(Aust Prescr 2001;24:27-8)
The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. Letters are usually published together with their responses or comments in the same issue. The Editorial Executive Committee screens out discourteous, inaccurate or libellous statements and sub-edits letters before publication. The Committee's decision on publication is final.
Topical ciprofloxacin and antibiotic resistance
Editor, – A generation or so ago, I was taught that if one wanted to renderantibiotics useless, due to resistance, as quickly as possible, apply themtopically. Why is ciprofloxacin being marketed in this way? Should there notbe a full re-evaluation of the use and misuse of all topical antibiotics? Isthere any convincing evidence that any of them are a good idea?
Peter Rout
General Practitioner
Darlington, NSW
Professor J. Turnidge, Microbiology and Infectious Diseases, Women's andChildren's Hospital, Adelaide, comments:
The concern expressed by Dr Rout about the topical use of ciprofloxacin isshared by many others. The standard teaching comes from the early experiencewith the use of topical antibiotics to treat infected burns, where resistanceemerged rapidly. It is possible that the very high counts of bacteria in infectedburns made the selection of resistance easier. Whether this problem occurswith all topical antibiotic use is not clear. The concentrations of topicalantibiotics are often 1000 fold higher than the minimal inhibitory concentrationsof the bacteria. Thus, in theory, there should be a lower risk of resistanceselection than with systemic use.
However, there is another principle that must be taken into account. The rateof resistance selection is related to the total amount of antibiotic use inthe community. We should prefer topical drugs which, when resistance is selected,do not jeopardise the valuable systemic antibiotics. Indeed, in the case offluoroquinolones, strenuous efforts have been made to ensure that availabilityof the systemic drug is restricted to cases of proven need. Topical applicationshould follow the same principle. Dr Rout will be pleased to know that theavailability of topical ciprofloxacin (and other topical quinolones) has beentaken up with national regulators. Although the outcome is not known, we hopethat these drugs will be restricted to (rare) cases of proven need.
Editor, – In writing about the `Treatment of panic disorder' (AustPrescr 2000;23:124-6) Professor Tiller provides the standard definitionused in psychiatry. The definition ignores the most outstanding characteristicof panic disorder and panic attacks: over-breathing. Indeed, the Diagnosticand Statistical Manual (DSM) does not provide a diagnosis for hyperventilationdisorder which is a common affliction in the community and certainly so amongthose with mental disorders.1 Caught in thisbind, Professor Tiller arrives at the task of management without any theoreticalexplanation of the measures he advocates.
I intend no criticism of the author. The fact that he deals with hyperventilationat all shows that he is well ahead of his academic colleagues and most workingin the field. He has rediscovered the wheel earlier than they. The part thathyperventilation disorder played received full acknowledgment long ago1 andthe symptoms of cerebral hypoxia caused by cerebral vasoconstriction were explainedin the 19th century. All that knowledge disappeared in the face of psychopharmacotherapy.Psychiatrists have discarded the simple clinical recognition of the deep breathstaken by the anxious patient, the revealing account of light-headedness, pinsand needles in the periphery, pain in the left side of the chest, the lumpin the throat, palpitations and panic. Instead of restoring normal breathingand confidence, doctors now take out the prescription pad and a reversibleprocess becomes irreversible. Advanced as he is in rediscovering the wheel,Professor Tiller still has not quite grasped the principles of restoring normalbreathing. Normal breathing is not deep. It is abdominal (diaphragmatic) ratherthan thoracic. Few people have paper bags these days. A plastic bag does justas well and does not make the noise which the author finds socially unacceptable.Tying a piece of tubing into the neck makes it easier to use it as a re-breathingbag. The real reason for not using it is that in most cases correct diagnosis,reassurance and instruction in normal breathing is all that is needed.2,3
David S. Bell
Psychiatrist
Mosman, NSW
References
1. Kerr WJ, Dalton JW, Gliebe PA. Some physical phenomenaassociated with the anxiety states and their relation to hyperventilation.Ann Int Med 1937;11:961-92.
2. Cluff RA. Chronic hyperventilation and its treatment byphysiotherapy: discussion paper. J R Soc Med 1984;77:855-62.
3. Lum LC. Hyperventilation and anxiety state. J R Soc Med1981;74:1-4.
Professor JWG Tiller, author of `Treatment of panic disorder', comments:
Dr Bell is correct that the DSM does not emphasise over-breathing as a commoncharacteristic of panic. This diagnostic classification tries to differentiatedisorders, so it omits features such as over-breathing which may occur in severaldisorders. I used DSM IV as it is the most common diagnostic system used inAustralian psychiatry. I did not attempt a treatise on respiration, notwithstandingmy interest in this area.1
When faced with hyperventilation, in getting patients to focus on slow, deepbreaths, I have not assumed what they might regard as `normal breathing'. Aslow respiratory rate is one element. If patients use slow shallow breathingthey simply shift air predominantly in their dead space. They feel they aresuffocating and their panic is reinforced. Hence the recommendation for slow,deep breathing as the first step in restoring normal breathing. The immediateresponse to hyperventilation may be exaggerated before `normal' diaphragmaticbreathing is re-established. I would not argue on the popularity of differenttypes of bag, paper, plastic or otherwise. Nevertheless, it would be a spectacularsight to see a patient in the middle of public transport tying a tube intothe neck of a plastic bag and then breathing in and out. I would suggest thatthis would be somewhat attention-grabbing and embarrassing.
My paper focused on psychological interventions rather than pharmacological,as the former will suffice for most patients. However, pharmacotherapy canbe uniquely efficacious for some disabled individuals. In my review, ratherthan rediscovering the wheel, I hope I have simply given it a further pushin what may be generally the right direction.
Reference
1. Tiller J, Pain M, Biddle N. Anxiety disorder and perceptionof inspiratory resistive loads. Chest 1987;91:547-51.
Editor, – The article on Panic disorder (AustPrescr 2000;23:124-6) had its relevance enhanced by the subsequent commentaryby comedian Garry McDonald, wherein reference was made to a book by BronwynFox `Anxiety attack: don't panic'. A footnote pointed out that this bookwas out of print.
However there is a more recent book by the same author on the same subject- `Power over panic'1 - with a foreword by GarryMcDonald. I believe it would be a worthy substitute for the now unobtainableearlier book.
Anthony Martin
Endodontist
Sydney
Reference
1. Fox B. Power over panic: freedom from panic/anxiety relateddisorders. Melbourne: Longman; 1998.
Editor, – Thank you for including the notes on ancestim (Stemgen) in theNew drugs section (AustPrescr 2000;23:137).
We wish to point out that the approved product information states that ancestimis indicated for use in combination with filgrastim only. There have been noclinical studies of the use of ancestim with a granulocyte colony stimulatingfactor other than filgrastim.
Jane Campbell
Senior Regulatory Affairs Specialist
Amgen Australia
Hawthorn, Vic.
The ethics of rational prescribing
Editor, – Regarding Dr Max Kamien's letter to the Editor (AustPrescr 2000;23:96) and the response from the Pharmaceutical Society,it seems to me that industry marketing to physicians and pharmacists continuesto play a greater part in prescribing than evidence. The `evidence' usedby industry to push new drugs in general and in this case COX-2 inhibitorsspecifically, is often far from clinically relevant. Statistical significanceand clinical relevance are often totally unrelated.
Regarding the pharmacist pushing new drugs (of the same class) onto patients,there is a case in Canada that is possibly on its way to the courts. The doctorprescribed a well-tested non-steroidal anti-inflammatory drug and the pharmacistreplaced it with the newer, so-called miracle drug, but the patient did notdo well.
Dr Kamien's conclusion is absolutely on the mark. It is neither socially responsivenor ethical for pharmacists to push new drugs. Our patients deserve better.
Carl Whiteside
Department of Family Practice
University of British Columbia
Vancouver, Canada
