Radio: Why Did We Do That?
Authors: Ian Kunkler
Journal: BMJ (2005)

Public awareness of antibiotic resistance is perhaps higher than any other aspect of health, possibly with the exception of cancer. The tabloid newspapers lambast dirty hospitals infested with resistant “killer bugs.” History, however, is often forgotten. Stepping back a generation, doctors were familiar with hospital wards full of patients succumbing to sepsis in the pre-penicillin era. Indeed, a finger run down the roll of honour of any first world war regiment often testifies to as many who “died from wounds” as were killed in action.

Chris Bowlby, the presenter of this programme, sought to trace the background of the overuse of antibiotics in a climate where a spokeswoman for the World Health Organization estimated, apocalyptically, that half of the antibiotics prescribed were unnecessary.

The story had three main players: the medical profession, the pharmaceutical industry, and the patient. All three had good intentions. However, all three were overzealous. A fourth, the postwar zeitgeist, also played a part. The discovery of penicillin corresponded with a national sense of euphoria. The “mould juice” became the universal panacea. It was even incorporated into toothpaste and lipstick.

The story was not, though, as Bowlby correctly identifies, about heroes and villains. It is entirely understandable that a drug (penicillin) that could save the life of a 15 year old boy from life threatening periorbital cellulitis would transform the prescribing habits of postwar doctors.

Where did it all go wrong? Sir Alexander Fleming, who discovered penicillin, warned of the risks of antibiotic resistance in his acceptance speech for the Nobel prize. A postwar GP identified a generation of patients seeking medication for minor complaints and a medical profession keeping them happy with a bottle of medicine. This was compounded by a low level of surveillance for antibiotic resistance in the United Kingdom and strong marketing by the pharmaceutical industry.

Political interventions and more prestigious research areas seem to have contributed to a prolonged downturn in antimicrobial research after the second world war. A US surgeon general claimed that infection was yesterday's problem. Research into new antibiotics withered as the research community supported by the pharmaceutical industry moved away from antibiotics with limited duration of usage to drugs such as cimetidine and ibuprofen with potential for more lucrative, lengthy, or lifetime use.

The international medical community has responded differently in establishing its thresholds for prescribing antibiotics. One man's respiratory infection appears to be another man's common cold or influenza. Recent evidence suggests that Dutch family practitioners fall into the former camp and Flemish ones into the latter. If I had one criticism of the programme, it would be that it underplayed the complexity of factors explaining the difference in use of antibiotics (incidence of community acquired infections, culture, and education).

If penicillin were discovered tomorrow, I suspect that we might all behave as our fore-bears did.