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December 30, 2002
Combating
antibiotic resistance: Medicine enlists community
awareness
There have been clear warning signs of a crisis ahead
in combating infection. For almost a decade, high
rates of antibiotic use have paralleled reports of
emerging antimicrobial resistance.
As recently as October, a Centers for Disease Control
and Prevention communiqué detailed a case of vancomycin-resistant
Staphylococcus aureus in Pennsylvania. A similar
case earlier this year in Michigan also proved resistant
to vancomycin, the drug of last resort for many infections.
If this weren't enough, additional data indicate
growing resistance to another high-tier infection
fighter, ciproflaxin. Among other trouble signs is
that Streptococcus pneumoniae bacteria are
now more than 35% penicillin-resistant -- which means
physicians will face limits in treatment options for
at least one in three patients with this type of infection.
These facts are disturbing. They are also the reason
that the AMA has long focused on raising physician
awareness about the dangers of inappropriate antibiotic
prescribing and has armed doctors with tools to educate
their patients about appropriate use. On that point,
there is some recent good news.
It comes from an analysis of data from the National
Ambulatory Medical Care Survey, published in the June
19 Journal of the American Medical Association.
The report found that the rate of antimicrobial prescribing
overall and for respiratory tract infections by office-based
physicians for children and adolescents younger than
15 decreased significantly between 1989-1990 and 1999-2000.
This represents a change from 1980 to 1992, when the
rate jumped 48%.
Still, the disciplined use of the prescription pad
may not be enough. Though the doctor's role in reducing
inappropriate antibiotic use is critical, truly addressing
the problem will require attention and cooperation
from a broader collection of stakeholders, including
policy-makers, parent and consumer groups, pharmacist
and nurse organizations, and health plans and managed
care organizations.
An initiative managed by the California Medical Assn.
Foundation -- the Alliance Working for Antibiotic
Resistance Education or AWARE -- offers an excellent
how-to model to achieve such collaboration.
AWARE began in January 2000 with the aim of mobilizing
communities to reduce improper antibiotic use through
education efforts geared to change physician behavior
and consumer understanding.
Physicians were at the heart of the effort, bringing
to the table the knowledge base and scientific understanding
that allow for a critical mass to be reached. In November,
AWARE's success was the cornerstone of a national
conference held in Sacramento, "Diverse partners,
common goal: Working together to promote appropriate
antibiotic use."
Considered groundbreaking, the meeting was attended
by representatives from 34 states, all of whom want
to build partnerships, like the ones AWARE cultivated
in California, which would move toward more prudent
antibiotic use within their own communities.
The AMA was a collaborating sponsor and has been
actively working within the Federation of Medicine
to spread the word about AWARE's innovative strategies.
Addressing the problem takes action at all fronts
-- from global organizations to federal agencies and
even state and local health departments. And ultimately,
success relies on education. This education occurs
when doctors work with individual patients as well
as on a larger scale -- including within state and
local medical and specialty societies -- to reach
out to other parts of the community.
The call to action is clear. The misuse of antibiotics
contributes to selective pressure that works against
the effectiveness of these drugs. But physicians feel
pressure from patients who do not yet understand why
these drugs are not always the answer. The AWARE model
offers doctors a method -- through grassroots leadership
and involvement -- to raise awareness in their hometowns,
make a difference in their patient relationships and
eventually lessen the risk of antibiotic resistance.
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