| Author | P Carabot | ||||||||||||||||||||||||||||||||||||||||||
| Abstract | INTRODUCTION The over prescription of antibiotics has long been a serious concern both globally and locally. The effects of this practise, in particular the ever increasing resistance of pathogenic bacteria are well documented. Treatment of any particular infection, (but gonorrhoea in particular) before sensitivity is known, should be with an antibiotic to which more than 95% of the local strains are sensitive. The capacity for inappropriate antibiotic use to mask disease without curing it is well known.
METHODS All patients attending the GU Clinic are asked about the use of antibiotics in the 4 weeks preceding the consultation. The notes of those who had been so treated where analyzed for the presence or absence of disease, and compared to those who had not received antibiotics before consultation. More specifically the cases of gonorrhoea seen in 2006 were analysed as to antibiotic sensitivity as well as previous antibiotic use. The results were compared to similar data from 2005.
RESULTS Antibiotic use During 2006, 1374 new patients attended the GU Clinic. The notes were scrutinized for previous antibiotics use. The information was available in 1104 case-notes. Of these 27.8% (308 of 1104 patients) had received an antibiotic in the 4 weeks preceding their clinic visit. In the vast majority of cases the specific name of the antibiotic was unknown. The rest 72.2% (796 of 1104) had either not received an antibiotic, or the patient had received (or taken) some medication but was not sure of its precise nature. The 2 groups were compared as to the presence of infections.
There seems to be no significant difference in the cases of Non-Gonococcal Urethritis (NGU). However NGU will only respond to a very narrow spectrum of antibiotics (chiefly tetracyclines) which are no longer commonly prescribed for empirical treatment. Muco-purulent cervicitis (MPC) can be considered to be the female equivalent of the male NGU. The same antibiotic spectrum applies and this might explain the similar numbers in the two groups. Chlamydia is responsible for 30-50% of Non-Gonococcal Urethritis (NGU) and 25-45% of MPC and shares the same antibiotic sensitivities. There seems to be no significant difference between the presence of gonorrhoea in the 2 groups. However, it must be noted that in the group that had not received antibiotics, 44% of the gonococcal cases were resistant to penicillin, tetracycline, and ciprofloxacin, whilst all cases in the antibiotic group were resistant. The number of cases is identical. However, the most of the cases (6 of 7) were Latent Disease where one would not expect any therapeutic response to the commonly used antibiotics. The main concern is the indiscriminate use of antibiotics in Early Infectious Disease, which can mask but not cure. PID is a sexually transmitted condition in 80% of cases and correct treatment needs to take this into account with a combination of the appropriate antibiotics. The use of a single broad-spectrum antibiotic will not suffice. Gonococcal antibiotic resistance During 2006, 32 cases of gonorrhoea were diagnosed. Of these, 19 (59%) were resistant to penicillin, tetracyclines and ciprofloxacin. One case was resistant to all but sensitive to ciprofloxacin. In the remaining 12 cases, sensitivities could not be determined as the organism failed to grow on sub-culture. All but one was sensitive to ceftriaxone and spectinomycin. Looking back at 2005, there were 23 cases of gonorrhoea of which 4 (17%) were resistant to first line treatment. 48% were sensitive and undetermined in the remaining 8 cases (35%).
DISCUSSION: During 2006, 28% of all new patients had received or taken an antibiotic in the immediate 4 weeks before attending the GU Clinic. (Comparable information is not available for 2005). Up till 2004 the first line treatment for gonorrhoea was ciprofloxacin 500mg stat orally. As already stated first line therapy is dictated by the necessity that less than 5% of the local strains are resistant to the chosen antibiotic. During the latter part of 2005 an increasing resistance to ciprofloxacin was noted which culminated in 17% of all isolates. The rate of resistance rose sharply in 2006 to 59%. The first line treatment was therefore changed to ceftriaxone 250mg im, which is the current treatment in the UK which had undergone the same problem in 2002. It is salutatory to note that two cases of gonorrhoea in 2006 were also resistant to ceftriaxone, which left us with only the old standby spectinomycin to use. Spectinomycin has become increasingly difficult to find, and these two cases caused the Health Department a very difficult and expensive search for it world-wide. A very small supply was eventually obtained from the GU Clinic in St. Thomas Hospital in London. Antibiotic use is rampant and, all too easy to obtain over the counter. Apart from general considerations, the GU Clinic needs to launch an educational campaign amongst all referring doctors not to prescribe antibiotics blindly to patients with possible STIs. Sensible prescribing is the only way to halt (? slow) the seemingly inexorable spread of super-bugs. | ||||||||||||||||||||||||||||||||||||||||||
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