• Bacterial resistance to antibiotics is becoming an increasingly worrisome problem.
• Some bacteria are now resistant to virtually every antibiotic in our arsenal.
• Bacterial resistance has arisen due to the widespread use and overuse of antibiotics.
• To decrease the threat of this growing problem, we physicians need to resist the urge to prescribe antibiotics "just in case" or because patients demand we "do something."
• The CDC and other organizations are now encouraging a "back to basics" approach to infection - culture first and treat with antibiotics only when that culture is positive or the physical findings dictate.

The global rise in bacterial resistance to antibiotics has necessitated the development of more complex, broad-spectrum, next-generation antibiotics. These new antibiotics are prescribed over longer treatment periods, resulting in higher healthcare costs and disturbingly frequent deaths from antibiotic-resistant infections.

In 1997, the first two cases of vancomycin-resistant Staphylococcus aureus infection were reported in Michigan and New Jersey. Our firewall to this dangerous hospital infection is beginning to crumble as it did in past decades with penicillin, bacitracin and other "last stand" antibiotics.

Growing resistance is not limited to antibiotics of last resort, but also includes resistance to first-line, narrow-spectrum, inexpensive ones like erythromycin, which are favored by our formularies. A Finnish study reported in the New England Journal of Medicine stated that Group A Streptococcus resistance to erythromycin increased two and one-half times over a one year span. Over the next two years, resistance continued to rise almost 20%. This occurred in spite of urgent recommendations for a decrease in antibiotic usage and subsequent physician compliance, which cut usage by almost one half.

How did this become a problem?

In the early 1940's, when sulfonamides (or "sulfa" drugs) were our only antibiotics, a physician visited his New England alma mater to refresh his skills and knowledge. While he was there, he was told about a new drug being tested against bacterial infection. The success stories and cases he witnessed were remarkable. He arranged for samples of this experimental drug to be shipped to his practice for trial usage. His first trial case was a comatose child with meningitis. After 36 hours of treatment with a 250 unit dosage every 6 hours, the child was afebrile and awake. Other similar outcome cases were recorded. That drug was penicillin and it became known as "the Wonder Drug." It was an easy next step for physicians - eager to help their patients suffering from infections - to prescribe this new drug for everything.

Over 282 million antibiotic prescriptions were written in the United States last year. The Centers for Disease Control and Prevention (CDC) estimates at least 50 million (1 in 5) were unnecessary. A recent article in JAMA reports a study citing significant rates of over-usage of all antibiotics. We are now facing the results of decades of over-treatment with antibiotics.

What can we do about this growing problem?

We physicians are busy. Although we feel guilty about phoning out antibiotics "just in case," we often do. Busy families demand that we "do something" quickly to reduce their anxiety or keep them from having to visit our offices. Day care center policies dictate that a child "see the physician or be under treatment" to return to their care.

Regardless of the reasons for over-prescribing antibiotics, we must do something to reverse the pattern of increasing bacterial resistance and overuse. The CDC, Academy of Pediatrics and Family Practice and the Society of Microbiology are now campaigning to decrease the use of antibiotics. These organizations are encouraging a "back to basics" approach to infection - culture first and treat only when that culture is positive or the physical findings dictate antibiotic use.

Worldwide print and electronic media are also sending the message about antibiotic overuse. As physicians, we can use this exposure to educate our patients to never demand antibiotics and, when antibiotics are prescribed, to take the entire prescription.

As we see symptoms of fever, cough, sore throat, congestion and headache this flu season, let us resist the temptation to prescribe an antibiotic, and follow the mandate of our oath to "at least do no harm."