Download Inappropriate Antibiotic Use in the Philippines

Inappropriate Antibiotic Use in the Philippines
Emmanuel Edwin R. Dy, M.D.*
(*Senior Research Specialist II, Philippine-Australia Cooperation Project on National Drug Policy)
Inappropriate antibiotic use refers to improper administration with respect to drug dose, interval duration
(whether singly or collectively) in the light of proper clinical situations and/or financial considerations. The recognized
effects of inappropriate use (whether overuse or underuse) of antibiotics are multiple: (1) rapid emergence of
resistance, (2) selection pressure on resistant microorganisms, (3) adverse reactions, (4) treatment failures, (5)
occurrence of preventable morbidity and mortality and (6) waste of resources.
This is a review of local and foreign/published and unpublished literature from 1985 to 1995 with the
objective of gathering data explaining the multidimensional problem of local inappropriate antimicrobial use and
attendant development of resistance.
Inappropriate use comes as a result of a miltiplicity of factors. The community/consumer is
influenced/characterized by misconceptions, financial constraints. The behavior is reinforced by pharmacists’/drug
sellers’ practice of conducting transactions without prescription. The physician's behavior is greatly influenced by lack
of access to unbiased drug information and standard national treatment guidelines. High drug prices (an offshoot
largely of promotions and/or a result of preset profit margins) and lack of emphasis on cost and adverse effects of
promoted antibiotics are the identified contributions of the drug industry to the problem. The use of antibiotics in
agriculture and aquaculture is still another contributory issue: presence of antibiotic residues in products from these
industries, which do not disappear with freezing or cooking prior to human consumption.
Since routine local antimicrobial resistance surveillance commenced in 1988, there has been an upward trend
in resistance rates for most microorganisms. Nosocomial infections have been increasing in number in tertiary medical
centers in Metro Manila. Tuberculosis has assumed another dimension in its continued domination as one of the leading
causes of morbidity and mortality with the identification of multiple drug resistance. This is often a result of poor
patient compliance and/or physician adherence to recommended treatment guidelines.
This paper was developed as part of a multisectoral process which is working towards a coordinated strategy
to improve use of antibiotics. (Phil J Microbiol Infect Dis 1997; 26(2):77-87)
Key Words: antibiotic, inappropriate use
Inappropriate antibiotic use refers to improper administration with respect to drug, dose,
interval, duration (whether singly or collectively) in the light of proper clinical situations and/or
financial considerations. It is a wide spread phenomenon that has been written about in foreign
literature. Largely a result of a complex interplay of several factors, it often arises from failure to
define accurately the objectives for which the agent is given or from lack of knowledge of the
properties of the drug. 56
Antibiotics are generally beneficial in treating susceptible bacterial infections but such
beneficial effects are counter balanced by rampant irrational use.52 The prime consequence of
misuse is the rapid emergence of antimicrobial resistance48,73,76 and its attendant disease
aftermath. 48 Irrational use leads to selection pressure on resistant microorganisms and subsequent
spread of resistance genes, and preventable morbidity and mortality arising from treatment
failures. Adverse reactions are an unwanted feature of all drugs. Some practitioners would
consider underdosaging because of fears of a reaction. But scientific investigations have clearly
shown that when an antibiotic regimen is inadequate, therapy is ineffective, resistant strains
emerge, superinfections ensue and therefore both efforts and resources are wasted2 and ultimately
the total cost of therapy increases.7
Modern medical microbiology has established that the dominant factor in the selection of
bacteria with either intrinsic or acquired resistance in the hospital and in the community is the
extensive use of antibiotics.7,48 Multiple resistance (where bacteria are resistant to several
antibiotics) can be transferred from one species to another.7 Misuse is found in both developing
and developed nations but the problem is more acute in the former because of limited finances.
Some nations have limited the extent of misuse through implementation of regulations coupled
with education. Resistance to antibacterial agents is more prevalent in some parts of the world
than in others.52 There tends to be higher levels of resistance in Shigella, penicillinase producing
Neisseria gonorrhoeae, and M. tuberculosis in developing countries. Moreover in developing
countries with few laboratories to detect resistant strains on first appearance or no new agents to
treat infections caused by these strains, greater prevalence of such strains can be expected.52 Also,
resistant bacteria frequently cause nosocomial infections.37
What is the local antibiotic scenario?
Antibiotics account for 15 - 30% of drug expenditures, the largest of any therapeutic
group of drugs.15,41,79 A study by the World Health Organization's Programme for Appropriate
Health Care Technology (ATH) has shown a correlation between the occurrence of multiresistant
bacteria and antibiotic consumption patterns.7 The Philippines has the highest percentage in 1983
of antibiotic utilization among countries (including USA, Japan, United Kingdom) surveyed
(>25%).15 In a more recent survey (1990), the Philippine figures did change significantly.
However, majority of the people whether rich or poor allot minimum expenses for medical care at
2.7% and 1.2%, respectively. 72 Yet the local market is flooded with volumes of medications.8 Are
the overwhelming drug consumption figures reflective of an "artificially created market and not
the actual medical need? 60 Or, are there significant nonhuman sources of antibiotic use?
There is as much underuse as there is overuse.15 Lansang et al44 revealed that community
purchases were made without prescriptions in 66.3% of 1608 transactions. There was a low
median number of dispensed medications citing financial constraints as the more common reason
for noncompliance with the prescribed regimen. More important than this reason is the lack of
patient awareness that the regimen should be completed as exemplified by the common practice
of discontinuing the treatment once symptoms subside and as typified by anti-tuberculosis
treatment practices.
Information on antibiotic use on a national level has always been found to be scanty, and
hospital consumption contributes little in total drug use in much of the developing world. 16 At
best, conclusions can be inferred only from data/trends noted in tertiary training hospitals in
Metro Manila. An illustrative case is the problem of antibiotic utilization in acute diarrheal
diseases in children. The oral rehydration therapy (ORT) has been actively promoted since 1980
by the DOH as the cornerstone of therapy and that antibiotics have a limited role since only 10%
of cases are caused by dysentery. In 5 different provinces since 1987, there has been a consistent
and progressive increase in the use of antibiotics and antidiarrheals. This was explained by
caretakers' practice of self-medication and consultation with private practitioners who favor
antidiarrheal and antibiotic therapy over rehydration therapy. 8 At set indicator levels for the use
of intravenous rehydration, antibiotics and other drugs, there was note of disparity between
standard treatment guidelines and actual practices.
A 15-year review of infections at the Philippine General Hospital (PGH) from 1971-1987
showed that gram-negative bacteria constituted the most commonly isolated organisms 76 with an
average of 37-63 percent of antibiotic resistance In 1994, these findings were consistent with
foreign literature. Costs of antimicrobial utilization of the different departments in the same
institution from January to March 1994 revealed that surgery (P381.740.94), obstetrics and
gynecology (P506,996.13), medicine (P677,054.65) and pediatrics (P337,910.21) had 32.35%,
16.21%, 10.07% and 6.25% respective of their budgets allocated for restricted to very restricted
antibiotics respectively.
In a retrospective analysis of 1,578 antimicrobial prescriptions at the institution's
emergency room complex in 1989, prescribed antibiotics were considered inappropriate in 65.2%
of cases and 61% were given prophylactically. Respiratory tract infections comprised the most
common condition noted. Unemployed patients made up 42% of the population studied. 77 The
value was similar to the figure of 64% for inappropriate prescription cited by the Health and
Public Policy Committee of the American College of Physicians.7 At the Clinical Division of the
Santo Tomas University Hospital, Villar et al79 studied the antimicrobial utilization pattern from
1990 to 1991. Fifty-eight percent of the patients received antibiotics singly or in combination.
There was no clear indication for the antibiotic in 4 percent; 42% of patients received the
antibiotic for therapy and 54% received the antibiotic for surgical chemoprophylaxis. Based on
accepted standards for antimicrobial usage, there was inappropriate use of antibiotics in at least
35% of cases. The greatest identified problem was in surgical chemoprophylaxis with respect to
the indication, timing, duration and choice of antimicrobials. Antimicrobial utilization trends at St
Luke's Medical Center showed that 45.7% of therapeutic regimens and 89.4% of prophylactic
regimens were considered inappropriate.21
Is the problem recognized locally?
The problem of inappropriate antibiotic use is not the physician's alone - it is shared by
the other health professionals drug sellers/pharmacists, barangay health workers, government,
community and the pharmaceutical companies as well. Local literature documents some revealing
practices which should be taken into consideration in attempting to curb the problem.
The Community
Understanding behavioral patterns related to antibiotic use in the community should go
beyond the routine KAP surveys. Antibiotics use is influenced at least in part, by cultural
preferences and beliefs about medications.41 Common misconceptions include: (1) for every
symptom, there is a specific remedy; (2) antibiotics as wonder drugs; (3) the more expensive a
drug is the more likely it is to be effective; (4) injections as more "powerful" forms of
medicines; and (5) drug use should be stopped when symptoms subside.
Patients/caretakers (like some physicians) generally consider antibiotics to be relatively
risk-free and are often not troubled by considerations of under treatment or development of
resistant organisms.6 Some generalities about behavioral patterns related to antibiotic use include:
(1) knowledge is not necessarily about antibiotics, e.g. "gamot sa ubo" or "gamot sa sipon"
(medication for cough or medication for colds); (2) antibiotics are used for infections but notion
of the latter is usually vague leading to the belief that infection is synonymous with fever; (3)
"strong" antibiotics are considered "bad"; (4) antibiotic dosage is directly related to severity of
disease (e.g. rifampicin at 450 mg is for "weak lungs" while 600 mg of the same drug is for
tuberculosis).
Widespread self-treatment often with the least effective agent in an incorrect dosage, is
considered a major factor in the development of bacterial resistance in developing countries.7
Locally, Hardon29 noted the practice of recycling prescriptions for recurrence of symptoms
initially assessed by a doctor. Self-medication is a prevalent practice influenced by the cost of
consultation and/or the confidence in the prescription habits of the doctor.29,41,43 This is
substantiated by the observation that ampicillin was the most common antibiotic prescribed by
the physicians and used as self-medication. 29 Recycling of prescriptions is further explained by
the usual concept of "hiyang" i.e. a drug is perceived as useful for a particula r patient’s illness
leading to its repeated use.71 An example of this is caretaker's perception and management of
diarrheal disease which may result from milk formula that is not "hiyang" or from something
"marumi" (dirty).71 Correspondingly, caretakers resort to changing the milk formula or (worse)
using anti-infective treatment depending on which concept appealed/applied at that particular
instance. Sia et al63 furthered Hardon's findings with the following data: (1) antibiotics comprised
21.6 percent of stored household drugs, (2) stored medications averaged 3.6 per household, (3)
60.7 percent of population adopted the practice and (4) reasons for storage included first aid
measures and left-overs.
Commercial sex workers share beliefs and practices according to experiences and pieces
of advice passed on from group to group. Symptomatic and/or prophylactic antibiotic use is/are
tailored to type of customer, presence of symptoms and effectiveness of previous prescriptions.
The notion that antibiotics are much easier (and more accessible) to use aggravates the problem
of widespread drug resistance in sexually-transmitted diseases.
The Pharmacist/Drug Sellers
The person behind-the-counter, whether the pharmacist or the drug seller, also has a large
contribution to the pervasive practice of self-medication. Lansang et al noted that written
prescriptions were available in only 57 percent of 6404 drug transactions in a rural pharmacy and
that median number of antibiotic units dispensed on a single visit was 6 capsules/tablets or 1.5
vials/ampules.43 Financial constraints, the cultural concept of "hiyang", discontinuation of
antibiotic upon relief of symptoms and the allocation for other forms of treatment are factors
curtailing the patient's ability to purchase the full course. Worse, pharmacists/drug sellers may
also act as "pill consultants" for walk-in patients who are just "shopping" for affordable
medications or may substitute/choose another medication (non-generic equivalent) in lieu of the
prescription; such practices definitely make antibiotics (and other drugs for that matter) far too
accessible. Analyzing further the situation, the bottom line is that the physicians are unable to
enlighten the patient about repercussions of poor compliance and self-medication with antibiotics.
There is also need for better communication between physician and pharmacist. The
pharmacist/drug seller is also an essential client of the medical representative. The medical
representative monitors the physician's prescriptions by doing weekly checks on the local
pharmacy for his monthly report. The ability to gain access to such data and the unspoken
potential of the drug seller's clout in pushing his product to walk-in customers depend on the
rapport between medical representative and dispenser which is generally furthered by giving them
samples, gimmicks and deals.75 Realizing the strong influence of the person behind-the-counter
and still using the diarrhea situation as the example, a survey was recently conducted by the
National Control of Diarrheal Diseases Program of the Maternal and Child Health Services
regarding knowledge, attitudes and practices of Manila pharmacists on diarrhea treatment.51 It
showed that the respondents had ample knowledge of the disease. However, inadequate advice,
recommendation of mild substitutes and antidiarrheal agents and less utilization of oral
rehydration solution (ORS) were commonly noted. ORS was perceived as a drug to stop diarrhea
and not as fluid and electrolyte replacement. Findings generated from the study shall be utilized
to correct the situation of continued antidiarrheal/antibiotic use and lack of emphasis on ORS.
The Prescriber
The physician often has to contend with self-medication practices of patients which may
mask underlying infection. 41 With this reality, he often resorts to newer broad spectrum agents.55
The practicing physician has the medical representative and the Philippine Index of Medical
Specialties (PIMS)60,61 as his ready references for acquainting with new drugs. This is also
compounded by the lack of standard national guidelines (or the lack of dissemination thereof) and
the inability to individually address efficacy. Limited surveys on doctors' prescribing habits show
that pharmaceutical products are being prescribed inappropriately. 60
Doctors-in-training prescribed more rationally than practicing ones; prescribed antibiotics
less frequently when confronted with diarrhea, fever or sore throat cases; and favored non-drug
therapy over drugs.60,61 Polypharmacy or multiple drug utilization is a common practice, i.e. a
therapy for every (potential) symptom. 16,30,32,44 Hardon29,30 particularly noted that there was a
higher average number of medications per illness case in doctors' prescription than in self-
medication. Physic ians also utilized antibiotics as diagnostic tools in severe cough and diarrhea
cases to determine whether the cause is bacterial or not.29-30
The dentist similarly prescribes antibiotics but there are no local studies on his
prescribing habits available. Dental infections are commonly caused by Streptococcus,
Peptostreptococcus, Peptococcus, Fusobacterium, Bacteroides and Actinomyces sp. Antibiotics
widely accepted for dental indications are the penicillins, cephalosporins amino-glycosides, and
erythromyc in.54 Of these, penicillin remains the drug of choice because of efficacy, low cost and
ease of administration. 54-67 Aside from the undocumented contribution to irrational antimicrobial
prescription, antimicrobial resistance is linked to mercury resistance (from amalgam fillings)
because of common genetic locus(i). Mercury released from amalgam can cause an enrichment of
mercury resistance plasmids in normal bacterial flora.67
The Drug Industry
In 1993, the total pharmaceutical market in the Philippines was valued at P23.8B
($930M), up by 5.8% over the previous year58 despite increased regulatory controls. Close to 80%
(P18.9B) of total sales were through drugstores the volume of which has improved by 5% with
prescription products accounting for P13B. In line with previous years, almost all therapeutic
products were branded and the Metro Manila area accounted for nearly 45% of nationwide
drugstore sales. Systemic anti-infectives continued to lead the pack accounting for 22.2% of the
total value of drugstore sales at P4.187M.
An intriguing observation is the fact that retail drug prices are highest in the Philippines
compared with other Southeast Asian countries (Table I).20,30,62 In fact, medications exported to
other countries (e.g. Hongkong and Singapore) are cheaper than the locally marketed
counterparts.
Medicines continue to be expensive and are often inaccessible for common illnesses.72
Tan noted that the Generics Act of 1989 which should have helped people make cost-saving
choices, has been poorly implemented. This resulted from: (1) physicians disregard for generic
prescribing, (2) few generic products carried in drugstores, and (3) effects of continued
advertising on people.72 Retail pharmacies have a limited mark-up so the high costs can well be
attributed to production, distribution and marketing expenses.
Largely responsible for the success of the industry are extensive promotions and fostering
of close personal relationships with physicians, built on a number of core Filipino cultural values
like "utang na loob" (debt of gratitude).23 Direct face-to-face presentation by medical
representatives continue to be particularly effective thus the industry's vast expenditure.
Medical representatives, among other tools of the drug companies are often the first
source of information about new drugs and are influential in physician's decisions to prescribe a
drug for the first time.1,81 As detailers of drug information, medical representatives are grossly ill
equipped. Thus, physicians rarely ask them additional information about their products.23,48 The
PIMS which is frequently utilized similarly as source of drug information, is practically a product
of the industry. 32,60,61 Locally, 68% of the average promotional budget is spent on representatives
salaries and travel expenses23,53 while the remainder covers literature and documentation (14%),
samples (9%) and scientific seminars (9%).
Promotions are not limited to company-labeled items but may even extend to provision of
personal physician amenities/necessities as anonymously disclosed by medical representatives
when enjoined to participate in a research conducted by van Staa.75 Studies have shown that such
behavior is common among local practitioners.1,14,68
A number of studies have identified the "missing essentials" in the industry's thrust: (1)
rare mention of costs6,23/side-effects6,80 and (2) educational value.80 These are considered
essentials because nondisclosure of the good and bad effects of the drugs may spell harm for the
end-user (i.e. the patient) whose outcome is decided for by the physician. 18,23,80 In an era where
several similar drugs are often available for a given condition, it is more important that physicians
be provided with accurate information. 80
Table 1. Retail drug prices of 100 unit s (tables/capsules) of 24 commonly used drugs in 29 countries all values are given in US dollars
at the current exchange rate. Two economic indicators and retail prices of four food items are given. 70
DEVELOPING COUNTRIES IN THE ASIA PACIFIC REGION
Bangla
deesh
Minimum daily wage
USD
Real GOP per capita
(PPP$)1991
Name
Strength
of Drug
in mg
Amoxycillm
250
Atmoxil
250
Capoten
25
Cimetidtne
200
Tagamet
200
Cotnmoxazole
480
Septrin
480
Diazeparn
10
Valium
10
Diclofenac
50
Voltaren
50
Erythromvcin
250
Erythrocin
250
Furosemide
40
Lasix
40
Adalat
5
Adalat
10
Propranolol
40
Inderal
40
Inderal
80
Ranitidine
150
Zantac
150
Common Food item
Rice
Sugar
Milk
Eggs
Average
1 kg
1 kg
1L
1 dozen
HK
150
India
Indo
nesia
Malay
sia
1.6
Nepal
Pakis
tan
Philip
pines
1.7
2
5.6
Sri
Lanka
Thai
land
5.6
1160
18,520
1,510
2,181
7400
1130
1970
2.440
2.650
5,270
6-9
4-6
03
02
10
01
20
33
01
05
33
47
73
12
42
26
31
23
31
47
119
09
10
05
03
03
03
03
02
02
12
11
2
3
04
8
03
03
10
40
06
56
07
25
48
52
10
37
02
33
18
04
74
150
16
34
54
20
35
08
16
03
16
29
08
12
06
22
25
41
05
12
86
08
09
05
03
03
03
02
02
03
03
05
oe
21
09
14
03
05
03
07
16
05
07
0.6
02
01
28
14
39
22
29
54
95
20
53
46
52
25
37
20
35
40
12
25
95
04
24
25
02
23
01
09
0.14
03
02
29
05
09
0.6
05
09
0.6
05
63
05-24
17-26
33
03-12
34
04
8-14
08
04
40
6-16
20
9-14
20-26
04
13
26
20-40
74-132
0.4 6
0.79
0.62
0.89
1.44
0.97
1.37
0.67
0.47
0.47
0.50
0.47
0.40
0.72
0.36
1.34
0.56
0.52
1.00
0.76
0.32
0.44
0.28
0.75
0.52
0.50
0.39
0.65
0.40
0.68
1.63
1.02
0.39
-0.62
0.50
055
1.00
1.25
0.69
1.11
0.48
0.71
071
0.45
052
0.93
0.83
Source: Personal Communication from HAI partners in the respective countries.
PPP$ UNDP, Human Development Report, 1194 New York, Oxford University
Measures such as curbing drug advertisements,17,20 occasional DOH warnings 19 and
issuing ethical guidelines1,49 have been put in place but the sales figures cited earlier certainly
belie the effectiveness of such tools. Appropriate intervention should be directed at helping the
physician understand the complexities of the drug industry, aside from knowing the drugs utilized
in his practice.79 There are no means to check on the claims of drug ads, leading to proliferation
of drug advertisements with unfounded claims.20
In response to this paper, the Pharmaceutical Health Care Association of the Philippines
(PHAP) and the Philippine College of Pharmaceutical Medicine (PCPM) issued a position paper57
acknowledging occurrence of antibiotic resistance caused by a multiplicity of factors - over-thecounter (OTC) sales, self-medication, poor patient compliance, poor quality of products (e.g.
DOH rifampicin) and empiricism due to unavailability of laboratory facilities. The paper also
highlighted self-regulating mechanisms by the industry. It also contained the commitment of the
industry to cooperate with the DOH in solving the problem of inappropriate antibiotic use. The
paper also strongly suggested that critical appraisal of literature using only well-controlled and
large studies can help avoid making generalizations about drugs.
The Use of Antibiotics in Agriculture and Aquaculture
Animal feed additives have for many years constituted the largest and most controversial
category of antimicrobial use.26 Col and O'Connor 35 noted that non-human uses accounted for a
significant share of the market in developing countries and confirmed that data on production and
trade generally do not distinguish between human and non-human uses or between therapeutic
and non-therapeutic uses. In a largely agricultural country like the Philippines, antibiotics are
utilized extensively in animal feed production. Such may partly explain why the antimicrobial
consumption is disproportionate to the purchasing power of the average Filipino.
Commonly utilized and advertised antibiotics include cotrimoxazole and cotrimazine.
Chloramphenicol, at one time, was utilized in aquaculture. The primary concerns addressed have
been the generation of antibiotic resistance in animal bacteria and the influence of such resistance
on human health. 82 The presence of antibiotic residues in meat, milk and their products poses
potential human health hazards since cooking and freezing have minimal effects on residues.7
Experience in Germany showed a distinct reduction in selection pressure and decrease in
oxytetracycline resistance among Enterobacteriaceae after reduction in 1981 and final prohibition
in 1983 were enforced as a government strategy. 74
New resistance genes and multiresistant organisms with increased pathogenicity are
emerging in animals as a direct consequence of antibiotic exposure.82 Cabrera in a local
experiment elucidated the role played by the popular practice of supplementing animal feeds with
antibiotics in the spread of multiple resistance among microorganisms through either selection of
resistant strains or through genetic recombination via conjugation. She demonstrated transfer of
chicken multi-drug resistant Escherichia coli plasmids to human antibiotic sensitive E. coli.
Is antimicrobial resistance a problem in the Philippines?
That misuse results into resistance requires proof of presence of the latter locally. In a 6year surveillance (from 1988 to 1994) of mostly Metro Manila institutions 12,13 there has been
noted an increasing resistance for Salmonella typhi against ampicillin, chloramphenicol and
cotrimoxazole; shigellae against cotrimoxazole; Pseudomonas aeruginosa against ceftazidime
and fluoroquinolones; Escherichia coli against gentamicin and cotrimoxazole. In general,
Enterobacteriaceae has increasing aminoglycoside resistance (Figures 1 - 5) while Neisseria
gonorrheae now has established fluoroquinolone and beginning ceftriaxone resistance.
Unfortunately, there have been no concurrent antimicrobial consumption pattern studies to help
establish a link between misuse and resistance.
Multi-drug resistant tuberculosis is one nagging problem that has been acknowledged as a result
of poor adherence to prescribed drug regimen. The surveillance done in selected areas provide
valuable information on resistance pattern. Recognizing the problem, Mendoza et al50
investigated the nature and predictors of multi-drug resistant tuberculosis (MDT-TB) at the PGH
from June 1992 to May 1995. Of 299 subjects, 165 (55%) had cavitary chest radiographs, 245
(82%) had acid-fast bacilli in sputa and 167 (56%) had anti-TB treatment previously. Among
these parameters, previous anti-TB treatment was the sole predictor of MDR-TB. Table 2 shows
the overall drug susceptibility pattern.
What can be done about the situation?
The problem of misuse is difficult to solve single -handedly and success may be difficult
to achie ve. The multifaceted problem deserves a complex multisectoral solution. In the current
set-up, physicians are hardly reminded about the repercussions of antimicrobial misuse. The drug
industry is implementing self-policing measures but the situation is still far from ideal.
Meanwhile, there are still little efforts to educate and/or investigate the Filipino patients self-
medicating practice. While a minority of physicians is inclined towards conservatism, the
majority and their patients still adhere to the belief that "without a prescription, a doctor is no
good."
Figure 2. Yearly resistance rates of shigellae all institutions, Sept. 1988-Dec. 1994.
Resistance rates are not within acceptable range and should be continuously surveyed
with possible inclusion of more institutions nationwide. Projections for developing countries in
the next 10 years regarding established antimicrobial utilization and consumption indicate no
change in trend. 52 This calls for a more urgent stand and the urgency stems from the need to
prevent the potential aftermath of spread of resistant micro-organisms. The output of the
surveillance program should be disseminated to as many institutions nationwide as possible. To
be able to arrive to this end, a certain level of awareness should be raised starting with solicitation
of active support from government and non-government organizations (NGOs). The surveillance
program has been without funds until 1994 and the present funding is from research projects
which shall end on June 1997.
The situation still allows some leverage for policymakers to resolve the problem by
adopting a multisectoral approach. Rational drug intervention programs must be primarily
directed at students while they are in the medical school. They should be reinforced during their
training years in the hospital, and while in active medical practice. Educational efforts should also
be targeted at the dispenser the barangay health worker, the aquaculture/agriculture sector
because they are also recognized stakeholders in the problem.
The absence of role models should be realized and addressed for the stakeholders to emulate.
Local medical journals should also take the step in checking the claims of advertisements and
should consider non-pharmaceutical but doctor-related products as part of their advertising
clientele to support their viability.
Table 2. Overall drug susceptibility pattern of multidrug resistant tuberculosis at the Philippine General Hospital
(1992 - 1995)50 N = 299
Sensitive to 5 drugs (RHESZ)
Total drug resistance
Rifampicin (R)
Isoniazld (H)
Ethambutol (E)
Streptomycin (S)
Pyrazinamide (Z)
Multidrug resistant
HR
Not HR
Total
Number
50
249
Single Drug Resistance (SDR)
2(0.7)
7 (2.3)
77 (25.8)
1 (0.3)
2 (0.7)
Percent
16.7
83.3
Total (MDR and R)
102 (34)
135 (45)
210 (70)
66 (22)
51 (17)
95 (38)
65 (26)
160(64)
SUMMARY
1. Clinically and economically inappropriate use of antibiotics is a major problem in the
Philippines and internationally as well. There is both overuse and underuse. The problem is more
acute in developing countries because of limited resources.
2. The consequences of antibiotic misuse include increased selection pressure of resistant
microorganisms, preventable morbidity and mortality from treatment failures, adverse drug
reactions and wastage of limited health care resources.
3. The problem of inappropriate use of antib iotics is complex, multi-factorial and
involves numerous stakeholders.
4. There is no simple solution but the first step is to get all stakeholders to acknowledge
that a major problem exists and that cooperation is essential if national and global solutions are to
be achieved.
RECOMMENDATIONS
An urgent campaign should be developed to address the issue of antibiotic misuse and the
emergence of antimicrobial resistance. All stakeholders need to be involved in the development
and implementation of the educational strategy to address the problem.
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4. Antibiotic resistance and dispensing regulations. Drug Monitor 1987; 2(3):15-16.
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