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Prescrizioni inutili di antibiotici: il ruolo di medici e pazienti

Hanno in comune lo stesso tema due articoli pubblicati recentemente su JAMA Internal Medicine e sul sito BBC News Health, ovvero la prescrizione inutile di antibiotici per tosse, mal di gola o raffreddori, che continua a crescere in modo preoccupante, nonostante le raccomandazioni di istituzioni e mondo sanitario per limitarne l’impiego e arginare il fenomeno della resistenza agli antimicrobici, una minaccia per la salute globale che rischierebbe di “far piombare la medicina ai tempi bui del Medioevo”, come ha commentato il primo ministro inglese David Cameron.

Uno studio a cura dell’University College di Londra e del Dipartimento della Salute britannico ripreso dalla BBC dimostra che dal 1999 al 2011 vi è stato un incremento nelle prescrizioni di antibiotici di oltre il 40%, per patologie lievi per le quali in effetti tali farmaci agiscono solo nel 10% dei casi.

Lo studio ha interessato 500 medici inglesi evidenziando significative differenze nelle attitudini alla prescrizione tra la fine del scolo scorso ad oggi, dettate nella maggior parte dei casi da pressioni ricevute dai pazienti, che per il 97% dei casi insistevano per ottenere un antibiotico per curare anche una semplice tracheite. Questo perché gli antibiotici sono senz’altro farmaci molto efficaci (se usati in modo appropriato) su cui nel corso del tempo i pazienti hanno manifestato una crescente fiducia che rischia però di ritorcersi loro contro se impiegati impropriamente.

Questi ultimi devono quindi essere coinvolti e responsabilizzati in prima linea insieme ai clinici per approcciare l’utilizzo dell’antibiotico in maniera più razionale e consapevole. Al tempo stesso, i prescrittori devono illustrare ai loro assistiti tutte le alternative di cura possibili, incluso il non trattamento se necessario.

E’ quanto afferma un medico a commento dello studio di cui sopra e quanto accaduto ad un suo collega statunitense che racconta su JAMA Internal Medicine la propria esperienza di “paziente” al quale è stato erroneamente prescritto un antibiotico non necessario, proprio a margine della sua partecipazione ad una conferenza sull’antibiotico-resistenza.

“Da clinico ho sempre pensato che sono i pazienti ad esercitare pressioni sui medici affinché prescrivano loro antibiotici inutili. Ho scoperto che questo non è sempre vero quando mi sono ammalato mentre partecipavo – ironia della sorte -a una conferenza sull’antibiotico-resistenza promossa dal Dipartimento della Salute e Servizi Umani degli Stati Uniti. La mattina dopo il seminario mi sono svegliato con mal di gola. Pensando alle possibili cause mi sono ricordato che la settimana precedente ero stato con mia nipote che aveva una infezione all’orecchio ricorrente e già allora mi ero chiesto se non si trattasse di una infezione batterica resistente. Seduto nella mia stanza d’albergo, con la sensazione di febbre e debolezza, ho deciso di effettuare un tampone faringeo per escludere una infezione da streptococco.

Questa decisione mi sembrava quanto mai indispensabile, anche perché avrei dovuto effettuare una colonscopia di lì a pochi giorni una volta tornato a casa. Se non avessi avuto una infezione da Streptococco, non avrei preso certo un antibiotico che avrebbe potuto rendermi più vulnerabile ad una infezione da una specie di batteri ancora più virulenti, come il Clostridium difficile. Una ricerca su Internet dalla mia camera d’albergo mi ha quindi fornito il nome di una clinica di cure urgenti “doc-in-a-box”. Al cortese personale al bancone ho detto che avevo mal di gola e che necessitavo di una cultura della gola. Il medico mi ha esaminato, ha dichiarato che la mia gola era arrossata, e ha eseguito un tampone che, per fortuna, ha avuto esito negativo. Poi mi ha consigliato degli antibiotici. Gli ho detto che non volevo un antibiotico perché il risultato della cultura era negativo. Il medico insisteva, spiegando che gli schermi non sono sempre precisi e che un sacco di malattie erano state contratte “andando in città”. Quindi mi ha prescritto azitromicina, una scelta che mi è sembrata strana, perché è più efficace sulle infezioni delle basse vie respiratorie.

Avendo appena partecipato ad una conferenza sulla resistenza agli antibiotici, sapevo che non avrei dovuto prendere un antibiotico inutilmente e di certo non avrei dovuto prendere un antibiotico sbagliato per un mal di gola. Ma la conoscenza non è sufficiente. Quando sei un paziente, ci si trova in una posizione di dipendenza. In quel momento di confronto, seduto di fronte a un prescrittore, mi sentivo troppo male per discutere sia in merito alla prescrizione di un antibiotico sia sulla scelta del farmaco.

In seguito, ricetta in mano, mi sono chiesto se potevo essere etichettato come un paziente non aderente se non avessi dato seguito alla prescrizione. Mi sono anche chiesto se l’insistenza del medico non avesse a che fare con gli incentivi finanziari e onorari più elevati della clinica in caso di prescrizioni di antibiotici. Alla fine, non ho riempito la ricetta e ho deciso di rinviare la colonscopia fino a quando il mal di gola non fosse passato completamente, cosa che è accaduta da sola in pochi giorni.

Ripensandoci, la mia volontà di seguire “gli ordini del medico”, o almeno di non discutere con lui su quanto scritto sulla ricetta, mi ha dato un barlume di comprensione di quanto sia difficile per i pazienti esprimere le preoccupazioni quando si è in presenza di un figura autorevole da cui essi dipendono. Nel mio Stato, il Kentucky, abbiamo il più alto tasso nazionale di prescrizioni di antibiotici per pazienti ambulatoriali. Se avessi compilato la prescrizione e preso la medicina, forse avrei contribuito al problema grave e crescente della resistenza agli antibiotici. Tutte le conferenze di tutto il mondo non intaccheranno mai l’uso eccessivo degli antibiotici a meno che la professione medica non affronti il problema e cambi le proprie abitudini”.

Due punti di vista complementari, quello di medico e paziente, che sul tema del corretto uso degli antibiotici (e di tutti i farmaci più in generale) devono convergere verso l’appropriatezza prescrittiva e la giusta informazione, in un dialogo aperto e paritario.

Leggi l’articolo su BBC News Health
Leggi l’articolo su JAMA Internal Medicine

fonte: agenziafarmaco.gov.it

 

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