Antibiotic resistance frightens medical community

By Maria Kegel

JAKARTA (JP): We use them for everything from earaches to tuberculosis.

Ever since the 1940s, when they were first introduced, antibiotics have been hailed as the simple answer to any kind of infection which plagues us, and they are in easy reach in Indonesia.

Some doctors are quick to hand out prescriptions, while many pharmacies here do not require one to dispense the 150-plus types of antibiotics on the market.

And that alarms Dr. Amien Soebandrio, a veteran clinical microbiologist at Cipto Mangunkusumo Hospital in Jakarta, who said pharmacies dispensing the drug without a prescription could be breaking the law.

Law No. 782/1996 states that a person wishing to buy strong drugs must have a doctor's prescription.

"The problem is a patient will usually return to the pharmacy to get antibiotics for something else that has similar symptoms. And that makes it very difficult to control the use of the drug."

Too much of a good thing, or too little of it, spells trouble for the patient if any subsequent infections hit. The misuse of antibiotics has contributed to a looming crisis: antibiotic resistance.

According to a report in the New England Journal of Medicine on April 28, 1994, researchers had identified bacteria in patient samples that were resistant to all currently available antibiotics.

Experts from the American Society of Microbiology called this problem "global in scope and very serious" in a public warning issued in 1995. And doctors report that diseases we were once able to cure are rapidly becoming no longer treatable by antibiotics.

Dr. Amien said patients purchasing antibiotics at the pharmacy without a prescription were likely to stop taking the drug when they felt better instead of finishing the course.

Stopping short of completing a treatment is dangerous because microbes can survive and return, and the next time they will be resistant to that drug. Researchers have said this is a major cause of antibiotic resistance.

Dr. Amien said he knew some doctors overprescribed antibiotics, often giving strong drugs for simple infections to prove their expertise in curing illnesses. "That, in my view, is not wise."

On the other hand, patients also pressure doctors to dispense strong antibiotics, believing this will cure their ailment.

"Some patients cannot accept that they don't need antibiotics, and believe they are necessary for a cure, while some have a different view and refuse to take antibiotics when they are prescribed," Dr. Amien said, adding that those who refused were aware of antibiotic resistance.

Supervision of antibiotic intake is also necessary to guard against the risk of overdose or reactions with other medicines, Dr. Amien said.

He had a patient come to his office after he developed an adverse reaction to the antibiotics he was taking improperly while he was on other drugs for high blood sugar.

As a result, the patient was in bad shape and had a dangerously low blood sugar level, he said.

"We always tell doctors, pharmacists and the hospital management that we have to control the use of antibiotics in the hospital, because without their support it will be difficult to have everyone follow the antibiotic policy here."

In most cases, physicians at the hospital prescribe doses of antibiotics from three to seven days, depending on the severity of the infection.

"After three or five days, the patient's condition is reevaluated, and if there is an improvement or still signs of infection, they'll have the patient continue for another three to five days."

On the market

There are different strengths of antibiotics on the market; from a narrow spectrum to a broad spectrum, from limited strength to high potency and from cheap to expensive, he explained.

Antibiotics are prescribed depending on the infection; for example, strong single doses are needed for sexually transmitted diseases.

Costs vary from Rp 3,000 to Rp 5,000 for a treatment of three days, to Rp 500,000 for a single injection at the hospital.

Oral capsules are also available at Rp 20,000 each, but for many people the price puts the drug beyond reach.

Many turn to the black market, which is widespread in Jakarta, but concentrated at the infamous Pramuka market.

"Some people justify the existence of it (black market), saying it lets them get the drugs at an affordable price, but you just can't be sure of the quality of the drug."

In fact, Dr. Amien warned, buyers could be duped. The packages are the same, but the contents may vary. In other words, it is a big risk.

"Most people buy Quinolone, which is most effective in treating gonorrhea, on the black market. But there's been several times when patients have come back to me with purchased products from there, and only half of them are real while the rest are junk."

He said they found one vial of antibiotics from the black market had no active ingredients in it, and in another case, out of 20 capsules 15 were real antibiotics while five were fake.

"Some shops do sell good drugs, but there is always bad ones out there, so why gamble," he said.

"In the end, controlling antibiotics is a real big problem at this stage."