the context of farming is recognised by politicians and the press. 75. The flashpoint is the fluoroquinolones. In 1995 the FDA approved the prescription of sarafloxacin for the prevention of pneumonia in poultry, subject to resistance monitoring up and down the food chain. There was apparently some ambiguity in this decision: Dr Levy, who was involved, was left with the impression that approval would be provisional, but it turned out not to