he Annals of Internal Medicine on Tuesday reminded physicians that they shouldn’t routinely prescribe antibiotics for upper respiratory infections like bronchitis, sinusitis, sore throats, or the common cold. Why not? Most upper respiratory infections are caused by viruses, and antibiotics don’t work against them. In addition, antibiotics can cause unwanted side effects like upset stomach and diarrhea; they account for one of every five emergency department visits for drug reactions. And their overuse contributes to the frightening rise of antibiotic-resistant infections.
I’ve been hearing the admonition not to prescribe antibiotics for upper respiratory infections for at least 20 years. My first reaction to the new paper: Why can’t doctors get this right?
It turns out that some — much? — of the blame goes to doctors’ patients. In the infamous words of the cartoon character Pogo, “We have met the enemy, and he is us.”
Wayne J. Riley: Two strategies to help
Timothy G. Buchman: Antibiotic overprescribing a social, behavior problem
Tanya Stivers: Four ways to avoid “the battle”
H. Cody Meissner: We’re victims of the success of antibiotics
Alan Roth: Minute clinics, patient satisfaction scores may contribute
Robert L. Wergin: Prescribing antibiotics an “individualized decision”
By Wayne J. Riley: We’ve known for 20 years or more that most upper respiratory infections are caused by viruses, not bacteria, rendering antibiotic therapy less than useful and potentially harmful. Yet many physicians are still prescribing antibiotics for these illnesses. The American College of Physicians undertook the review published in Annals of Internal Medicine to offer the best advice available today and to refocus attention on appropriate antibiotic prescribing.
Mistaken or unrealistic patient expectations contribute to antibiotic overuse. Many people believe that antibiotics fight the symptoms of an upper respiratory infection and help make it go away. Many also believe that antibiotics are relatively benign drug. That’s not the case. They can cause short-term stomach upset or diarrhea. A growing number of Americans develop an antibiotic-related infection with Clostridium difficile (C. diff), characterized by persistent diarrhea. It often requires hospitalization and kills up to 30,000 people every year in the US alone.
As a way to reframe the issue, I have begun talking with my patients about the movement to take antibiotics out of our food supply, as evidenced by pledges from Chipotle and Panera to use antibiotic-free meat and poultry. This may help them see the issue of antibiotic overuse in a new light.
Physicians certainly bear some of the blame. It’s easier to whip out a prescription pad or make a few clicks to the pharmacy than discuss the reasons why an antibiotic won’t work and the potential hazards of taking it, especially when it offers no benefits.
In the paper, we offer physicians two evidence-based strategies help avoid prescribing antibiotics for upper respiratory infections while maintaining patient satisfaction:
- Use terms such as “viral upper respiratory infection” to make the point that the problem is caused by a virus.
- Instead of a prescription for antibiotics, offer a “symptomatic prescription” for ways to manage symptoms with over-the-counter medications.
Wayne J. Riley, MD, is president of the American College of Physicians and clinical professor of medicine at the Vanderbilt University School of Medicine.
By Timothy G. Buchman: Overprescribing antibiotics is more a social and behavioral issue than it is a medical problem.
At the population level, it makes no sense to give antibiotics to people with upper respiratory tract infections on the first visit. The likelihood you will do something useful is low, while the likelihood you will do something harmful — cause side effects or contribute to antibiotic resistance — is measurable and real.
But from a patient’s or parent’s perspective, a different calculus is at work. Say you are a parent with a sick child. You take your child to the doctor, investing time to do that and possibly needing to take time off from work to do so. Your child doesn’t feel well; you are harried. The clinician looks at the situation and says, “This is probably a run-of-the-mill virus that your child will be over in 72 hours no matter what we do.” As a parent, you might be thinking two things: What if it’s something more than run-of-the-mill virus? If I don’t get antibiotics now, will we need to come back again to see the doctor?
It may be a rational economic decision to press for antibiotics then and there. In Western medicine there is an abiding belief that for any ailment there is a medical response — a pill, salve, procedure, and the like — to make it better faster. Even though antibiotics have absolutely no effect on the vast majority of upper respiratory infections, there’s an almost a talismanic belief that antibiotics can fix them.
There are four standard levers that can be used to affect large-scale social change in medicine: exhortation, regulation, simplification, and positive or negative incentives. The first two are helpful, but haven’t moved the needle much to prevent antibiotic overprescribing. Making the best thing to do the simplest thing to do can be an effective strategy. The symptomatic care package described in the Annals article is an example of this. Patients and parents already have a positive incentive to ask for an antibiotic, since it may prevent a return visit. That’s especially true if the co-pay is low or nonexistent. Whether penalties imposed on physicians for inappropriate antibiotic prescribing will work remains to be seen.
It’s essential that organizations such as the American College of Physicians and Centers for Disease Control and Prevention remind clinicians of evidence-based best practices. That said, what happens in the office between a caregiver and his or her patient is informed by social and behavioral norms that may often shift medical decision making away from best practice recommendations.
Timothy G. Buchman, MD, directs the Emory Critical Care Center and is professor of surgery and anesthesiology at the Emory University School of Medicine.
By Tanya Stivers: As part of my research into uncovering the underlying structures of conversations, I have watched hundreds of video recordings between physicians and parents whose children were being evaluated for upper respiratory infections in community practices in the Los Angeles area.
For the most part, these physicians consistently tried to avoid prescribing antibiotics. But this often put them in a subtle or overt battle with parents who either believed their children needed this medication or who seemed to expect this medication. Once engaged, it’s difficult to get out of this battle without writing the prescription. Avoiding the battle altogether is a better scenario. We observed four helpful strategies:
Go straight to the exam. Physicians are more likely to prescribe antibiotics when a parent says early in the visit that he or she is worried about a potentially bacterial diagnosis like strep throat or pneumonia. Beginning the encounter by taking the patient’s history and doing a physical exam, rather than by asking, “How can I help you today?” can potentially avoid raising this issue.
Be a narrator. During the physical exam, tell the parent what you are seeing or feeling, like “the ears look perfectly clear,” “the lungs sound great,” and the like. This gives a parent insight into your rationale for not prescribing antibiotics.
Lead with the positive. Clinicians often want to get across two messages in this situation: There’s no need for an antibiotic, and there are several things that can be done to ease symptoms. Delivering the messages in that order gives the parent time to raise an objection. Reordering the conversation to put the positive, actionable item first — “Here are four things you can do to make your child feel better. She doesn’t need an antibiotic because it won’t work against a viral infection” — is a much more successful strategy.
Be specific. Instead of saying “give your child some cough medicine,” go with a more specific one like, “I recommend Robitussin DM three times a day.”
Although we only observed physicians’ interactions with parents of sick children, it is likely that these strategies with would also work with adult patients.
Most clinicians understand the problem of overprescribing antibiotics, and do their best not to contribute to it. But many don’t understand how parents — and adult patients — can influence the outcome of the interaction. Being prepared with conversational strategies can help physicians hold the line.
Tanya Stivers, PhD, is professor of sociology at the University of California, Los Angeles, and author of Prescribing Under Pressure, which takes a detailed look at conversations about antibiotics between physicians and parents of children with upper respiratory and other infections.
By H. Cody Meissner: Inappropriate antibiotic use is one of those issues we hear about again and again because it is such an important topic.
Most physicians and patients don’t immediately see the consequences of excessive antibiotic use. We are entering an era where people are dying from bacterial infections that can’t be treated because certain bacteria are resistant to all existing antibiotics. With few new antibiotics in the pharmaceutical pipeline, we must be careful about the use of antibiotics. That means prescribing them only when their use is justified.
For example, in many patients it can be difficult to tell the difference between viral and bacterial upper respiratory infections. A rapid strep test may help diagnose the cause of a sore throat, but for other types of infections, a decision regarding the need for an antibiotic is based on symptoms and judgment. Physicians worry about not prescribing antibiotics for a treatable bacterial infection, and so sometimes may err on the side of recommending an antibiotic.
We are, in part, victim of the tremendous success of antibiotics. When used appropriately, they fight bacterial infection and save lives. When used inappropriately, antibiotics lead to resistance and the risk of side effects.
It is interesting that some people are afraid of receiving vaccines, which generally are much safer than antibiotics, while many people want antibiotics, which can have more frequent and more severe side effects than vaccines.
One recent development may muddy the water for antibiotic prescribing. For a while we’ve been telling patients not to go to the doctor for an upper respiratory infection (which is likely caused by a virus), since there isn’t a lot he or she can do about it. But now we’re telling patients, especially children under age 5, that if you think you have the flu (which is definitely caused by a virus), get to the doctor quickly so you can get a dose of Tamiflu, an antiviral medication. Patients may have a hard time drawing the distinction between antibiotics not working against a viral upper respiratory infection and Tamiflu that works against influenza virus.
Cody Meissner, MD, is a professor of pediatrics at Tufts University School of Medicine and a member of the American Academy of Pediatrics Committee on Infectious Diseases.
By Alan Roth: As a newly minted MD 30 years ago, I was taught to prescribe antibiotics to patients with upper respiratory tract infections unless I was quite sure they had a viral illness. Even just six or seven years ago, if a patient came into my office with two days of sinus pressure and fever, I’d prescribe an antibiotic. Although the recommendations for treating upper respiratory infections are now more conservative with regards to antibiotic use, it can be difficult to change that mindset.
Reminders such as the new report from the ACP and CDC help keep the issue fresh for physicians and for the general public. Institutional efforts will also help combat inappropriate prescribing. For example, my health network reviews all patient charts. Those with an upper respiratory infection diagnosis are scanned to see who got a throat culture or antibiotics. Analyses like these can help improve patient care.
There are two trends that may be working against appropriate antibiotic prescribing. One is the surge in urgent care centers. I have seen several patients who told me they had visited one of these clinics for what looked like an upper respiratory infection and had been prescribed a Z-Pak, a popular antibiotic prescription. I worry that these clinics are overprescribing antibiotics.
The widespread linkage of patient satisfaction scores to physician compensation may also be an issue. If you hold the line against giving a patient an antibiotic for an upper respiratory infection, you are doing the right thing. But worries about a poor satisfaction rating could nudge some physicians in the wrong direction.
Alan Roth, DO, is chairman of the Department of Family Medicine, Ambulatory Care, and Community Medicine at the Jamaica Hospital Medical Center in New York. He also chairs the primary care council for the RightCare Alliance, an organization that focuses on improving health care and reducing overuse of drugs, tests, and procedures.
By Robert L. Wergin: As a family physician, I have a continuous, ongoing relationship with my patients. This, I think, allows me to have an in-depth discussion with them about antibiotic use for upper respiratory infections, more so than if I provided acute episodic care in the setting of an urgent care or retail clinic.
There’s no question that physicians of all stripes are overprescribing antibiotics for upper respiratory infections. We now have good guidelines that, if they are followed, will help reduce antibiotic use. Physician education and outreach is also essential. Wiser use of antibiotics is an important aim of the American Academy of Family Physicians’ Choosing Wisely campaign.
It’s important to keep in mind that choosing whether or not to prescribe antibiotics must be an individualized decision. A physician should consider how long the patient has been struggling with the problem, the number and severity of his or her symptoms, the presence of unusual symptoms, and whether he or she has diabetes or other chronic conditions. Those factors could tip the balance to earlier use of antibiotics.
Papers like the one in Annals of Internal Medicine can have a ripple effect. Although it is aimed at clinicians, reports in the media can put the issue in front of the general public. It might help some people better understand the dangers of unnecessary antibiotics, and it could even get some to wait a while before seeing a physician about an upper respiratory infection.
Robert L. Wergin, MD, a family physician in Milford, Neb., is board chair of the American Academy of Family Physicians. He was part of a White House forum last June on enhancing antibiotic stewardship and combating drug-resistant bacteria.