“Antimicrobial Resistance and Antibiotic Overprescription”

A Review of the Literature on Antimicrobial Resistance from Antibiotic Overprescription and Parental Awareness

 

 

Christian Xu

The Division of Science, The City College of New York

ENGL 21003: Writing for the Sciences

Professor Brittany Zayas

March 24, 2023

 

 

Introduction

The ubiquity of antibiotics in today’s healthcare system and the crucial roles they play in human health cannot be overstated. The prevalence of antibiotic use occurs the most in the children demographic. As Alejandro et al. (2022) illustrates, more than half of children in Australia have received single antibiotic dispensing in 2013. In the broader scope of antibiotic use, 40% of the overall population of Australia has had at least one antibiotic dispensed within their communities in 2019, according to the Australian Report on Antimicrobial Use and Resistance (AURA). However, with the widespread use of antibiotics it is undoubtedly bound to garner subsequent misuse as well further down the line. Namely, the looming presence of antibiotic overprescription, prompting its overuse, has been an enduring issue for children’s health, parent-general practitioner (parent-GP) relationship, and parent’s themselves, who are the primary caretaker of their sickly children. This leadership role involves the guardian(s) being informed of the proper treatments for different types of microbial infections that children may be prone to by following the opinions and recommendations of general practitioners. As Bassegoda et al. (2018) proposes, the presence that antibiotics hold in modern medicine could yield disastrous consequences if their effectiveness were to be compromised. Even the most common bacterial and viral infections today could pose a tremendous challenge to the healthcare system in treating when faced with microbes that have developed resistance to the prolonged use of specific drugs. Therefore, a sense of knowledgeable responsibility must be instilled within the child’s parent(s) in order to appropriately nurture them back to health.

Thus, this review of the literature showcases the need for parents to take knowledgeable accountability of proper antibiotic use through a healthy parent-GP relationship, thereby understanding how misuse could lead to drug resistance in microbes and the implications on children’s health.

Antibiotic Misuse and Antimicrobial Resistance

The misuse of antibiotics constitutes a major burden not just to human health and lives but also on the economic sector. The deaths attributed to antimicrobial resistance (AMR) reach 700,000 annually, with numbers suspected to reach ten million by 2050, and an economic burden of over 20 billion dollars on the U.S. healthcare system (Bassegoda et al., 2018). More specifically the overuse of antibiotics imposes the risk of simple microbial infection becoming too difficult to treat through conventional methods. As Richmond et al. (2019) points out, various antibiotic-resistant strains of bacteria such as methicillin‐resistant Staphylococcus aureus (MRSA) and Clostridium difficile, an infectious bacterial disease, are already resistant to numerous antibiotics. Thus, these AMR pose a greater difficulty in treating with conventional antibiotics. On the opposite end, needless prescribing of antibiotics from physicians has warranted the misuse of antibiotics to treat viral respiratory conditions. Too elaborate, the use of prescription antibiotics on respiratory illnesses such as the common cold and bronchitis is extensive. As much as half of prescribed antibiotics for acute respiratory conditions are unneeded (Richmond et al., 2019). Consequently, the leading factors contributing to rampant AMR occurrence is the general lack of knowledge patients have with respect to antibiotic capabilities and limitations. Similarly, how patients are able to seek this information out is hindered through poor communication with their general practitioners.

Parental Knowledge of Antimicrobial Resistance

The knowledge that parents possess in regards to proper antibiotic use and the effects that misuse may have on their children’s health is especially paramount. When a child is ill the parents are expected to take the leading role in providing the proper care in order to nurse them back to health. This role involves taking the initiative to learn about the potential drawbacks and limitations of a specific treatment for their child’s illness and weighing the options respectively. The involvement of antibiotics in children’s health has always been widespread and ubiquitous. Around 17.7 billion standard units of prescription antibiotics are sold globally every year. Of the total units, a quarter represented oral antibiotics formulated for children (Alejandro et al., 2022). Thus, it demonstrates its persistent staying power. In a study conducted by Alejandro et al. in Perth, Western Australia (WA) consisting of 26 participants, researchers focused on assessing parental knowledge of antimicrobial resistance (AMR) and the awareness of their potential threats. The researchers organized participants for their study from two local government areas of Perth: Cockburn and Kwinana. The purpose would be to provide the widest and broadest scope of where individual knowledge of AMR stands in relation to the varying socioeconomic background. Using the Socio-Economic Indexes for Areas (SEIFA), Western Australian State Government determined that the local government area of Cockburn presented a higher SEIFA score than Kwinana, indicating a healthier socioeconomic background. Moreover, based on the disparity of certain socioeconomic groups in Western Australia, Alejandro et al. (2022) indicated a relationship between a poor socioeconomic background and viral infections such as acute respiratory infections (ARIs), with a higher occurrence of children from such backgrounds being hospitalized. This is evident in a report illustrating that around 26% of emergency department visits from 2002-2012 was the result of ARIs (Alejandro et al., 2022). This undoubtedly highlights the underlying idea that the prevalence of antibiotic use and its overuse is also the gateway to antibiotic misuse, from the overprescription of antibiotics.

In the case study, some argued that because their children seemed healthy and weren’t subjected to large quantities of antibiotics, they were thus less prone to AMR (Alejandro et al., 2022). The belief that people develop resistance to AMR from less antibiotic use is portrayed in Davis et al., (2020) study as one participant comments, “But now people are given it willy-nilly and people are becoming immune to it. The body’s getting used to the antibiotics so it doesn’t do anything”. The consensus of many participants in the initial study was admitting that they didn’t have enough information on the effects that AMR posed on their children. However, participants demonstrated their knowledge on antibiotic capabilities by explaining that proper systematic use of antibiotics could limit development and spread of AMR (Alejandro et al., 2022). Correspondingly, participants are aware of the idea that the implications of antibiotic misuse are detrimental beforehand.

Parent-General Practitioner Relationship

Although parents are expected to shoulder much of the responsibility for enforcing the proper treatments of their children’s illness, where the parents acquire this information is the pivotal preliminary step. The first place guardians are most likely to seek trusted information for in the proper treatments of child illnesses is their general practitioners (GPs). Subsequently, the relationship between parent and general practitioner is the bridge between the knowledge of AMRs and acceptable antibiotic use. However, parents can oftentimes be caught up in what they believe is “best for their child” instead of settling to the recommendation offered by a GP. As a result, this belief that parents have about their child’s health is a deeply rooted contribution to the outpour of antibiotic misuse, more precisely its overuse from antibiotic overprescription. For reference, one-third of Australian parents who visit their GPs believing their child is in need of antibiotics would consult another physician for prescription antibiotics if their initial doctor’s opinion didn’t approve of the need for antibiotics use (Alejandro et al., 2022). The results exemplifies an example of the miscommunication within the patient-physician relationship leading to the misuse and more importantly, the overuse of antibiotics. This is evident in an annual U.S. statistic demonstrating that around 47 million physician prescribed antibiotics and 30% of all oral antibiotics in outpatient settings are unnecessary (Richmond et al., 2019).

In a similar case study to Alejandro et al., (2022), researchers from Richmond et al., (2019) study presented three pre/post deliberation statements to three groups (two variable groups  and one control) of participants regarding physician’s autonomy to prescribe antibiotics. The two variable groups are Citizens’ Panel (CP) and Community Deliberation (CD). Each group had their own unique agenda and methods of deliberation. To illustrate, the CD group had fewer total hours in deliberation time compared to the CP group. However, the difference in these two groups is that CD deliberations took place both in-person (face-to-face) and online via discussion boards, whereas CP only conversed in-person. Lastly, CD had the opportunity to communicate with experts about antibiotic overuse and study varying points of views about this topic through the expert’s presentations. Researchers analyzed participant’s level of agreement with these statements on the five-point Likert scale, a 1-5 number scale, with 1=strongly disagree and 5=strongly agree. The statements surrounding antibiotic use are as followed: 1) if  patients should [not] be able to readily obtain antibiotics if they simply wanted them, even if they might not provide any health benefits, 2) if physician should [not] be able to prescribe antibiotics even if there is a small chance that it would provide health benefits, and 3) the government should be able to limit the physicians’ ability to prescribe antibiotics (Richmond et al., 2019).

Prior to deliberation, mean scores for statements 1), 2), and 3) are as follows: Control = 3.6, 2.4, 1.9; CP = 3.9, 2.6, 2.0; CD = 3.5, 2.5, 2.0 respectively. These initial results suggest that, on average, participants lean towards agreement with the first statement and disagreement with the second statement. Lastly, results from the third statement show that participants clearly disagree with government-imposed limitations on antibiotics. Based on the evidence from the first statement it can be inferred that participants are aware of the extent of antibiotics’ capabilities. Yet, when presented with the statement that antibiotics should not be prescribed if they yield a small possibility in treating an infection, participants’ average scores leaned away from a neutral opinion and more towards disagreement. This could be indicative of a common notion believed by patients who believe using antibiotics, even if they yield limited returns in terms of benefits, would be better than not using them at all. This viewpoint is further developed by a participant in the CP group illustrating how antibiotics have garnered a care-all and miracle-like status. The participant states, “That’s the first thing we said…That’s all you grow up knowing, antibiotic… My baby get a cold, he needs some antibiotics… They cure everything” (Richmond et al., 2019). Tying this to the previous study conducted by Alejandro et al., 2022 and the present topic of parent-GP relationship reveals that the relationship between these two critical roles are strained as a result of insufficient time, rushed or dismissive consultations, and the parent’s desire for a “quick fix”. However, participants revealed that when GPs take the time to involve parents in the decision-making of their child’s treatment, a healthier outlook on antibiotic use is produced (Alejandro et al., 2022). Participants likely develop this positive outlook on antibiotic use due to fewer instances of feeling written off or dismissed because they assume their GPs are in a rush. On the other hand, GPs may readily hand out prescription antibiotics  simply to satisfy their patients’ wants, since convincing them to reconsider would be too much of a hassle or time consuming, promoting a dismissive parent-GP relationship once more. Nevertheless, this relates back to the overarching theme of parents acquiring the proper knowledge on antibiotic limitations and their childs’ needs. One way parents can achieve this is by harboring more trust in their physician’s recommendations, rather than a second or even multiple opinions. In turn, procuring this parent-GP trust can be achieved through clear communication and the direct asking of questions.

Conclusion

            Some of the strengths of the studies include a large and diverse sample sizes, which gave way to in-depth analysis of dissimilar participant viewpoints (Richmond et al., 2019). Some limitations that the studies did not take into consideration the complications associated with immediate antibiotic overuse in children, such as diarrhea (Richmond et al., 2019). Had the studies focussed on this aspect the result would have yielded a vastly different conclusion. Parents hold the utmost priority in receiving the adequate education regarding proper antibiotic use and the detrimental effects that misuse can have on children, ultimately leading to subsequent drug resistant microbes. The significance of parent-GP relationship on parental knowledge of antibiotic capabilities and limitations cannot be overstated as well. Together parents and general practitioners are the cornerstone to providing vital precautionary details on antibiotic use and antimicrobial resistance.

References

Alejandro, A. L., Bruce, M., & Leo, C. (2022). Parents’ awareness of antimicrobial resistance: A qualitative study utilising the health belief model in Perth, Western Australia. Australian and New Zealand Journal of Public Health, 46(6), 764–770. https://doi.org/10.1111/1753-6405.13265

Bassegoda, A., Ivanova, K., Ramon, E., & Tzanov, T. (2018). Strategies to prevent the occurrence of resistance against antibiotics by using advanced materials. Applied Microbiology and Biotechnology, 102(5), 2075–2089. https://doi.org/10.1007/s00253-018-8776-0

Davis, M. D., Lohm, D. B., Whittaker, A., & Flowers, P. (2020). ‘Willy nilly’ doctors, bad patients, and resistant bodies in general public explanations of antimicrobial resistance. Sociology of Health & Illness, 42(6), 1394–1408. https://doi.org/10.1111/1467-9566.13111

Richmond, J., Mangrum, R., Wang, G., Maurer, M., Sofaer, S., Yang, M., & Carman, K. L. (2019). An informed public’s views on reducing antibiotic overuse. Health Services Research, 54(6), 1283–1294. https://doi.org/10.1111/1475-6773.13175