Antibiotic resistance in Malta is among the highest in Europe, and all stakeholders need to come together if the current “alarming” situation is to be controlled and possibly improved, National Antibiotic Committee chairman Michael A. Borg wrote in the June 2009 Malta Medical Journal.

Committee secretary and antibiotic pharmacist at Mater Dei Hospital Peter Zarb agreed, telling this newspaper that antibiotic resistance, particularly in the hospital setting, is undoubtedly alarming.

“Old drugs such as penicillin and ampicillin are still effective in countries like Sweden, Denmark and the Netherlands, but not in other European countries, including Malta. So we have no choice but to use more advanced, more expensive drugs. The older ones are likely to be ineffective,” said Mr Zarb.

Resistance means that people with infections are ill for longer periods and are at greater risk of dying, and disease epidemics are prolonged.

Since their discovery, antibiotics have revolutionised the way we treat patients with bacterial infections and have contributed to reducing rates of mortality and morbidity from bacterial diseases.

They are also an essential tool for modern medicine, and common procedures such as transplants, chemotherapy for cancer and even orthopaedic surgery could not be performed without the availability of potent antibiotics.

Unfortunately, antibiotics have also been liable to misuse and are often unnecessarily prescribed for viral infections.

Similarly, when diagnoses are not accurately made, more often than not broad-spectrum antibiotics – antibiotics that kill a large proportion of various bacteria and not only the bacteria responsible for the disease – are prescribed because the micro-organism responsible for the infection is not known.

According to the World Health Organisation, even if the pharmaceutical industry were to step up efforts to develop new replacement drugs immediately, current trends suggest that some diseases will have no effective therapies within the next 10 years.

Dr Borg writes: “Antimicrobial resistance is increasing and it brings with it the possibility of untreatable infections and a return to the pre-antibiotic era.

“The repercussions of resistance are not simply restricted to the individual patient. Resistance also has a direct impact on health care facilities.”

In fact, patients with resistant infections would need longer hospitalisation to treat their infection.

“It is therefore logical to conclude that attempts to reduce resistance should focus on reducing the unnecessary use of antibiotics”, Dr Borg argues.

He goes on to say that emphasis on improved hand hygiene compliance within health care facilities remains a paramount component for all infection control programmes and various models have been proposed to achieve the desired results.

Dr Borg proposes more judicious antibiotic prescribing attitudes, together with greater ownership and accountability of infection control policies and procedures.

“The way forward is quite obvious; the only uncertainty lies in getting all stakeholders to buy into it and thereby translate words into day-to-day practice.”

Pharmacist Anne Marie Spiteri told The Malta Independent on Sunday that antibiotics are often used to treat non-bacterial infections.

“Antibiotics are ineffective against say, viral infections. To avoid increasing antibiotic resistance, they should only be used when needed and they should definitely not be handed out without a prescription because that reduces control.”

From a pharmacist’s point of view, one useful practice is to tell patients to wait two to three days before taking antibiotics to treat an infection, said Ms Spiteri.

“Most people will get better, and pharmacists must emphasise that the whole course of antibiotics should be taken. If a lower dose is taken, or the course is left unfinished, the patient might be leaving some of the stronger bacteria there. They will then become resistant since they will be exposed to a dose of antibiotic that does not kill them.”

Contacted for comment, Medical Association of Malta president Paul Pace said that the situation in Malta is very similar to that in other Mediterranean countries.

The Mediterranean region is generally less disciplined than the Nordic countries, which have stricter antibiotics policies, he said.

In these countries, it is common practice to have experts, such as microbiologists, decide which antibiotics to prescribe. In Malta, however, doctors have a free hand.

“The most the MAM can do is to draw the matter to the doctors’ attention, if they were prescribing too heavily, but no action can be taken. The doctor could argue that it was for the good of the patient.”

Some practitioners conform to the policy, whereas others will give antibiotics to ensure that people go back to them time and time again, or because they genuinely believe that the patient is their responsibility, so they will not be taking any chances.

“There needs to be enforcement, policies alone are not enough. Right now, it is simply a question of voluntary conformity. The consultant responsible for the patient could ask for expert advice,” said Dr Pace.

The private sector was even less controlled than Mater Dei Hospital and other public hospitals, which keep tabs on the antibiotics that are given out, he concluded.

Unfortunately a lot of people ignore the facts and this newspaper is told that doctors often give in to patients’ requests.

Pharmacists, on the other hand, are often faced with pressure from patients to hand out antibiotics without a prescription.

The challenge of the “microbial threat” is even recognised by the European Union, through numerous communications over the past year, culminating in the adoption of a community approach titled “A strategy against the microbial threat, which was approved in 1999.