Université Lille II & Fédération de Maladies Infectieuses et Réanimation, Centre Hospitalier, 59208 Tourcoing, France
Sir,
We read with interest the report of the BSAC Working Party (WP) on self-medication of antibacterials without prescription.1
The WP thoroughly analysed the probable benefits and drawbacks of self-medication. However, despite far more numerous and severe drawbacks than advantages, it chose to advocate the availability, without prescription, of some topical and oral agents. We realize that this report is primarily a British issue; however, as noted by the WP, it could have applications within the other members of the European Union (EU). The introduction of a European Marketing Authorization, replacing national authorizations, is the perfect example of the growing intricacy of health policies within EU states. Thus, we wonder if the decision to move antimicrobials to self-medication status can still be taken at a national level, especially in view of the antimicrobial resistance issue. We strongly disagree with self-medication of antibacterials and wish to emphasize a few points that, though addressed in the WP report and the accompanying editorial,2 need to be stressed.
Antibiotic efficacy is not always predictable, based on clinical signs. The antibiotic prescription decision process integrates clinical signs, previous experience of the physician, recent resistance data and other factors. It is unlikely that the average individual patient will be able to acquire sufficient knowledge to make proper use of antibiotics. Similarly, we wonder about the proposed switch of counselling and decision-making to pharmacists. We believe it is a medical process requiring specific training and knowledge. Particularly, we feel that medical advice is necessary to warn about signs of upper urinary tract infections which could be masked if the patient, besides self-prescribed antibiotics, also took antipyretic agents. Similarly, we fear a risk of increasing the number of cases of necrotizing fasciitis in patients using self-medicated non-steroidal anti-inflammatory drugs, while treating this infection with a topical agent. Many patients do not realize that the word antibiotic includes many different drugs with various targets and indications. There is a risk that patients will use the self-medication antibiotic for any symptoms they think require antibiotic use. The WP cites the antecedent of self-prescribing for vaginal candidosis and herpes labialis. However, we believe these situations to be different from bacterial infections. Except in specific populations, resistance to antifungals or antivirals is not an issue, in contrast to urinary tract infections for instance. Furthermore, few therapeutic agents are licensed for these indications and most have a similar spectrum, minimizing the risk of error.
In our opinion, the issue of bacterial resistance has been underestimated by the WP. Most of the discussion focused on short-course or single-dose therapy for urinary tract infections. While we agree that the impact on resistance would be limited for agents with no or little systemic concentration, we do not think it is the case for other agents, particularly fluoroquinolones. With regard to skin infections, most can be cured with antiseptics and disinfectants, without the need for antibiotics. We are particularly concerned about the risk of selecting Staphylococcus aureus strains resistant to fusidic acid, rifampicin and other drugs used in the treatment of staphylococcal infections, including MRSA. We also believe that large media campaigns will result in a huge increase in antibiotic sales, far outweighting the expected benefit resulting from a reduction of long antibiotic courses prescribed by physicians. Furthermore, when most agencies and governments choose, at last, to aggressively target antibiotic consumption, both in human and animal use, the availability of antibiotics through self-medication would send contradictory and confusing messages to the public. Among the supposed benefits of self-medication, the WP cites the difficulties in getting healthcare during weekends. While this may be true in the UK, it is not the case in most other countries of the EU. In France for example, general practitioners organize a duty roll, including house visits, 24 h a day in most districts.
In conclusion, we believe that antibiotics should remain prescription drugs. Furthermore, we believe the selfmedication status of some antifungal and antiviral drugs should be re-evaluated if new data in the future shows an increase of resistant microorganisms.
Notes
* Corresponding author. Tel: +33-3-20-69-44-30; Fax: +33-3-20-69-44-39; E-mail: alfandari{at}nordnet.fr
References
1
.
Reeves, D. S., Finch, R. G., Bax, R. P., Davey, P. G., Van Po, A. L., Lingam, G. et al. (1999). Self-medication of antibacterials without prescription (also called over-the-counter use). A report of a Working Party of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 44, 16377.
2
.
Wood, M. J. (1999). Over-the-counter antibiotics. Journal of Antimicrobial Chemotherapy 44, 14950.