Q.In most Western countries, antibiotics are only obtainable by prescription. In China and a few other countries they can be obtained in pharmacies as easily as toothpaste. Why do other countries restrict antibiotic use?

A. It is difficult to recall the pre-antibiotic era. Penicillin has now been available for more than half a century. The discovery of penicillin by Alexander Fleming in the 1930s, and its development by a team at Oxford changed the way that infectious diseases are treated forever. It is amazing to read old accounts of diseases that are easily treated today, but were considered fatal before the arrival of these truly miraculous drugs.

The speed and efficiency of antibiotics makes people use them too casually. You feel ill, you have a fever. Take a couple of Amoxicillin and you will be better in a few days. Who needs a doctor when these miracle drugs are so easily available? Power to the people!

The problem is that bacteria are living organisms that can adapt to the threat of antibiotics and take evasive measures in order to survive. Resistant strains of antibiotics have developed. This is to some extent inevitable but has been assisted by the inappropriate use of antibiotics. The process works like this: Imagine a site of infection with a million bacteria present. Antibiotics are given and they kill 99% of the bacteria. This leaves 10,000 bacteria alive. In some situations these bacteria reproduce and in a short period of time there are a million bacteria present again. Now, there are not only a million bacteria, but a million bred from the bacteria that were immune to the antibiotic. A larger proportion of the new bacteria are immune.

This can happen when a prescribed course of antibiotics is not completed. You are sick, you take the antibiotics for two days, you feel better, the antibiotics sit in your bathroom cabinet and as you feel well you don’t remember to complete the course. Even worse, two weeks later you feel sick again and after two more days of antibiotics, you feel better and stop the drug again. The bacteria just love this. You have shown them your firepower but not pursued them with any enthusiasm so that they can organize a defense against the next antibiotic attack.

Some scary things are happening. A relatively new condition with a horror film name has appeared: the so-called flesh-eating disease is caused by a fairly common, previously easy-to-treat bacteria that has become more aggressive. It is now resistant to most antibiotics and has resulted in many deaths. Another instance of a previously innocuous disease becoming a serious health risk has occurred in the American Southwest. A group of children contracted a run of the mill ear infection and again there were several fatalities from a disease that is usually easy to treat.

Perhaps the most widespread use of antibiotics is in the treatment of colds and the flu. These diseases are not caused by bacteria which can be killed by antibiotics but by viruses which do not respond to these medications. Physicians can come under terrific pressure from parents to prescribe antibiotics. If you have a sick child who has an ear infection and is screaming with pain, you may not be in the mood for an academic discussion on the problems of emerging bacterial resistance. If you think that there is even a small chance that antibiotics will hasten the end of this illness, you will ask for newer and better antibiotics.

One aspect of antibiotic treatment in Asia that surprises Western physicians is the widespread use of intravenous antibiotics. In the West this is only used for patients so sick that their ability to absorb food or drugs through the stomach is impaired, or in a few situations where the required drug does not exist in an oral form. Western doctors tend to believe that the oral route is superior, as the drugs absorb more slowly and a more even level of drug in the tissues can be maintained. In many Western countries, daily prescription of intravenous antibiotics would lead to investigation if not disciplinary action against physicians.

Perhaps one of the unfortunate effects of our reliance on antibiotics is that research has been directed to finding newer and better antibiotics instead of investigating the immune system - the natural defense mechanism of the body - to see how it can be stimulated to deal with infection. This is probably the answer to the problem. It is rather ironic that this work is now being done in order to find a cure for AIDS, a disease in which the immune system fails almost completely. There is a feeling that this work will lead to a better understanding of the whole process of infection, resistance and recovery.

This column was contributed by Dr. Moreton, an Obstetrician and Gynecologist at Beijing United Family Hospital. Email your questions to Doctor Doctor at beijingscene@bigfoot.com