5.27.2008

The Antibiotics of Least Resistance

Having worked many a Saturday in the ER, I see a lot of weekend runny nose kids whose frantic parents just want kid's cold to be over with. Yesterday our doc took a call from a worried mother who asked if she needed to bring her 18 month old with a runny nose and a "fever" of 99.9 in to the ER. She wanted "the antibiotics that people have been getting for the virus that's going around." The doctor responded "Any doctor that prescribes antibiotics for a virus is one I wouldn't want my kids to go to."

Of course, all of us on the front lines of medicine know that antibiotics are overprescribed not because the practitioners don't understand the difference between a virus and bacterial infection, but rather because of the expectations of patients.

Or maybe not...

In the "Pink Bubblegum Flavored Dilemma" ER doc Zachary Meisel explains why doctors in clinics and emergency rooms routinely write scripts for viral upper respiratory infections.
In the doctor's office or the ER, it's hard to tell the difference between bacterial and viral infections, and so doctors are tempted to prescribe antibiotics whenever they're unsure. That's especially true when doctors think that patients expect to take the medicine home, according to a recent study. Investigators interviewed patients with respiratory infections who went to the ER in 10 hospitals affiliated with medical schools, asking whether the patients expected to receive antibiotics and about whether they were satisfied with the care they received when they were discharged. The researchers also asked physicians why they prescribed antibiotics. The main conclusion was that doctors were significantly more likely to prescribe if they believed that patients expected them to—but did a lousy job predicting which patients those actually were. And the patients most satisfied with their care were the ones who left the ER with a better understanding of their condition, antibiotics or no antibiotics. The take-home message for doctors like me: Spend an extra five minutes talking to your patients about their medical problems, and you can send them away happy and without unnecessary medicine.

However, the doctors who write these scripts are often worried about a lack of follow up in a overstressed health system. The tension becomes one of public health versus immediate need to treat the patient -- a patient who appears unlikely to have the judgement to watch and wait for 48 hours, or to return if symptoms get worse. As Meisel writes...
The real dilemma of antibiotic prescriptions is that the most serious consequence for writing them unnecessarily is not a risk to the individual patient but the emergence of the superbugs that pose a risk to public health in general. Nowhere is this tension between individual care and public health greater than in the ER. Office-based cultures for bacterial infections, which take days to turn around, are not feasible in what we call "the trenches." And because follow-up can never be assured, it's hard to follow recommendations such as those of the American Academy of Pediatrics, which advocates "watch and wait" for 48 to 72 hours for children with middle-ear infections rather than an immediate dose of antibiotics. If we overprescribe antibiotics in the ER, that's because in the trenches the care of one patient often trumps the care of the public. Maybe that's myopic, but there you have it. And it is why efforts to reduce antibiotic use by giving out more information about resistant infections or teaching doctors how to manage patient expectations may ultimately fall flat.

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