The Observer, September 19, 2008
Volume XLI, Issue 4
Antibiotic resistance: a lesson in scarcity
I have to start this week with a clarification (err, correction). In my previous column, which addressed the issue of compliance ("Compliance and the doctor-patient relationship," Aug. 29), I used as an illustration the rhetorical question, "When was the last time you skipped the last few doses of an antibiotics prescription…?" In hindsight, that was a poor choice. While the general point of following through with physicians' instructions is in general sound, antibiotics in particular actually might be an exception or at least a bit more complicated.
The use of antibiotics, by their very nature, simultaneously treats an infection and yet also breeds resistant strains. While it is detrimental to the patient to stop taking antibiotics before an infection has been eradicated, it is conversely detrimental to society as a whole to keep taking them after the infection is successfully treated, for doing so breeds resistant bugs that will be harder to treat in subsequent infections. The grand problem is that we have as of yet few if any randomized studies indicating exactly for how long antibiotic regimens should go and are thus stuck with what is essentially guesswork.
This unique nature of antibiotics yields an interesting perspective on the issue of scarce medical resources, which I have also written about before ("Why are people talking about a market for organs?," April 11). When we discuss scarce medical resources, we do so usually either in the context of a physical resource (i.e. organs) or a fiscal resource (i.e. Medicare dollars). Anyone who has enjoyed an economics class should interject here that while such resources (organs and Medicare dollars) may be physically different, they can both be considered as dollar amounts: the level of scarcity of a physical resource can indeed be priced.
Antibiotics can be considered scarce in two contexts. Traditionally, they can be considered as a physical resource, like organs, for which there is a limited supply. They can also be considered a resource in terms of their efficacy. With a rise in resistant strains of microorganisms, the efficacy of the antibiotics currently available decreases. While the overall amount of the physical resource (the number of milligrams, for example) has not decreased, its overall utility certainly has (e.g., the efficacy per milligram).
Clinically, this means that the supply of antibiotics (for which we now mean a composite of physical supply and clinical efficacy) can be effected both by changes in the physical flow of antibiotics into a given region (an issue with rather distant origins with respect to any one community) and the efficacy of antibiotics in the region (effected directly by practices of antibiotic use in that area).
When a physician, then, is evaluating an infectious patient for treatment, he or she has dual responsibilities: treating the patient, and doing so in a manner that best preserves the strength of our antibiotic arsenal. Treatment is generally begun with what is called empiric therapy, multiple drugs based on common bugs for a given clinical presentation, and then narrowed down to only those drugs necessary once a specific bug(s) is definitively identified. The need to maintain a strong antibiotic arsenal puts significant pressure on physicians to make definitive diagnoses faster, on researchers to better understand precise durations for antibiotic regimens, and on the health care community in general to improve our record on hospital-acquired infections that contribute greatly to the growing population of resistant strains.
George L. Anesi, B.S., is a second year medical student and a bioethics graduate student at Case Western Reserve University School of Medicine. He can be contacted at george.anesi@case.edu.
