Previous Antibiotic Abuse Leads to Quinolone Increase: Accountability Must Be Taken by All
March 27, 2015
Antibiotics have been in the news a lot lately and one class in particular known as quinolones are getting a bad rap in the media without examining all the facts. And the facts show that both patients & doctors are responsible for antibiotics becoming resistant and why in some instances quinolones (usually a last resort) are now being prescribed first line. Might not be what we want to hear but it’s what we need to hear.
Here’s a quick overview for antibiotics for the purpose of this Case Study Antibiotic Resistance:
Antibiotics treat bacterial infections (not viral-antibiotics do not work on the flu).
Bacterial infections include but are not limited to: sinus infections, UTI’s and skin & skin structure (open wound)
Patients can determine the class of antibiotics by the last letters of the chemical name (not the manufacturer or brand name):
Penicillin is the class of antibiotics and includes any drug ending in icillin
Macrolide is the class of antibiotics and includes any drug ending in thromycin
Quinolone is the class of antibiotic and includes any drug ending in oxacin
For the purposes of the Case Study Antibiotic Resistance:
Penicillin (first line) meaning this drug, in a normal circumstance, should be prescribed first to a patient provided it treats the indicated infection and the patient is not resistant or allergic to penicillin.
Macrolide (second line) meaning this drug, in a normal circumstance, should be prescribed second to a patient after first line treatment fails provided it also treats the indicated infection and the patient is not resistant or allergic to macrolides.
Quinolones (third line) meaning this drug, in a normal circumstance, should be prescribed third to a patient after first and second line treatment fails provided it also treats the indicated infection and the patient is not resistant or allergic to quinolones.
As a patient ask yourself if you’ve ever taken an antibiotic and become frustrated it wasn’t working or working fast enough. Put a pin in that until the end.
And in full disclosure I am this Case Study:
As mentioned previously on this site, I had open heart surgery at 18 (1990) for an atrial myxoma (tumor on the heart) and while going through that initial process prior to finding the myxoma a slight murmur was found and the AHA guidelines at the time were to take an antibiotic prior to any dental work (six an hour before and two several hours later) to prevent infection reaching the heart through the mouth. (These guidelines have since changed-but for understanding antibiotic resistance it’s necessary how this happens and that I’m not unique to this situation). This process is what started me down the road to knowing something was wrong. I was prescribed a macrolide (Erythromycin) and had an allergic reaction causing massive heart palpations.
My dentist started me on what would have been considered second line therapy (but I was allergic) so for the next twenty years I took penicillin (Amoxicillin) any time I went to the dentist. That’s a lot of antibiotic twice a year over twenty years. I’ve built up a tolerance to penicillin and since I’m allergic to marcolides when I have an infection (sinus or UTI) quinolones are now first line.
The reason I share this is to help people understand how antibiotics resistance starts for many who have been dependent on antibiotics throughout their lifetime. So while it may seem negligent of a physician to start someone first line on a quinolone there are many factors as to why that’s become more common in patients.
Early in my career I sold a quinolone which has since been removed from the market called Tequin or Gatifloxacin. As one of the top producers of the company and as someone who’d had open heart I had concerns when the company began to gloss over problems the drug created showing prolonged QTc intervals which could have led to the development of torsade de pointes (Tdp) which could have resulted in ventricular fibrillation. Tequin, long after I left the company, was pulled from the U.S. market as the company “decided” to stop the commercialization of the drug without providing any other information. Anyone sense a theme here?
The training for antibiotics was extensive and it was an extremely competitive market. The biggest competitor was the Z-Pak (macrolide) which was generating billions a year for Pfizer in the mid to late-1990’s until it went generic after the turn of the century. Don’t feel too badly for Pfizer though because in 2012 the drug still produced $ 434 million (despite less expensive generics availability).
At the time of my training it was very popular for a rep to preceptor with a physician or follow them in the office while they saw their patients during the day. This is something I was never comfortable with and while I respected the patients the company pushing and the physicians so willing to allow this for $250 payment never set well with me (this differs from being in OR where it’s necessary to help with product set-up and device trouble shooting). This was mandatory at the company in order to fulfill training requirements.
During my preceptorships I learned that antibiotics as a whole were over prescribed or prescribed to get an unrelenting patient who demanded something for their “cold” be given to them prior to leaving (or after leaving six calls for the office staff) and a tired beat down physician relenting. It’s not right but it happened. And it happened to the tune of billions of dollars a year. Companies advertising direct to consumers, physicians trying to stay on schedule and not fight with patients about what drugs they should receive (if any), and patients who were unwilling to understand that antibiotic abuse would harm them down the road are all to blame the current situation.
So if you were one of the millions of people who called your physician anytime you had a sniffle for the Z-Pak and took to it like a Pez dispenser then yes you are now part of the problem and can’t blame your physician for first-lining a quinolone because you’re now likely resistant to anything weaker than the nuclear bomb of antibiotics-a quinolone.
As a patient ask yourself if you’ve ever taken an antibiotic and become frustrated it wasn’t working or working fast enough. Now it’s time to take that pin out and think about how you can communicate your drug history to your physician so that you’re aware of your options (are you willing to try a weaker drug first and pay a second co-payment or cash for additional drugs?) If you’re not then a physician will likely start you (and rightfully so) a stronger antibiotic from the start.
Ask yourself if you’ve ever “saved” part of your antibiotic prescription for the next time you’re sick? Because, if you have, then you’re part of your own problem– If you don’t take the prescribed amount until completion you’ve allowed yourself to become more quickly susceptible to that same bug in the future. Meaning it will take more of the drug to kill off what you should have killed off by taking the full prescription in the first place.
And physicians don’t get away without blame here either. I don’t care if it takes you an extra ten minutes to explain it to your patients but you owe it to them to explain why you’re first-lining a third-line drug and you owe it to them to explain all the risks associated with a quinolone. Physicians ultimately must approve a prescription and they knew this day was coming-they’ve helped create the problem. Giving a patient an antibiotic over the phone (without seeing the patient) or because the patient wanted to leave with a prescription when they knew it was probably viral-helped created the antibiotic resistance problem we have today.
Understand your part, your physician’s part and drug maker’s part in all of this and make sure everyone takes their fair share of the blame/accountability. Better still educate yourself on your antibiotic history and understand the dangers of over prescribing (next sniffle tough it out until you’re sure it’s bacterial) and know the dangers associated with each class of antibiotics. At the end of the day it’s up to your physician to prescribe what they view is best based on your history , willingness to be compliant as a patient (taking all your meds and not saving for the next infection), and other health factors. It’s up to you to educate your doctor on any unknown parts of the history or any concerns you have at the time of prescribing. Remember you must be your own healthcare advocate.