Data published on the occasion of European Antibiotic Awareness Day illustrates the high antibiotic use in Maltese hospitals and households. A high consumption of antibiotics does more harm than good, and GPs should avoid prescribing them for influenza or sore throats, Prof Michael Borg tells Sarah Carabott.

Antibiotic use in local households is the highest in Europe, with nearly half the Maltese consuming antibiotics at least once a year, mainly for sore throats, colds and flu, according to Prof Borg.

“According to worldwide data, at least half of antibiotics prescribed in general practice are unnecessary. In Malta we think that the figure is even higher, because almost 70 per cent of antibiotics are prescribed for sore throats, colds and flu, all of which are caused by viruses,” the chair of the National Antibiotic Committee said. In such cases, he added, antibiotics consumption was all in vain.

Prof. Borg was speaking to this newspaper following the release of data by the European Centre for Disease Prevention and Control showing that the consumption of antibiotics by the Maltese public outside of hospitals has dropped, placing the island below the European average.

According to this data, Malta is faring better than Iceland – something that was hard to believe, Prof Borg noted.

In fact, according to other EU research, which was subsequently validated locally, Malta has the highest population that consumes antibiotics out of hospital.

The discrepancy between the data provided by wholesalers to ECDC and that provided by consumers for the local research could be the result of insufficiently robust methodology or the tendency to underdose in Malta. Locally, we are used to prescribing low doses, but in high frequency, he added.

What remains unchallenged, however, is the significant level of unnecessary antibiotic prescription in the community.

READ: Local hospitals love using antibiotics, data shows 

One of the biggest misconceptions among general practitioners is that a viral infection such as a sore throat can shift to the lungs, leading to bacterial complications.

“If you prescribe antibiotics for every sore throat, you will, of course, statistically decrease the risk of bacterial complications.

“However, in order to prevent one single complication you will need to treat 4,500 patients with a sore throat unnecessarily.

“If you give antibiotics haphazardly, that occasional case of secondary infection will be avoided, however to get there, you have treated a massive number of patients unnecessarily, exposing them to the antibiotics’ side-effects and potentially exposing them to increased bacterial resistance,” Prof. Borg insisted.

Another misconception is that a severe sore throat is the result of a bacterial infection. This is not the case, since practically all sore throats are viral.

Prof Michael Borg, head of infection control and sterile services at Mater Dei. Photo: Mark Zammit CordinaProf Michael Borg, head of infection control and sterile services at Mater Dei. Photo: Mark Zammit Cordina

Prescribing antibiotics in such cases did more harm than good, and even minor sinus infections were self-resolving, Prof Borg said.

Meanwhile, ECDC data this week also showed that Malta topped the list in Europe in terms of the use of antibiotics in hospitals.

READ: Half of Maltese take antibiotics when they're not needed

While insisting he was not discrediting the data, he noted that these figures had not been confirmed by other research. In fact, another ECDC study, which provides a snapshot of antibiotic use in all hospitals across Europe, shows Malta’s use of antibiotics in hospitals falls within the average.

For this study, the ECDC estimates average hospital use of antibiotics depending on the number of patients and their conditions. Malta consumes slightly more than what is recommended, but is an average user.

One of the biggest misconceptions among general practitioners is that a viral infection such as a sore throat can shift to the lungs, leading to bacterial complications

In the Mediterranean there tends to be an uncertainty avoidance culture – meaning we are adverse to uncertainty – so we use antibiotics much more liberally than Scandinavian, northern and central northern European countries, Prof. Borg said.

“So just as there is data showing that we are the highest users, there is data that shows that we are in the middle. It boils down to the methodology, however we still need to work on bringing consumption in hospitals down.”

Among other problems, the excessive use of antibiotics maintains the level of MRSA in the wider community.

Another organism brought into hospitals from the community is E. coli (Escherichia coli). E. coli is usually transmitted through food that is not cooked properly or following direct contact with pets. Animals also have a high antibiotic resistance in E. coli because of frequent treatment with antibiotics.

Prof. Borg warned that during food preparation, cleaning your hands and work surfaces properly was especially important, ensuring that utensils used with raw meat did not come in contact with cooked food.

But the biggest treatment headache remains resistance in Klebsiella pneumoniae (from the carbapenem-resistant enterobacteriaceae family), another superbug and a common cause of urinary tract, respiratory tract and bloodstream infections.

It can spread rapidly between patients in healthcare settings and its treatment is especially challenging, because it is even resistant to last resort antibiotics.

As in the case of MRSA, Prof Borg’s team is screening all patients for Klebsiella, but the difficulty remains in that it is not treatable like MRSA, as it is present in the intestines.

Patients are therefore isolated and get rid of it gradually – which can take months.

Antibiotic overuse created Malta strain of superbug in the community

The abuse of antibiotics in Maltese households means that here, the superbug MRSA usually originates in the wider community rather than in hospitals, as it tends to do in other countries.

The Malta-specific MRSA (methicillin-resistant Staphylococcus aureus) clone, which evolved following widespread abuse of a popular fusidic acid antibiotic ointment, is now proving challenging to control outside Mater Dei.

“In the vast majority of countries, MRSA moves from hospitals to the community,” said Prof. Borg, head of the department of infection control and sterile services. “In Malta, it works the other way around – it moves from the community to hospital, and we have a very specific strain of MRSA that is limited to Malta.”

Experts believe that the excessive use of antibiotics and population density have contributed to the rise of this Maltese strain.

The local MRSA has replaced an English one (known as EMRSA-15) believed to have been introduced in the early 1990s through a British person admitted to St Luke’s Hospital.

A number of people are currently carriers of MRSA without knowing it: between eight and 10 per cent of healthy Maltese carry MRSA – one of the highest – if not the highest – community carriage rate ever reported.

In recent years, Malta has drastically cut down on MRSA infections at Mater Dei – with numbers dropping from three patients every two weeks to one a month.

One of the most important interventions was the introduction of screening for all patients in the medical, surgical or orthopaedic wards. The simple procedure – a swab from the nose – is followed with treatment to suppress MRSA.

This has, of course, brought an improvement in the community, as carrier numbers continue to decrease along with the possibility someone from the community will bring MRSA with them to the hospital.

Despite reducing carriers, MRSA prevalence remains high – among the highest in Europe, according to European Centre for Disease Prevention and Control data – mainly because of high antibiotic use.

Should penicillin and other ‘old’ antibiotics make a comeback?

Prof. Borg is urging a return to the very first medications, such as penicillin, found to be effective against many bacterial infections. These drugs are still very effective and at the same time treat a narrower spectrum, and therefore are less likely to cause resistance.

In Scandinavia, if a person is prescribed antibiotics for a respiratory infection, it is usually penicillin. In Malta, doctors usually prescribe wide-spectrum antibiotics, meaning they are less targeted and therefore lead to increased antibiotic resistance in various infections.

While in the past, ‘old’ antibiotics were not easily available at pharmacies, GPs are usually updated by the pharmaceutical industry about newer drugs rather than generic ones.

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