Reading 2

1. What were the most common sources of non-prescription antibiotics?

Non-prescription use of antimicrobials occurs worldwide
Most of the non-prescription use of antibiotics are outside North
America and Northern Europe
The most common source of non-prescription antibiotics is the
Pharmacy. Other sources includes, friends, family and home.
2. What safety concerns were associated with nonprescription use of
antimicrobials?

An additional safety concern was substandard quality of antimicrobials available without

prescription.
Expired drugs or those that, as a result of degradation, have decreased bioavailability
might both predispose a patient to treatment failure and promote antimicrobial resistance.
Outright counterfeit antimicrobials are available in developing countries and can lead to
treatment failure or direct harm
Non-prescription use of substandard antimicrobials is probably more common, although
low-quality antimicrobials have also been identified through official prescription sources.

3. Were the adverse effects of nonprescription antimicrobials regularly

reported? What health governance problem does it imply?

Definite adverse effects of non-prescription antimicrobials were rarely reported, probably

due in part to the decentralized health-care systems in most areas with non-prescription
sale of antimicrobials.
Adverse effects of non-prescription antimicrobials are rarely reported, but they are likely
at least as common as adverse effects of prescription antimicrobials.
Of adverse events requiring emergency room attendance, 79% were allergic reactions.

4. What practices of nonprescription use of antimicrobials were probably

related to emerging resistance? Cite specific examples.
Bartoloni and colleagues studied non-pathogenic E coli isolates from children under age
5 years in Bolivia. Overall, 40% of children harboured nonpathogenic E. coli resistant to
ampicillin, co-trimoxazole, tetracycline, and chloramphenicol (which were the
antimicrobials most commonly used in the communities studied). In this population,
antimicrobials were available without a prescription and were frequently used.
At a population level, clinically important bacterial resistance including penicillinresistant and erythromycin- resistant S pneumoniae and ciprofloxacin-resistant nontyphi salmonella has been associated with increasing non-prescription use of these
antimicrobials in a Thai community.
Frequency of resistance has been examined in respiratory pathogens in Vietnamese
children and Senegalese adults with urinary tract infections. In all studies, high rates of
community resistance were reported and were associated with patients receiving
antimicrobials 6 months before each study, in communities with high non-prescription
antimicrobial use.
5. Under what circumstances were patients exposed to the risks of an antimicrobial without
benefit? Cite specific examples.
Pharmacists dispensing non-prescription antimicrobials without knowledge of patients
allergies.
Poor regulation of antimicrobials due to inefficient enforcement of policies.
lnadequate guidance regarding appropriate antimicrobial selection for individual
syndromes.
inadequate health education regarding safe practices to minimise adverse drug effects.
Financial concerns of the patient often guide antimicrobial selection resulting in short
duration of treatment.
Reading 3
1. What is meant by antibiotic stewardship?
It is an emerging field in medicine currently defined by a series of strategies and
interventions aimed toward improving appropriate prescription of antibiotics in humans
in all healthcare settings.
2. In what ways does antibiotic stewardship improve the quality of patient care and patient
safety?

Antibiotic stewardship contributes to the improvement of quality of patient care and

patient safety by minimizing toxicity and frequency of adverse drug events, reducing the
costs of healthcare for infections, and limiting the selection for drug - resistant strains.

3. As a future Bedan physician, how will you uphold and practice EVERY core element of
antibiotic stewardship? Identify these core elements then cite concrete examples.
Leadership Commitment: Dedicating necessary human, financial and information
technology resources.
Accountability: Appointing a single leader responsible for program outcomes. Experience
with successful programs show that a physician leader is effective.
Drug Expertise: Appointing a single pharmacist leader responsible for working to
improve antibiotic use.
Action: Implementing at least one recommended action, such as systemic evaluation of
ongoing treatment need after a set period of initial treatment (i.e. antibiotic time out
after 48 hours).
Tracking: Monitoring antibiotic prescribing and resistance patterns.
Reporting: Regular reporting information on antibiotic use and resistance to doctors,
nurses and relevant staff.
Education: Educating clinicians about resistance and optimal prescribing.