Antibiotics: Too Much of A Good Thing

The reasons why this is uncomfortable for the patient are pretty clear. No one wants to feel rotten and, now more than ever, it seems, people feel pressured to avoid missing work. Someone who has had similar upper respiratory infections in the past may remember getting better shortly after a prescription for an antibiotic was called in. The clinician's unwillingness to provide what the patient wants and feels he or she needs may seem callous or even perverse.

Now consider the clinician's point of view. He or she knows that the vast majority of upper respiratory infections in adults are caused by viruses, not bacteria. Infections such as strep throat and otitis media (middle ear infection), so common in children--hence, all those bottles of gooey pink amoxicillin--are relatively uncommon in adults. Even when an adult is coughing or dripping "green gunk," it's still more likely to be viral.

A recent study from Washington University in St. Louis, nicely summarized here, showed that people with classic symptoms of sinusitis--fever, facial pain, congestion--were just as likely to recover given a 10 day course of placebo as antibiotics.

Also, medical professionals are very much aware of the growing global problem of antibiotic resistance and the frightening prospect that, with overuse of antibiotics, we'll have more and more "superbugs" for which no effective treatment is available.

The cost of antibiotics, especially of Cipro and other relatively new drugs, plus the potential side effects of antibiotics, including Candida (yeast) infections, c.difficile colitis, and allergic reactions (in up to 10% of people), also give clinicians pause when patients ask for antibiotics that may not be necessary.

A more subtle factor, though, is at play in a practitioner's discomfort. We want our patients to feel better and we, like everyone else, have been conditioned to think of antibiotics as good. Much of the dramatic increase in life expectancy in the past 50 years is attributable to antibiotics, which have made once mortal conditions such as pneumonia, sepsis, and wound infections curable. Even though we know that antibiotics are often not beneficial (and even harmful), it's been hard to shake off the reflex to prescribe them to people who are ill, especially to people who believe fervently that antibiotics will help them.

There's been much research into how to rein in clinicians' over-prescription of antibiotics. One particularly effective method relies on the so-called Hawthorne Effect, in which people change behaviors by being made more aware of them. (This is the principle behind food journaling for people trying to lose weight, for example).

My own hospital currently has a program that employs this method. Every time I prescribe an antibiotic electronically, a window pops up on my screen asking me whether I am treating an upper respiratory infection. If I answer "yes," I must answer further questions to justify my choice.

Physicians and nurse practitioners still have a role in caring for people with respiratory infections: ruling out bacterial conditions and recommending ways to recover more comfortably. But the role of antibiotics in such infections is, necessarily, becoming more limited. Patients need to ask for, and clinicians need to provide, other forms of care.