antibiotics without prescriptions

A recent review article addressed an important point regarding antibiotic overuse and the increased potential for microbial resistance: the frequent use of nonprescription antibiotics (see antibiotics without scripts AIM2019 in dropbox, or doi:10.7326/M19-0505).

Details:
--31 studies reporting nonprescription use of antibiotics, storage of antibiotics for future use, and intention to use antibiotics without a prescription
--4 populations studied: 
    --patients or parent of patients surveyed outside of health care settings (eg random phone interviews)
    --patients or parent of patients surveyed within health care settings (eg EDs and primary care)
    --Hispanic/Latino populations
    --injection drug users (specifically, self-treatment of abscesses and injection-related wounds)

Results:
--prevalence of nonprescription antibiotic use: varied from 1% to 66%
--storage of antibiotics for future use: varied from 14% to 48%
--prevalence of intention to use antibiotics without a prescripton: 25% (only one study looked at this)
--nonprescription antibiotics obtained for use:  previously prescribed courses, local markets or stores, family or friends
--factors contributing to nonprescription use: easy access through stores/markets that obtain antibiotics for under-the-counter sales, difficulty accessing the health care system, costs of physician visits, long waiting periods in clinics, and transportation problems
--per the above populaions studied:
    --in patients or parent of patients surveyed outside of health care settings: prevalence varied from 3-48%
    --in patients or parent of patients within health care settings: prevalence varied from 1-26%
    --in Hispanic/Latino populations, lowest prevalence (19%) was reported in uninsured Latino patients visiting South Carolina clinics and highest pervalence (66%) was in Latino migrant workers in Florida.
    --in injection drug users: prevalence of nonprescription antibotics varied from 5-32%

Commentary:
 --issues with nonprescription antibiotic use include unnecessary use of antibiotics, incorrect antibiotic or dose when appropriate, adverse microbiome changes and development of antibiotic resistance (including increasing antibiotic resistance within the household, and potentially more globally), and potentially devastating secondary infections with C difficile, etc. Also potential for adverse drug reactions, drug interactions, and masking underlying potentially severe infections, or superinfection
    --ED visits for adverse effects of antibiotics: 19% of all of the ED visits for adverse med effects
--antibiotic resistance: increasing dramatically, with treatment costs doubling since 2002 and now >$2 Billion/yr
--Southern and Eastern European studies, where there are lots of nonprescription antibiotics, have found high levels of antibiotic resistance 
--one concern here is that there is a fundamental structural issue in the US: there are lots of uninsured people (likely to increase in the current political climate), the copays and deductibles are often quite high for many people making them functionally uninsured (see http://gmodestmedblogs.blogspot.com/2019/05/health-insurance-deductibles.html), they may not be able to get off work or other tasks to see a clinician, and there may not be accessible care to many.  Other concerns raised in a California study were: migrant workers citing inability to take off work (or potentially lose their job), lack of access to transportation to go to a clinic, and fear of deportation; also mentioned was concern about being mistreated or judged by health care providers (eg for people concerned about sexually-transmitted infections). The best solution for some may therefore be to find/take antibiotics when they think they need them
--one internet survey cound that of 219 parents given antibiotics for a kid (48% of group) who then kept leftover antibiotics, 159 (73%) subsequently used them on their other kids, unnrelated kids, or unrelated adults

--sources of outside prescriptions in this study: leftover from prior prescriptions (the most commonly found source), diverted from family/friends, available without prescription (internet, under-the-counter, veterinary). A New York study of Latino patients found easy  access to antibiotics in bodegas, and friends/family bringing them back from countries where they are available without prescription [i have several patients where the availability or cost of meds is prohibitive in the US and family/friends in their native country buy meds there without prescriptions and mail them to the US, including injectable ones]
--types of antibiotics available without a prescription: a study in New York found ampicillin, tetracycline, erythromycin and amoxicillin. one in Texas found amoxicillin was most common, but followed by azithromycin, ciprofloxacin, ampicillin, trimethoprim-sulfa, tetracycline, ofloxacin and amoxicillin-clavulanate
--3 studies assessed the reason for antibiotics: mostly sore throat, cough, earache, cold and dysuria

--limitations of this review: no good studies of the overall prevalence of nonprescription antibiotic use in the general US population (and hard to generalize from studies in other countries, given the vastly different social conditions as well as health care systems), the lack of US studies targeting nonprescription antibiotics and their role in antibiotic resistance and adverse outcomes (though there are some data from other countries on this, and the study in Texas of the high use of broad-spectrum antibiotics including macrolides and fluoroquinolones is quite disconcerting); potential publication bias of studies done and then published; and the very different methodologies/outcomes measured of the different studies combined in this review, likely responsible for the large differences in outcomes found and undercutting reliable conclusions

--one interesting finding above, as noted by the authors, is that perhaps our preconceived notions about which groups are more likely to use nonprescription meds (eg, injection drug users, or Latino patients coming from countries where antibiotics are available without a prescription) was found to be incorrect: nonprescription antibiotic use was found in all socioeconomic and demographic groups
--they found only 1 study of an intervention to decrease nonprescription antibiotic use: an ineffective mass media campaign targeting a Latino population (they actually found an increase in use after the campaign started....)

so, this is a really important issue for many reasons (inadequate/inappropriate treatment for real infections and perhaps masking these infections and making them worse, adverse effects of the meds, serious changes in the microbiome and resultant serious diseases such as c diff, increase in potentially global microbial resistance, etc). Though we in primary care see this issue of nonprescription antibiotics quite frequently, this is not typically discussed in the literature on antibiotic overuse/misuse/microbial resistance. 

The one unsuccessful trial of a mass public education campaign suggests that the real fix to the problem is the structural one: having a responsive, nonjudgmental, inclusive, accessible, coherent and affordable general health care system for the entire population....

for the many blogs on antibiotic resistance, see http://gmodestmedblogs.blogspot.com/search/label/antibiotic%20resistance
and, for those blogs on antibiotic overprescribing, see http://gmodestmedblogs.blogspot.com/search/label/antibiotic%20overprescribing

geoff​

If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org

to get access to all of the blogs:

1. go to http://gmodestmedblogs.blogspot.com/ to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category​

3. or you can just click on the magnifying glass on top right, then  type in a name in the search box and get all the blogs with that name in them

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list