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Despite the pleas of public health officials and even the American Medical Association (AMA), panic over recent anthrax cases in Florida, Washington, DC, and New York has pushed prescriptions for Cipro — the primary drug designated as treatment for anthrax exposure — to almost double the number normally prescribed at this time of year.
A national survey of retail and mail-order pharmacies, conducted by the drug-marketing consultant NDCHealth of Atlanta, found that prescriptions for Cipro during the months of September and October increased approximately 49% over the amount written during the same time period last year. (Ciprofloxacin is manufactured under the brand name Cipro by West Haven, CT-based Bayer AG.)
"Pharmacists are telling us they are getting a lot of prescriptions for Cipro, and when they call the physicians to question the prescriptions, the patients are getting extremely irate with the pharmacists — asking why they are even questioning the medication," says Carmen Catizone, MS, RPh, executive director of the National Association of Boards of Pharmacy in Park Ridge, IL. "The doctors are indicating to them, Go ahead and give it to them. They haven’t been exposed to anthrax, but they are driving me crazy.’"
"We are not pleased with that, but it is the doctor’s prescription," he continues. "Pharmacists are getting upset that they are put in the position of being the nation’s police officers for the public’s use of Cipro."
Public health experts worry that the rash of inappropriate prescribing will significantly contribute to the spread of antimicrobial-resistant organisms and will gut the effectiveness of ciprofloxacin, one of the newer class of fluoroquinolone antibiotics often used to treat infections that are resistant to most other medications.
"Cipro is our only option for some organisms that are resistant to older antibiotics," explains Stephen Lerner, MD, chief of infectious diseases at Wayne State University School of Medicine in Detroit, and a member of the Michigan Antibiotic Resistance Reduction Coalition. "If resistance develops to ciprofloxacin, we may be faced with infections for which there is no readily available treatment."
Bacteria rapidly evolve and develop resistance to antibiotics they are exposed to. The more prevalent the use of a particular antibiotic is in the general population, the more likelihood exists that more bacteria will be exposed and develop resistance, says Lerner. For example, resistance often develops when a patient takes a prescribed medication, but does not take it for the prescribed length of time.
The medication may indeed kill enough bacteria to treat that infection, but stopping the medication early may allow some bacteria to survive; these will be resistant to the antibiotic taken.
These resistant bacteria may either reinfect the original person or spread to, and eventually infect, other people. Most people have a certain amount of bacteria harmlessly residing in or on their bodies. If a person takes an antibiotic and does not have a bacterial infection, these harmless bacteria will "breed" resistant organisms.
For years, infectious disease specialists have urged physicians to curb inappropriate prescribing of antibiotics, asking that physicians ensure patients are getting them only for bacterial infections because antibiotics are useless against viral infections. In addition, specialists recommend that physicians prescribe newer, broad-spectrum antibiotics only when they feel an infection may be resistant to the older medications.
But physicians often feel pressured by patients and parents of children to prescribe an antibiotic, even when unnecessary in order to "cover all the bases" and alleviate patient fears, says Catizone.
This is particularly true in the current situation, he says. Some pharmacists in New York and Washington have reported that patients were getting prescriptions of Cipro to have on hand "just in case" they were exposed to anthrax and there was a shortage of medication. Some physicians are frightened as well, with some reportedly prescribing Cipro for friends and family members to stockpile.
"I was getting calls — six to eight a day — asking for antibiotics, asking Can I have ciprofloxacin for myself, my wife, and my children?’" Matthew Parker, MD, a Washington, DC, internist, told Reuters news service on Oct. 15.1 "I knew that I had chosen on my own to have it available. What is good for myself and my family is what I should do for my patients."
That view is likely shared by many physicians, Lerner says. "Physicians are trained that their first duty is to their patients as individuals, not to the community as a whole," he adds. Particularly in areas that have seen anthrax cases, physicians might feel there is a real potential for anthrax spread and agree to prescribe Cipro for worried patients.
"I think they see patients who are distraught," Catizone says. "And from a clinical sense, they feel that they can do something for [these] patients to alleviate their anxiety and prevent them from doing something very risky. They feel that they know that the antibiotics won’t hurt the patients and might be able to help."
However, Cipro is not a totally benign drug. While approved by the U.S. Food and Drug Administration (FDA), its use has been associated with significant side effects, according to information provided by the FDA’s Center for Drug Evaluation and Research.
Reported side effects include central nervous system problems including dizziness, confusion, tremors, hallucinations, depression, and increased risk of seizures; drug interactions (may increase levels of theophylline and caffeine, and other vitamin and drug products may reduce the effectiveness of Cipro); hypersensitivity, pseudomem- braneous colitis, tendonitis, and tendon rupture; and photosensitivity.
The potential risk of these side effects may be considered reasonable for patients with an infection, but would not be an appropriate risk for patients not known to be infected or exposed to a dangerous organism, Timothy T. Flaherty, AMA chair warned physicians in a statement released Oct. 17. "All antibiotics have side effects," Flaherty said, urging physicians and the public not to hoard antibiotics. "In the absence of an actual infection, only the risk remains."
Stockpiling Cipro also is dangerous because symptoms not related to anthrax may prompt people to initiate unnecessary treatment with the powerful drug, he added.
"The AMA continues to stress that there is no indication for the widespread prescription of antibiotics to prevent anthrax, and no indication for the prescription of antibiotics to have on hand in case of a future incident."
Lerner disagrees with the argument that physicians should avoid prescribing "preventive" Cipro because of the reported side effects. "I don’t really think that is an issue. Cipro is a safe drug — all drugs have the risk of some side effects — and I don’t want to give the impression that it is not," he says. "The real problem is the potential for the spread of antibiotic resistance."
Physicians need to be supported by their local hospitals and health care systems, which can work to calm public fears and educate people about the need to preserve these antibiotics for the people who need them.
The Centers for Disease Control and Prevention (CDC) in Atlanta has several support resources available for physicians who need help talking to their patients about appropriate antibiotic usage, Lerner adds.
For more information, see the CDC’s web site at: http://www.cdc.gov/antibioticresistance.
"The key is the gatekeeper as the physician," says Catizone. "If he or she writes those prescriptions, that begins the whole process. They have to be able to say to the patient, I can’t prescribe this for you, that’s not what it is indicated for.’"
1. Fox M. Doctors struggle with demands for anti-anthrax drug. Reuters, October 15, 2001.