poured out before bed
“Sure, this may be viral, but whenever he gets a virus he always gets a bacterial sinusitis afterward. Can’t we just have the antibiotic now to head it off at the pass?”
“But I really want something to make her better – not just tylenol.”
“Look, I had this exact same thing last year and a Z-pack fixed it right up fast.”
I have not been in medicine for too very long, but I learned quite shortly into my first primary care foray that this sort of statement is more rule than exception. Sometimes it was a sharp, full-out demand, the language very direct. Other times the question was asked politely, pleadingly, in a very round about fashion. But no matter how it was requested, not a day went by during my outpatient rotations – pediatrics and adult alike – when someone didn’t “suggest” antibiotics.
We hate having the crud. The crud is inconvenient. It’s uncomfortable. It’s exhausting – for the crud-ee and caregivers alike. In facing this annoying foe, we want to be proactive – we want something that will make it better fast and get us back to good soon. We want symptom relief, of course. But what we really want is medicine – a medicine to mercilessly kill that crud-maker and any cruddy little superinfecting friends. We want the antibiotic – that nice little drug that seemed to work before, for us, or for someone else.
But this isn’t always what we need. And when we don’t understand this, when we pressure our physicians to give us the goods, and when physicians cave to that pressure to prescribe antibiotics inappropriately, we end up hurting not only our present and future selves, but everyone in the health care system.
And you’ve probably heard all this before – it’s all over the news. You’ve heard about the risk of side effects from unnecessary and especially broad spectrum antibiotics. Those pesky antibiotic-associated yeast infections in women. The rare adverse drug reactions some common antibiotics cause – like tendon rupture and cardiac conduction abnormalities. That exasperating antibiotic-associated diarrhea as the normal gut flora takes a hit, all the way to a dangerous superimposed C. difficile colitis. And – of course, and most frighteningly – the emergence of multiple drug resistant organisms (the famous “MDROs” you see on news station scrawls) which maim and kill thousands in our hospitals every year.
We all know this – patients and physicians alike. But sitting on that exam table, regardless of how well informed we are, we still ask if we might have an antibiotic – just in case. And on the other side of the table, regardless of how well trained they are, your physicians a) want you to feel better b) desire that you should like them, feeling at ease in their care and c) feel they need to practice defensive medicine, covering their white-coated butts just in case your case might be that unlikely, rare case to develop into some terrible, complicated bacterial infection.
We know this. But how can we change this?
Results of a randomized trial published in last weeks Journal of the American Medical Association (JAMA) address just that. In this study, explored with the lead author here, available here on the JAMA website, researchers at children’s hospitals in Pennsylvania and New Jersey implemented an experimental program designed to curb inappropriate antibiotic use in a pediatric primary care setting. The program included an antibiotic recommendation refresher course for physicians as well as quarterly audits, each physician being provided with personal statistics regarding their use of antibiotics. Antibiotic prescribing practices by the physicians enrolled in the program were compared to those of non-participating physicians over a period of three years. Results showed that participation in the audit/feedback program nearly halved the rate of use of broad spectrum antibiotics, and greatly improved adherence to evidence based best practice guidelines for antibiotic use.
Although the follow up study on outcomes – both short and long term – is still in the works, this is outstanding. Sign me up. And, on the flip side, I won’t ask my doctor to sign that unnecessary prescription for me.
And on a different note, enjoy another related and interesting read – why the development of new antibiotics is so painfully slow, despite the painful need.