Initiatives to control resistance must include a global perspective. Local or even country-specific initiatives are important but not sufficient; efforts must be undertaken within the context of a larger global population. Travel and immigration have highlighted the fact that countries are not closed systems and microorganisms do not recognize national borders. All nations, especially developed nations with the resources and expertise, must deal with policies and organisms that originate around the globe. For example, in a surveillance study of typhoid fever in the United States between 1985 and 1994, 72% of the affected patients reported international travel within 30 d before the onset of illness (10). Moreover, 30% of the isolates were resistant to either ampi-cillin, chloramphenicol, or trimethoprim-sulfamethoxazole, and 13% were resistant to all three drugs.
In many countries, antibiotics are either legally available without a prescription, or existing regulations are not uniformly enforced. Studies indicate that in countries with little regulation, a substantial amount of antibiotic misuse occurs (11). Data from many countries suggest that self-medication is common and frequently inappropriate (12-15). Antibiotics are often purchased without a proper indication, in insufficient quantities, and sometimes even when they are contraindicated. In Bangladesh, for instance, about half of the purchases of antibiotics were in quantities that fulfilled the requirements for a single day's dose (16). In a relatively affluent district of Manila, the Phillipines, 90% of antibiotic purchases were for 10 or fewer tablets or capsules (15).
The Indian Pharmaceutical Act restricts antibiotics to be dispensed only to someone with a valid, current prescription from an allopathic physician. In a study of pharmacies in India, the pharmacies tended to ignore the law and dispensed drugs for prescriptions from nonallopathic physicians and by self-request (17). The median number of tablets or capsules was five. As one client said to justify the self-prescribing behavior, "Whenever I get these symptoms and I go to a doctor, he gives me the same medicine and charges me 10 rupees. So why not just buy the medicine?" The pharmacists saw themselves as business people and rarely offered unsolicited advice to change the purchase.
There may be no simple solutions to improve the use of antibiotics in countries with antibiotics available over the counter. Even instituting regulations on access to medications may not be enough. A key to controlling resistance requires cooperation and shared belief systems from patients, physicians, and others in the health care system regarding appropriate treatment.
Industrialized countries are not immune to the problem of self-prescription of inappropriate antibiotics. In a town on the U.S. side of the United States-Mexican border, 75% of the respondents had purchased prescription medications in Mexico without a prescription (18). Recently, it has been reported that in many of New York City's immigrant neighborhoods, antibiotics are being obtained from pharmacies without a prescription (19).
The issue of needing a shared belief system about antibiotics and illnesses is particularly apparent in diverse communities that contain a substantial proportion of immigrants. In a recent study in New York City, nearly one third of the respondents believed that antibiotics should be available over the counter (20). Of greater importance, a substantial proportion of individuals obtained antibiotics outside of the avenue of a physician prescription for the condition. Individuals not only use "leftover" medication, but also obtain them directly from pharmacists or outside of the United States. It should be noted that individuals who have used antibiotics for viral respiratory infections in the past are much more likely to obtain antibiotics on their own without a prescription. Thus, these behaviors may be hard to extinguish because even in the United States, where a prescription is necessary to receive antibiotics, the majority of patients with viral respiratory infections receive antibiotics (21).
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