Chapter 2: Antibiotic Prescribing with Misconception

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The doctor may have following misconceptions while prescribing the drug: 

2.1.   Newer drugs are always better drugs  

There is a limited knowledge of new antibiotic at the time of marketing and therefore, caution should be exercised while prescribing a new antibiotic. The exact therapeutic status and adverse effect profile of a new drug are evident only after several years of its use in population. 

A new antibiotic is not the answer to all the infections. Tigecycline is not effective against Pseudomonas. Daptomycin is not an effective drug for management of Pneumonia caused by MRSA. Teicoplanin is effective against MRSA infection, but not against Methicillin sensitive staphylococci infection, it is an inferior drug in comparison to Cloxacillin. 

2.2.   Expensive drugs are always better than cheap drugs  

This is also not true. Uncomplicated UTI responds very well to Cotrimoxazole, Norfloxacin, Ciprofloxacin, Ofloxacin, Cephalexin and Nitrofurantoin while third generation Cephalosporins and newer aminoglycoside antibiotics should be reserved for complicated UTI. Expensive higher class of antibiotics offer no advantage over cheap Cefazolin in prophylaxis of surgical site infection. 

2.3.   Polypharmacy is always better

More the numbers of drugs in prescription, better will be the therapeutic effect is a wrong notion. Empirical polypharmacy is only indicated in polymicrobial infections (like intra-abdominal abscess, lung abscess) and in life threatening infections (like meningitis, septicemia etc.). Fixed dose combination is also indicated in case of Tuberculosis and Leprosy.

2.4.   Fixed dose drug combinations (FDCs) are always better

Though the market is flooded with too many FDCs, but only few drugs have scientific justification for combining the ingredients. Antibacterial FDCs are enlisted in National and WHO Essential Medicine List like Sulfamethoxazole-Trimethoprim, Amoxicillin – clavulanic acid, Piperacillin – Tazobactam and Ceftazidime – Avibactam. 

Unjustified Polypharmacy (such as Cefuroxime and Clavulanic acid) and use of irrational FDCs lead to increased cost of therapy, increased risk of Adverse Drug Reactions (ADR)s and difficulty in assessment of its causality, problems of drug interaction and risk of multiple drug resistant infections. 

Since the updated National Drug Policy 2016, the government of Bangladesh (GoB) has developed three major policy documents/guidelines with direct implications on the prevention and control of AMR in human sector: i) Pharmacovigilance and Adverse Drug Reaction (ADR) Policy 2017 for monitoring the sale and dispensing of drugs without prescription; ii) Standard Treatment Guideline (STG) for appropriate use of antibiotic in the sub-districts; and iii) a guideline for antimicrobial stewardship developed by the country’s premiere medical university.