Editor-in-Chief
This month the Journal of Antimicrobial Chemotherapy publishes the report of the BSAC Working Party (WP) on Self-medication of Antibacterials without Prescription. Many will find it somewhat surprising reading. The WP concludes that in certain, albeit few, circumstances there would be advantages in allowing selected antibacterial agents to be available to the public over-the-counter (OTC). This runs so counter to the traditional wisdom adhered to and promulgated by the BSAC that members may well ask; "How can the Society's journal publish these suggestions?"
The first thing to stress is that, as the authors of the report acknowledge, the conclusions and opinions expressed are not those of the BSAC but those of the individuals on the WP. Perhaps it is worth outlining the way in which WPs of the Society are constituted and function. At the outset, individuals propose a topic of relevance to the Society's aims and objectives and thought suitable for discussion by a WP. If approved by Council, the WP is formalized, provided with its terms of reference, financed and, in due course, produces its report for Council's consideration. By and large, previous WP reports have been enthusiastically received and endorsed by Council members. It is fair to say that this report proved the exception: indeed there were those on Council who felt that the report was so heretical that it ought to be suppressed.
The major concern was, of course, the impact OTC availability of antibiotics might have on the spread of resistant bacteria. Hardly a week goes by without the media highlighting the problem of multidrug-resistant bacteria and the threat they pose to the management of community and nosocomial infections. The worries have recently been expressed cogently and forcefully by politicians and policy makers from Europe and North America. 1 Central to these concerns is the doctrine that overuse and misuse of antibiotics is a key factor in facilitating emergence of resistance and the corollary that self prescribing plays a dominant role in the equation in the developing world. Experience suggests that the more antimicrobials are used, the faster they are lost to resistance. More prudent use of antimicrobials is thus perceived as one of the few levers that we have to control the problem of increased resistance. OTC availability does not fall in easily with this concept. However much one talks of patient enpowerment and possible lowering of costs, the major reason why pharmaceutical companies want to switch to OTC is to increase sales. Indeed the WP considers that one of the potential benefits of an OTC switch would be "a new marketing opportunity for the pharmaceutical industry". Their premise must be that there are large numbers of persons presently not receiving antibiotics for minor infections of the sort that they consider suitable for OTC therapy. Antibiotic use, therefore, would be bound to increase. Would this all be appropriate?
The problem of present inappropriate and profligate antibiotic prescribing is, of course, extensively addressed by the WP but the conclusions they reach are at variance with those of others. For instance, The Sub-Group on Antimicrobial Resistance of the Standing Medical Advisory Committee (SMAC), which provides expert advice to the UK government, recognized the need for more judicious prescribing in the community and suggested that national guidelines, improved surveillance, better use of laboratories by primary care physicians, and increased education of both health care professionals and the public was the way forward, 2 even though past experience suggests that such approaches have not been very successful. 3,4 On reading the WP report, it is difficult to avoid the simplistic analysis that, faced with the same evidence, the members felt that the misuse of antibiotics by primary care physicians justifies OTC availability on the basis that pharmacists couldn't do any worse! They may be right!
Indeed, it is difficult to fault the logic of this report, which, as one might expect from a group of such distinguished authors, is well argued and articulate. It is perhaps a little repetitive but it is in the detail and the emphasis that some will find fault. The potential benefits of OTC might seem weak when compared with the spectre of resistance. Some will consider it naïve to believe that pharmacists will ask customers to complete questionnaires, quiz them on their answers and decline sales of products if the answers don't fit. How can topical antibiotics be justified: would there not be potential risks of skin sensitization and the selection of resistant staphylococci after topical application of antibiotics to the skin or quinolones to the eye? What will prevent patients using the antibiotics for treatment of an infection for which it is wholly inappropriate (an antibiotic is an antibiotic to most members of the public)? Would such OTC switches be the thin edge of the wedge? When, for instance, a panel of experts in the USA addressed the proposal to switch the oral antiviral acyclovir to OTC use, they considered the most compelling reason for not supporting the proposal was the precedent this might set for other antimicrobials and the resistance to antifungals or antibacterials that might result. 5
At the end of the report the reader may be left wondering what all the fuss is about. The suggestions for OTC switches are extremely limited and it is perhaps unlikely that they would be sufficient to justify the complex measures and infrastructure that the WP consider would be needed to support such an initiative. On the other hand, it is possible that a switch to OTC could provide an opportunity for the education of the public about antibiotic use and misuse of the type that the SMAC advocated. Presumably, pharmaceutical companies would conduct advertising campaigns, which could focus on the infections as well as the therapies and educate consumers and health care professionals alike.
The WP is well aware of the controversial nature of some of their conclusions and the opposition in government quarters to their suggestions. The report of the House of Lords Select Committee, for instance, specifically condemns the OTC use of antimicrobials in Recommendation 11.11: "We commend the Government and the ABPI for their firm stand against over-the-counter antibiotics, and urge them not to give way." 6 It goes further. In a dig at other European states the report recommends that "the Government should engage in active diplomacy to ensure that, should the issue be raised in the EU Council of Ministers, their position is understood and their allies are in place: and, in the long term, to induce those Member States which are currently more relaxed about over-the-counter antibiotics to introduce more controls". 6 The UK Government has accepted these conclusions 7 and, in a debate in the House of Lords in response to the Select Committee report, the committee chairman, Lord Soulsby of Swaffham Prior, stated, "Finally, we are delighted to hear ... that the Government will abide firmly by the principle of no over-the-counter antibiotics." It is likely, therefore, that the conclusions of this report will be ignored, which in many respects, would be a pity. There is much thought and consideration behind them and I believe they deserve publication and discussion, even if only to crystallize one's own prejudices.
Read the report, reach your own conclusions as to the science and logic behind it and, if so moved, correspond with the authors or the Journal. Perhaps the biggest impact of the report will be upon the editor responsible for our correspondence columns!
References
1 . Wood, M. (1998). The politicization of antimicrobial resistance. Current Opinion in Infectious Diseases 11, 64951.[ISI]
2 . Standing Medical Advisory Committee. (1998). The Path Of Least Resistance. Department of Health, London.
3
.
Nyquist, A. C., Gonzales, R., Steiner, J. F. & Sande, M.
A. (1998). Antibiotic prescribing for children with colds, upper respiratory tract
infections and bronchitis. Journal of the American Medical Association 279, 8757.
4
.
Butler, C. C., Rollnick, S., Pill, R., Maggs-Rapport, F. &
Stott, N. (1998). Understanding the culture of prescribing: qualitative study of
general practitioners' and patients' perceptions of antibiotics for sore throats. British Medical Journal 317, 63742.
5 . Sande, M. A., Armstrong, D., Corey, L., Drew, W. L., Gilbert, D., Moellering, R. C., Jr. et al. (1998). Perspectives on switching oral acyclovir from prescription to over-the-counter status: report of a consensus panel. Clinical Infectious Diseases 26, 65963.[ISI][Medline]
6 . House of Lords Select Committee on Science and Technology. Resistance to Antibiotics and Other Antimicrobial Agents. (1998). 7th Report Session 199798. The Stationery Office, London.
7 . Government Response to the House of Lords Select Committee on Science and Technology Report: Resistance to Antibiotics and other Antimicrobial Agents. (1998). The Stationery Office, London.
8 . Resistance to Antibiotics (1998). Hansard col. 1095. 16 November 1998.