The Maltese still consume far too much antibiotics, which could cause resistance to them when they are needed later on. Sarah Carabott gets an update on the situation.

At least two out of five people taking antibiotics in Malta don’t need to, according to the chairman of the National Antibiotic Committee. 

The practice increases the risk that treatment will not work when a patient has a bacterial infection, warns Michael Borg.

Antibiotics are used to treat bacterial illness but are not effective against viruses. However, there are still not enough people who are aware of this. The figures show that the Maltese are the second highest consumers of antibiotics in Europe.

The practice of prescribing antibiotics for viral conditions has gone down among local doctors but their use within the community – which is where 70 per cent of the consumption takes place – continues to increase, says Prof. Borg, who is head of infection control and sterile services at Mater Dei Hospital.

He puts this down partly to the ageing population, with the elderly being more susceptible to bacterial infections. But it is known that in the Mediterranean, patients expect a quick fix, while some doctors prescribe antibiotics ‘just in case’, he notes.

“Despite the fact that the population is getting older, there is no doubt that we could reduce use in the community by about 40 per cent.

“We are not telling people to refrain from using antibiotics, but not to abuse them: do not take them when you have viral infections such as sore throats, coughs, colds and the flu.”

Prof. Borg acknowledges that general practitioners are sometimes pressured by patients to prescribe antibiotics. However, he urges them to delay the treatment by a couple of days (delayed prescription) or to explain why they will not prescribe antibiotics for a viral infection.

Malta has one of the highest trust levels in GPs, so patients will accept what their doctor tells them and will not go doctor shopping, he reassures practitioners.

He is also calling on them to prescribe antibiotics that target specific bacteria rather than wide spectrum ones.

We are not telling people to refrain from using antibiotics but not to abuse them: do not take them when you have viral infections such as sore throats, coughs, colds and the flu

The most popular antibiotics target a wide range of different bacteria, meaning that apart from targeting only the ‘bad bacteria’ that is causing the infection, they also work against the ‘friendly’ ones.

“With their competition destroyed, ‘bad bacteria’ can multiply and become the dominant ones, meaning that while you might be cured of the infection today, you could get an infection caused by the antibiotic-resistant bacteria later on,” Prof. Borg explains.

“The use of widespread antibiotics in the community is counterproductive, so we are trying to wean doctors off from the wide-ranging ones and get them to use narrow-spectrum instead.”

The infection control department has devised a smartphone app that helps 600 Mater Dei doctors take a decision on whether the patient needs antibiotics or not, and which kind – always opting for a relatively narrow-ranging one. The plan is to roll out a similar app for community GPs in the future.

Care at Mater Dei is becoming increasingly more specialised and advanced, especially when it comes to intensive care, cancer treatment and complicated surgery, all of which require the consumption of antibiotics as a precaution. Antibiotics are given ahead of serious surgical operations or interventions in order to prevent infections, however even here Malta could do with cutting down on consumption.

Scientific evidence shows that these antibiotics are only needed for the duration of the surgical operation and should definitely not be continued for more than 24 hours after the surgery, as anything more will not improve the situation and only risks increasing resistance.

In 2011 Malta topped the list of countries that administer antibiotics for more than 24 hours after surgery. Back then, nearly 80 per cent of patients used to be given antibiotics well after the recommended 24-hour period. This has gone down to around 50 per cent, bringing Malta down to the European average.

Meanwhile, when it comes to general use of antibiotics in Maltese hospitals, the European Centre for Disease Prevention and Control estimates that on average, 35 per cent of patients should be on them. In Malta, the actual figure is 40 per cent, meaning that a reduction is possible here too.

Malta’s antibiotic use in hospitals is the eighth highest in the EU. Other countries with similar use are mainly Mediterranean and Eastern European.

How much do we take?

The European Centre for Disease Prevention and Control uses a World Health Organization statistical method to calculate consumption by looking at the number of antibiotic doses (known as defined daily doses or DDDs) consumed per 1,000 inhabitants per day. While in 2007, Malta registered 21DDD, this increased to 24DDD in 2017.

Back to the roots?

Penicillin turns 90 this year. After saving World War II soldiers from septicaemia, it soon started being used for other infections such as meningitis and pneumonia.

Since then the use of antibiotics has increased and varied, pushing up resistance as some bacteria became immune.

Contrary to most other treatment, the more we use antibiotics, the less effective they become. Over 25,000 people die every year from antibiotic-resistant infections in the UK and Europe.

But some doctors are hopeful that turning back to the original antibiotic – Penicillin V – could be the solution for simpler upper respiratory infections.

In Norway, 80 per cent of respiratory infections are treated with penicillin and  as a result antibacterial resistance there is very low.