Question your doctor about your antibiotic prescription

I gave a talk at the Canadian Society for Laboratory Science annual general meeting today concerning antibiotic resistance. In it I suggested that everyone has a role in the solution to the problem. Afterward someone asked me if they should question their physician more thoroughly when they are given a prescription. It is something I have been asked before and have generally been reluctant to suggest that questioning their doctor’s prescription decision was appropriate. I have been very conscious of the need for a cooperative, blameless approach.

I have changed my mind.

Everyone should demand very specific information about all antibiotic prescriptions. You should be aware of the exact diagnosis, the expected course of illness and symptoms that would suggest need for further medical assessment. Discussions of alternatives are completely appropriate. If your doctor can’t or won’t give you the information you want consider another opinion.

Taking antibiotics is serious business and deserves serious personal consideration. The more questions asked the better.

The case for a national Antibiotic Drug Plan

Antibiotic resistance is rapidly escalating and is a threat to us all. It is the “global warming” of medicine and just as energy consumption will necessarily continue, so will consumption of antibiotics. Resistance to antibiotics can’t be completely “fixed” but must be actively managed – forever. As antibiotic consumption cannot be optimized by market distribution active regulatory control is the only option.

At present there are many uncoordinated levels of regulation of drug distribution in Canada. Federally, a new drug must be approved for sale by Therapeutic Products Directorate (TPD). Once approved (given a “notice of compliance” with regulations) a manufacturer can market the drug to prescribers. However, the central marketing effort is directed toward large governmental and third party payers as the vast majority of human drugs in Canada are payed for by these institutional drug plans.

Each province and territory has their own drug plan and their are several large private plans that provide coverage to employees of private companies, unions members, government employees, and some individuals. The provincial drug plans vary widely in structure, eligibility, coverage, administration and means and levels of cost sharing. Once a company is successful in having their drug covered marketing efforts rapidly shift to influencing prescribers. Physicians are “detailed” – visited by pharmaceutical company representatives and provided with promotional materials and samples. Educational events are organized and often enticed with dinners, trips etc. with speakers recruited from the ranks of the “infection expert elite” who are payed with money, or by support for research or other programs directed by the speaker. The majority of the Canadian “infection expert elite” are directly or indirectly involved in pharmaceutical company marketing efforts and not in governmental programmatic approaches to optimizing utilization.

Because of this disparate structure antibiotic consumption varies widely in Canada. The highest consuming province consumes at a rate that is almost double the lowest consuming. Rates of individual drug consumption vary by several hundred percent in many cases. And once added to the formulary of a drug plan there is very little scrutiny of changing consumption. Antibiotics are relatively inexpensive when compared to several other classes of drugs. Rapidly increasing costs of cardiac, gastrointestinal, cancer and neurologic / psychiatric drugs have commanded all of the drug utilization attention.

What is the answer to this obviously ineffective, inefficient system? A national Antibiotic Drug Plan – a completely rational and economically sound response that would distinguish these publicly essential drugs from all other pharmaceuticals. Buying power would lower overall costs. The provinces would welcome federal guidance especially if accompanied with funding. Drug approvals and post-marketing surveillance activities could be tightened. Provincial differences in utilization would be scrutinized and drive an agenda of research into “best practice” of antibiotic use. Professional bodies could be engaged to participate in government supported targeted research into new agents and approaches to infections.

Several years ago at their first ministers conference the premiers unanimously called upon the federal government to establish a national drug plan. It was rapidly dismissed as a money grab by the provinces and simply too expensive for the federal government to consider. I feel it was an opportunity squandered. The idea should be resurrected, limited to antibiotics and federally funded. This bold step would position Canada to become a world leader in the management of antibiotic resistance.