They’re widely available over-the-counter at Egyptian pharmacies, and often regarded as a fast remedy for the fever and flu. They’re given to children by concerned mothers, and gulped down by adults who don’t want to bother or don’t have the money to first consult a doctor for a prescription. But the rampant misuse of antibiotics is actually endangering our health.
By Dominika Maslikowski
The pharmacies in Downtown Cairo are about as numerous as the kiosks and cafes. If anyone in the neighborhood is running errands, they can stop there to pick up some grape-scented shampoo or a new toothbrush. If they come down with a respiratory infection or fever, they can also pick up some powerful antibiotics if they just complain to the pharmacist behind the counter of their pains and answer a few simple questions. They may realize popping antibiotics isn’t exactly healthy. But most probably don’t know that this practice is contributing to antimicrobial resistance, a global problem so serious that the World Health Organization (WHO) says it “threatens the achievements of modern medicine.”
The WHO recently warned in an April report of a “post-antibiotic era, in which common infections and minor injuries can once again kill,” unless urgent action is taken to curb the global misuse that leads to antibiotic resistance. In Egypt, unregulated sales of antibiotics are soaring because of profit-driven pharmaceutical companies, misguided doctors and a demanding public who doesn’t often believe that milder medicines are enough to treat common ailments, multiple studies say.
“We have the abuse of antibiotics in Egypt because they can be bought directly in pharmacies without a prescription, so most people, especially mothers and those with infections like the flu, go to the pharmacy,” says Dr. Wael Safwat, an internal medicine consultant. “And for viral infections like the flu, they for sure don’t need antibiotics.”
The inappropriate use of antibiotics is a “significant public health problem” in Egypt, says a study titled “Pattern of antibiotic abuse,” published in the Egyptian Journal of Chest Diseases and Tuberculosis in January 2013. Doctors say antibiotics should only be taken when absolutely necessary, as prescribed by a well-qualified physician. But the study, conducted on 1006 participants by Ain Shams University researchers, found that some 34% of adults consult a pharmacist before taking antibiotics, while 23% self-medicate; only 29% consult a physician. Those surveyed give various reasons for taking antibiotics without a prescription. Housewives mostly cite financial reasons for not seeing a doctor before buying the pills, while workers, students and the unemployed mostly claim that common diseases aren’t worth a doctor’s visit.
The misuse of antibiotics can have serious and sometimes deadly consequences. When a patient uses an antibiotic for a weak infection, they lose the antibiotic’s effect when they come down with a more severe infection, Safwat explains. When their case is serious, more powerful and potent antibiotics are needed, which can be more expensive or have more side effects that must also then be medicated.
“It starts with side effects of the antibiotic itself, like allergies. Then comes resistance to different antibiotics. Then the [ineffective] response to antibiotics in serious cases, and after surgery they won’t have the same outcome on the patient’s cure rate,” says Safwat. “This is in addition to the financial impact of receiving unnecessary medications and then treating side effects.”
Dr. Wanda Shawky, a physiotherapist, has seen firsthand how powerful the side effects can be when antibiotics are improperly prescribed or when they’re misused. A doctor in a Cairo hospital had prescribed the wrong kind of antibiotic to a patient who was recovering from surgery for a brain tumor, she recalls. “[The patient was] fainting and after several days the doctor saw that the wrong antibiotic had been given,” she says. “This added about three days to the patient’s recovery time.”
Shawky is an experienced physiotherapist, but even her friends don’t always trust her medical advice. “They’re heavy users [of antibiotics]. It’s a habit,” she says. “If I tell them the opposite, they don’t believe me and go to another doctor.” Shawky says that her sister, who works as a doctor in the United States, waits two or three days before prescribing antibiotics to patients to make sure they’re really needed. But in Egypt, she says, mothers can get impatient and believe they’re putting their children at risk if they don’t give them antibiotics quickly.
But it’s misusing antibiotics that puts children at risk. Safwat says that giving antibiotics to children when there’s no need for them “destroys” their immune system and doesn’t allow them to develop antibodies, which are used by the immune system to identify and neutralize bacteria and viruses. The child will then always depend on antibiotics and will later develop resistance, Safwat says. The complications range from simple allergies, to diarrhea and nausea and vomiting to anaphylactic shock to death. “Some types of antibiotics are forbidden for children,” Safwat adds. “So if a doctor or a mother gives them, they can even cause death.”
Safwat advises patients to first discuss their symptoms with a well-qualified and trusted doctor and postpone the use of antibiotics whenever possible. He also recommends discussing alternatives to antibiotics and getting a second opinion from another doctor if the first prescribes antibiotics too hastily.
A Hard Sell
While many see the local pharmacy as a substitute for a clinic visit, doctors say that pharmacists can be motivated by profit when giving out antibiotics without a prescription, and that they are not a good source for medical advice because they’re unable to examine the patient over a period of time to determine whether antibiotics are necessary.
“Most pharmacists are for business and making more money. They may give out medications not suitable for the case so they can get the income,” Safwat asserts. “Pharmacists must have regulations and education because they should not be allowed to prescribe medications.”
Cairo University researchers looked specifically at this issue in their 2011 study “Antibiotic dispensing in Egyptian community pharmacies,” which surveyed 36 pharmacies in Greater Cairo over three months. While some 63% of antibiotics were purchased with a prescription from a doctor or dentist, about 23% of all antibiotics sold at pharmacies were dispensed to those who were self-medicating, and pharmacist recommendations accounted for some 13% of sales. The study’s authors judged that when it came to the antibiotics bought based on the recommendations of pharmacists or patient requests, only 61% were appropriate for the listed illness or symptoms.
“A third of all dispensed antibiotics were not considered appropriate for the condition in question. Additionally, a third of antibiotics dispensed on prescriptions were not in the correct quantity. Not all antibiotics were dispensed by a pharmacist. Instead, technicians dispensed a large proportion,” the study noted. Pharmacists tended to recommend new or broad-spectrum antibiotics, which act against a wide range of disease-causing bacteria, without thoroughly reviewing the patients’ conditions or considering their allergies, the study found.
It may seem like doctors and dentists should be leading the fight against antibiotic abuse, but that isn’t always the case. The Cairo University study noted that only 70% of the antibiotics dispensed on prescriptions were appropriate. Doctors also tended to use “newer, more expensive agents as opposed to cost-effective or well-established, evidence-based antimicrobial agents,” the study says, noting that “aggressive campaigning by pharmaceutical companies” contributes to the problem.
The brochures that pharmaceutical companies send out to doctors to encourage them to prescribe their products, are “always biased,” Safwat says. “In Egypt, there are no guidelines for prescribing antibiotics so doctors prescribe them based on the descriptions from the medicine companies. The national authorities must have special guidelines and research, and there must be education for doctors on when to prescribe antibiotics. It’s important for doctors not to follow the pharmaceutical companies all the time. They have to judge the situation themselves.”
Sitting in his office in Mohandessin, cancer surgeon Diaa Saleh says he’s spoken to pharmaceutical companies about curbing their campaigns and to pharmacists about combating the abuse of antibiotics. “But they can’t do it, because they want to sell,” he asserts.
Curing the Culture
Another crucial factor can push doctors to prescribe antibiotics when they’re not necessary: pressure from the patients themselves, who demand prescriptions for the pills and reject milder cures.
“I have a relative who’s a very good doctor. She’s over-qualified and sticks to scientific rules,” Saleh says. “A patient, or a mother with a baby or a child, comes to her with a slight fever or sore throat. She gives them Vitamin C then a decongestant. But sometimes patients or mothers just insist on getting antibiotics because if the child doesn’t get well in a couple days, they’ll go to an idiot doctor who’ll give them the antibiotics. And they’ll think this is a good doctor, and that one isn’t.”
Most mothers use antibiotics as the first treatment for their child’s fever, says Safwat. If the doctor doesn’t prescribe it, then the mother “gets irritated.” This attitude comes from “malpractice and the miseducation of the public and the doctors who say that once there’s a fever, you have to take antibiotics.”
Patients often demand antibiotics and request specific types that worked for them in the past, said a study titled “Understanding Antibiotic Use in Minya District, Egypt,” which surveyed 719 physicians and pharmacists in that governorate in early 2011. “Physicians usually comply with patient requests in order to maintain a good reputation,” said the study, published in the Antibiotics journal this June. “Younger physicians and those who saw adult patients were more likely than their counterparts to inappropriately prescribe antibiotics for colds. Younger physicians may be seeking to build their practice by satisfying patient requests for antibiotics,” the study noted.
Pharmacists, on their part, were driven primarily “to make financial profit and gain loyal clients,” the study concluded, after interviews with 483 pharmacists. Public pressure and people’s demand for a fast cure often lead to pharmacists dispensing antibiotics. “Most pharmacists agreed on the importance of gaining a reputation as a clever pharmacist who prescribes medications that work,” the study noted. “The pharmacists’ primary objective was to make financial profit and gain loyal clients.”
New scientific research on the consequences of antibiotics abuse should be made available to pharmacists, Haitham Abd Alaziz, a member of the General Syndicate of Pharmacists, told Al Masrawy newspaper in May. The Ministry of Health and Population should also supervise pharmacies to prevent them from dispensing strong antibiotics without a doctor’s order, Abd Alaziz added, “There should be severe punishments for those who breach that.”
The Ministry of Health oversees pharmacies, and antibiotics are medications that, according to Egyptian law, are not legally available without a prescription from a doctor.
However, “the enforcement of this law by regulatory bodies is not very strict,” and in practice they’re widely available and self-medication is widespread, says the Cairo University study, which concluded that there needs to be better enforcement of pharmacy laws and public awareness of the consequences of antibiotic misuse.
While pharmacies must keep strict records of addictive medicines sold to prove they were not given out without a prescription, Safwat says, there are no such requirements when it comes to antibiotics.
The Ministry of Health has issued a national guide for addressing infections caused by strains of bacteria that are now resistant to the antibiotics which were previously effective, so doctors know not to prescribe them. The guide notes that the “misuse of antibiotics on a wide scale for simple illness” has lead to the emergence of such strains.
Experts have been aware of the problem for some time. A study conducted in 2008 at Tanta University Hospital found high rates of resistance to most bacteria studied. “Antibiotic treatment in our Orthopedic Department appears to be substantial. Increasing and justifying efforts are needed to improve appropriateness of antimicrobial therapy and minimize the development of antimicrobial resistance,” said the study, published in the Egyptian Journal of Medical Microbiology in October 2009.
A health ministry campaign in early 2013, sponsored by the WHO, drew attention to antibiotics abuse when it encouraged parents to have their children vaccinated to prevent 13 strains of pneumonia. The vaccine was a better way to tackle the strains of bacteria that have become resistant to antibiotics, the campaign said.
But there have been no government crackdowns on pharmacies that give out antibiotics without prescriptions in Egypt. Doctors have a guideline from the health ministry that governs how drugs are prescribed for certain diseases like diabetes and hepatitis, but no enforcement or penalties for those who don’t apply the guidelines, says Safwat. If a patient suspects malpractice, they can report their case to the police or the medical syndicate. The case then goes to court, where the judge calls on a panel of experts or consultants in the field or refers the case to the medical syndicate, where a special committee deals with malpractice.
Saleh believes public awareness is the solution, and the only way to get rid of the problem of antibiotics abuse. When he started working on raising public awareness in Egypt about the early detection of breast cancer in 2001, methods like self-exams weren’t very well-known. Now, after working with the media and making TV appearances, he says about half the patients he sees come in for check-ups. “For antibiotics abuse, the only way is to get the media. If we solve this problem with the media, then even if a doctor gives a patient the antibiotics, they will refuse to take them.”
Undoing Modern Medicine
It is no coincidence that nations like the Netherlands with the strictest policies on antibiotic prescription have the lowest rates of resistance, says an article in the May issue of the scientific journal Nature, co-authored by Mark Woolhouse, professor of infectious disease epidemiology at the University of Edinburgh. “In developing countries with rising incomes, consumption is surging; sales of even relatively expensive antibiotics increased fivefold in India and tripled in Egypt in 2005–10.”
The problem of antibiotic abuse is serious in Egypt, but it’s also a worldwide crisis recently tackled by the WHO in its first-ever global report on antimicrobial resistance. Common infections like pneumonia, once treatable with penicillin, may not respond to available drugs anymore in some parts of the world and put patients’ lives at risk, the report said. Common infections in neonatal and intensive care are becoming increasingly difficult, or impossible, to treat. The antibacterial drugs used to prevent infections after surgeries have become less effective.
“Antimicrobial resistance is not a future threat looming on the horizon. It is here, right now, and the consequences are devastating,” said WHO Director-General Margaret Chan, during a conference on antimicrobial resistance at the Hague on June 25. “Here is the central question. How bad will things have to get before the recommendations we have been making for decades are finally acted upon? How much more evidence do we need?”