The problem may have many sides, but the behaviour of doctors plays a key role in continuing the cycle of antibiotic resistance.

Doctors are known for their uncanny ability to retain, absorb and spit out vast amounts of knowledge all at once. The formative years of medical school prepare them for this but when they finally get out into the pressurised field of medicine, what they learn and what they practice can be very different. It turns out this ‘know/do’ gap is a contributing factor to antibiotic resistance, the worldwide phenomenon that, according to the United Nations, can cause 10 million deaths every year by 2050.

Antibiotics (or ‘antimicrobial agents’) have been a miracle of modern medicine since 1928. Since then, healthcare systems around the world could not function without these vital (and relatively cheap) treatments that have been used to combat a wide range of bacterial infections for decades.

So what’s the problem? Medical practitioners are overprescribing the same standardized set of drugs to combat bacterial infections but bacteria has evolved. The microorganisms have learned to outsmart antibiotics used to treat them, leading to a complicated and highly dangerous global healthcare crisis.

Once easily treatable bacterial infections such as tuberculosis, pneumonia and gonorrhea are potentially leaving millions of people finding themselves falling ill without a solution. The cost to public healthcare systems already burdened with high rates of infectious disease, such as South Africa, is said to be catastrophic.

What caused the crisis?

“The everyday bacteria that we’re all exposed to, those are getting increasingly resistant to common antibiotics…the antibiotics that used to work 20 years ago, the cheaper, simpler ones, don’t work anymore,” said Dr Duane Blaauw, a senior researcher in health systems and health policy research at the Wits Centre for Health Policy (CHP).

According to the United Nation’s Interagency Coordinating Group on Antimicrobial Resistance (IACG) 2019 report called ‘No time to wait, securing the future from drug-resistant infections’, “at least 700 000 people die each year worldwide due to drug-resistant diseases, including 230,000 people from multidrug-resistant tuberculosis.”

There is no single cause of antibiotic resistant bacteria (ARB). South Africa has a high burden of infectious disease. A significant portion of the population lives with compromised immune systems because of the high rates of HIV/Aids. Inadequate water and sanitation in most parts of the country and issues with public service delivery also compound the problem of ARB.

But a study published by the Wits University School of Public Health and the London School of Economics and Political Science in March 2019 found that over-prescription of antibiotics could be one of the leading factors for South Africa having one of the highest rates of ARB in the world. And the crisis is partially coming from doctors.

The study, called ‘Unnecessary antibiotic prescribing in public and private primary care in South Africa’, found 78% of patients in public clinics and 67% seen by private general practitioners were prescribed antibiotics unnecessarily, mostly for infections caused by viruses. The more you prescribe antibiotics for diseases that are ineffective against them, the more diseases can mutate to become stronger and more resilient against the very same treatment.

It all boils down to behaviour

Over-prescription of antibiotics is a leading cause of ARB: so why are doctors doing it?

“In this area, there is quite a well-described problem which we call the ‘know/do’ gap, which is the differences in behaviour between what people know what they’re supposed to do and what they actually do in practice,” said Blaauw, co-author of the study along with Dr Marylene Lagarde.

Any medical practitioner can tell you not to prescribe antibiotics for viral infections like colds or flu, but sometimes pressure of the practice and accepted ways of doing things intuitively, rather than based off evidence, can spread harmful behaviour.

“It’s difficult when you start working as a doctor,” said Blaauw.

“You’re a bit overwhelmed, you learn these quick short-cuts, you learn how to cope and sometimes as part of that you’re learning bad behaviour particularly around antibiotics,” said Blaauw.

Professor Guy Richards, head of intensive care at Charlotte Maxeke Hospital in Johannesburg, said that education around antibiotics for medical school students should be more specialised to avoid creating these problematic habits.

“The antibiotic lectures are taught by lecturers not specialised in antibiotic stewardship, [which is the] practical use as opposed to pharmacology,” said Richards.

“Antibiotic prescribing has become a science: a non-oncologist would not prescribe chemotherapy and similarly not all doctors should be allowed to prescribe antibiotics. We are moving toward a system where a specific examination must be passed before the doctor may prescribe antibiotics,” he said.

What do student doctors have to say?

A doctor’s journey starts at medical school but because of the high-demand for learning and churning out information at break-neck speed, student doctors may be clued up on the theory but the gaps in practical education start to show when it’s time to practice.

Naeem Vallee, 24, a sixth-year Bachelor of Medicine and Bachelor of Surgery (MBBCh) student at Wits, said the education around antibiotics is thorough and med students are exposed to the South African Antibiotic Stewardship Programme, an initiative to help create a coordinated program that raises awareness around the appropriate use of antibiotics, but pressures of being a med student can sometimes widen the gap.

“As a student, we have a huge volume of work to digest and perhaps regurgitate, especially for exams,” said Vallee.

“We often forget about our basics if we try to cram or don’t commit things to memory and that’s a normal process but one that needs to be addressed.”

Vallee also said that there could be a clearer link that student doctors are not dealing with data and cases. There are real patients behind the choices that they make.

“I think what’s overlooked is actually teaching students that we learn about these drugs to help our patients and not to test our own knowledge,” said Vallee.

“That mindset shift can help us to learn even more as it makes us responsible for the patient’s care and therapy.”

Layla Cassim, 21, is doing her third-year in MBBCh and feels that the move towards greater awareness of antibiotic resistance should also emphasise evidence-based diagnostics and not rely on intuition to address patient needs.

“In my opinion, there could possibly be more awareness created surrounding antimicrobial stewardship,” said Cassim.

“Although all med students are taught that antibiotics only treat bacterial infections, there are many doctors who prescribe antibiotics without sufficient evidence that their patient has a bacterial infection,”

Finding solutions

How does the ‘know/do’ gap get filled when it seems to be getting bigger? Dr Blaauw emphasizes the need for doctors to be confident in the decisions they make without fear of potentially unhappy patients who may influence their course of action to prescribe antibiotics even when it’s unnecessary.

“Thorough examinations should be encouraged and certainty regarding a prescription should be enforced,” said Cassim.

Antibiotic resistance threatens to unravel the significant strides modern medicine has made including increasing life expectancy and allowing for life-saving procedures. If we didn’t have antibiotics, we’d be in huge trouble, but it’s how healthcare tackles this new challenge that counts.

FEATURED IMAGE: Naeem Vallee, a sixth-year MBBCh student, on the pressures of being a medical
student expected to digest and absorb massive amounts of work and what that means for
their practice later on. Photo: Busang Senne