Street's Health Discussion. Volume 1 Issue 1

[Street Pharmacist]

I figured I could start a discussion on health topics for everyone as it's my area of passion and there's obviously big things happening with regards to public/private finances, health promotion, vaccines, etc.

My biggest passion is antibiotic resistance, so I figured it’d be a good place to start. This is mainly because I feel as a pharmacist, it's one of the issues most in my control. Here are some basics.

There are many mechanisms that make antibiotics work. For example, they can interfere with cell wall formation rendering bacteria porous which leads to cell death (penicillin), it can also interfere with DNA copying, protein synthesis (Biaxin), and others. Antibiotic resistance develops when bacteria have been subjected to antibiotics either repeatedly, or at sub-therapeutic levels. They then evolve resistance mechanisms due to mutation and natural selection. These mutated genes that code for resistance mechanisms can then be shared between different species of bacteria through a variety of different ways (eg. Plasmids, bacteria having sex). This basically means that just because a type of bacteria has not shown resistance and maybe has not had experience with a type of antibiotic, resistance can still be found in a specimen. These bacteria that evolve to develop resistance mechanisms (eg, developing an enzyme that destroys penicillins, changing the binding site for the drug rendering it useless, etc) then propagate that ability. Resistance is simply evolution. Even in a perfect world where all antibiotics were used appropriately, resistance would develop, albeit slowly. We can, however, modify the course of resistance and buy time until technology can catch up.

There are now many bacteria that have multiple resistance mechanisms (MRSA – Methicillin Resistant Staph. Aureus). In fact, we now actually have drugs that are not sensitive to anything (eg. Some tuberculosis strains, VRSA). Obviously, this is a big concern as it means we may be headed back to an era without antibiotics to save us from simple infections. Already, people are dying in developed nations due to infections that we have no ability to treat properly. Though this is less of a problem here in Canada, it is likely going to get worse. The causes of the growing resistance are many – simple evolution, overuse of antibiotics, inappropriate use of antibiotics, widespread agricultural use, improper disposal of antibiotics, and overuse of "anti-bacterial" washes.

Currently there are many studies looking at better ways to prevent infection (methylene blue+ultraviolet light before surgeries, pre-surgical cleaning procedures, ozonated water,etc). Unfortunately, nothing widely used yet.

Virtually no new antibiotics have been developed in the last decade. Worse still, none are in the pipeline either. This means as more resistance is forming, we have no new weapons to fight them. Resistance to one drug usually means any drug using the same mechanism will likely also be ineffective. This leads to many drugs becoming ineffective as most of the antibiotics we have are in the same classes. For example cloxacillin, amoxicillin and penicillin all have the same mechanism, so if a bacteria it's resistant to one, it likely will be resistant to all.

Many antibiotics are used in feed for livestock to PREVENT infection as it increases overall weight in the herd due to less illness. I do not know the Canadian numbers, but I assume they would be the same as in the US where between 50-70% of all antibiotics consumed are for livestock, almost exclusively added to feed. In fact, the only oral antibiotic we have to treat a really nasty human bug called Pseudomonas aeruginosa is Ciprofloxacin, and 80% of all produced is used in feed. If we lose that drug for Pseudomonas, only IV antibiotics will work. Some sub-species (?) of bacteria found in chickens are now 100% resistant to Cipro (this means 100% of the samples found of this sub-species were found to be resistant). Obviously, this means they can transfer these mutations to human pathogens.

Antibacterial soaps are the devil. Studies have shown that traditional antibacterial soaps are no more effective at preventing infection, and increase resistance rates. Our society is becoming increasing germophobic and ironically, this extreme fear of bacteria may be leading to the development of more pathogens.

In areas where antibiotics are available for self selection, macrolide resistance in some respiratory pathogens is above 90%. Not only does this mean that these bugs can share and make things worse here, but these people can travel and bring these bugs here too.

Some antibiotics breed resistance due to their pharmacokinetics (they way the drug is absorbed, distributed and eliminated in the body). For example, azithromycin has such a long elimination half-life, that sub-therapeutic doses are seen in the body for days after the last dose is taken. Some studies have shown resistance found in almost 50% of S. pneumonia isolates taken 3 months after therapy.

By far though, the most modifiable part of this growing problem, is prescribing; especially in respiratory illness. For those not familiar with respiratory infections, they are mostly either viral or bacterial. Bacteria are treated with antibiotics. Viruses on the other hand, are not alive and cannot be treated by antibiotics.

Many studies have shown the scope of this issue. In my health region, IHA, 70% of patients who received a diagnosis of acute bronchitis received antibiotics. Acute bronchitis is virtually never bacterial, so antibiotics should never be prescribed. Pharyngitis (sore throat) is mostly viral; bacterial "strep throat" can only be diagnosed with a swab. Despite this, many patients received antibiotics and no swab. Acute sinusitis is not often bacterial either (depending on the study, bacterial sinusitis is between 0.5 and 15% of cases), and antibiotics are not recommended. Despite this, the majority of patients received antibiotics. The problem goes beyond simply over prescribing though, as proper selection, duration and dosing are also often improper.

Now, before we blame the doctors, we should look at the patients. In a survey, 80% of patients felt if their respiratory illness was "bad enough" they should get antibiotics. The kicker was that 80% of those who felt that way said they would see another doctor if they didn't get antibiotics. Another exasperating factor is time. With the current fee-for-service model, doctors really are limited in their ability to spend the time explaining this to the patient. Liability concerns are bound to influence prescribing habits as well. The fact that the problem is so large suggests that the pressure is an issue.

What can you do? Ask your doctor if you truly need antibiotics when they are prescribed. Obviously, your doctor will know better than you, so don't argue the point, but explain that you do not expect antibiotics. Understand that severity of illness does not increase the chance you need antibiotics.

Thoughts?

[TheGrimm]

Colloidal Silver?

That should get rid of those pesky infections.

[Street Pharmacist]

Originally Posted by TheGrimm

Colloidal Silver?

That should get rid of those pesky infections.

I have patients accuse me of being a part of a conspiracy to sell antibiotics as cayenne pepper extract is more effective

[AR_Six]

Okay man I get that we're all really twitter obsessed as a society right now but the hashtags in the middle of prose just cannot be tolerated.

[Street Pharmacist]

Originally Posted by AR_Six

Okay man I get that we're all really twitter obsessed as a society right now but the hashtags in the middle of prose just cannot be tolerated.

Sorry, copy and posted from another program. Formatting error

[AR_Six]

I was just kidding. Partly because I just saw a facebook update with like 5 hashtags in it.

[undercoverbrother]

Originally Posted by Street Pharmacist

I have patients accuse me of being a part of a conspiracy to sell antibiotics as cayenne pepper extract is more effective

I have had the vaccination argument with my buddy that is a chiropractor too many times to count.


Thanks for starting this thread.

[Raekwon]

A good example was last year when I had a persistent cold/sinus infection that wouldn't go away, my family doctor just threw antibiotics at me to try and resolve it even though I thought it wasn't the answer.

The funny thing about that was that I had an allergic reaction to the antibiotics and eventually had to take a course of prednisone. 1 year later I go back to the doctor for something unrelated and he still has me prescribed for prednisone. this was him looking at my chart.

"WTF Prednisone, you aren't still taking that are you? We will just take that off of here"

[Ashartus]

While some of the blame for antibiotic overuse belongs with patients, a lot does belong with some (but not all) doctors. My family doctor has never prescribed anything for me. When I go to a walk-in clinic, they've pretty much got the antibiotic prescription ready to go when the doctor comes into the room.

My son had an unusal infection a couple of years ago we couldn't get in to see his family doctor for a couple of weeks. A doctor at a walk-in clinic prescribed antibiotics right away. When that didn't work, he prescribed a different antibiotic. When we finally got in to his family doctor, she sent us to a specialist who right away could tell what it was and that it was not treatable by antiobiotics but rather had to be surgically removed. The walk-in clinic doctors in general just don't seem to be interested in figuring out what the problem is though, they just want to deal with the patient as quickly as possible.

[Raekwon]

Its my understanding that walk-in clinics get paid more per visit if they write a prescription? Can someone clarify?

[Street Pharmacist]

Originally Posted by Raekwon

Its my understanding that walk-in clinics get paid more per visit if they write a prescription? Can someone clarify?

No. They get paid on a fee per service model, so they need to see a lot of patients to make it "worthwhile". They get paid for assessment and procedures, not prescriptions

[undercoverbrother]

Originally Posted by Street Pharmacist

No. They get paid on a fee per service model, so they need to see a lot of patients to make it "worthwhile". They get paid for assessment and procedures, not prescriptions

Is there any incentive to precribe a certain type of drug, ie: name brands vs generic?

[Street Pharmacist]

Originally Posted by undercoverbrother

Is there any incentive to precribe a certain type of drug, ie: name brands vs generic?

No. This would be illegal.

[Mean Mr. Mustard]

I am reading your post and I am coming up with questions on the fly - you mention how "anti-bacterial washes" is leading to an increase in antibiotic resistant organisms. I have never heard of the two being connected - do you have any recommendations for journal articles that would link the two? Does it have to do with people being exposed to fewer bacterium, which results in a less honed immune system, which then results in more rampant infections and the body being unable to fight off the infections as they arise?

I actually love it when people wash their hands with an alcohol based hand wash, especially in a health care setting, and even in the community because with the rise in community based care it really is unknown who in the community does have a compromised immune system. MRSA is absolutely everywhere regardless - and I shudder to think what is on a Safeway carts handles.

[puckluck2]

Originally Posted by Street Pharmacist

No. This would be illegal.

And it happens all the time.

[undercoverbrother]

Originally Posted by puckluck2

And it happens all the time.

please go on

[Mean Mr. Mustard]

Originally Posted by puckluck2

And it happens all the time.

Where did you get your medical license from?

[Flabbibulin]

Street pharmacist, dont mean to change topics entirely, but hope you dont mind me asking a different topic question as my doc recently brought this up with me. what is your opinion on the huge emphasis over the last few years on vitamin D supplementation? Is this just the latest medical industry hype, or are vitamin D levels really as important as they say? From what I can tell, everyone in Canada will be low on vitamin D in winter months, and it seems to be nearly impossible to get to those ideal levels through food and sunshine alone?

[Street Pharmacist]

Originally Posted by Flabbibulin

Street pharmacist, dont mean to change topics entirely, but hope you dont mind me asking a different topic question- what is your opinion on the huge emphasis over the last few years on vitamin D supplementation? Is this just the latest medical industry hype, or are vitamin D levels really as important as they say? From what I can tell, everyone in Canada will be low on vitamin D in winter months, and it seems to be nearly impossible to get to those ideal levels through food and sunshine alone?

Studies on Vit D supplementation for colon and breast cancer are quite convincing. Many pain and rheumatology specialists are increasingly prescribing it, though I personally haven't looked or seen any evidence for it. We do have some evidence for it's use in SAD as well. I can't as of yet see a downside. I take 2000iu daily myself. Benefits>>>>> risks

[puckluck2]

Originally Posted by undercoverbrother

please go on

http://ethicalnag.org/2012/08/13/big-pharma-persuasion/

McGill University’s Dr. Ashley Wazana in Montréal reviewed 29 studies on doctors’ prescribing behaviour in the U.S., Canada, Holland, New Zealand, and Australia.

In his review, Dr. Wazana noted how a number of other persuasive marketing tools in use by drug companies impacted their targets in the medical profession:

free samples, honoraria, and research grants led doctors to be significantly more likely to prescribe that drug;
freebies also led doctors to request the drug for formularies (hospitals’ official lists of drugs that can be prescribed there);
hearing a drug sales rep deliver a presentation led doctors to recommend “inappropriate treatment” more often than other doctors, including treatment that cost more and was more invasive;

medical residents who heard drug reps speak at lunch rounds were more likely to have inaccurate information about drugs on the market;
doctors who “occasionally” attended Pharma-sponsored meals were 2-3 times more likely than other doctors to request that the sponsor’s drug be added to a hospital formulary;

doctors who “often” ate these meals were 14 times more likely to do so;

85% of doctors said they had some interaction with drug reps, with an average of three to four encounters a month;

86% of doctors accepted free drug samples, and half got research grants

two out of five doctors attended company-sponsored meals, and a similar proportion accepted funding for travel or lodging to attend company-hosted conferences