Your patients are sick, but do they need antibiotics?
From the November ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
- How to say 'no' to patients who demand antibiotics
- College resources to help you fight antibiotic resistance
While physicians have made some progress in the struggle against antibiotic resistance, experts are still urging them to moderate their use of antibiotics-or risk a return to the pre-antibiotic era.
First, the good news: Physicians appear to be writing fewer prescriptions for antibiotics for certain conditions. In 1999, U.S. internists, pediatricians and family physicians prescribed antibiotics to only 50% of their patients with respiratory infections. In 1995, by comparison, that same group of physicians had prescribed antibiotics to 63% of their patients.
"That's a reduction of 15 million prescriptions a year," said Ralph Gonzales, ACP-ASIM Member, associate professor of medicine at University of California, San Francisco, who presented findings on prescription reductions at the Society of General Internal Medicine annual meeting earlier this year.
The bad news, however, is that the medical community still has far to go. According to Dr. Gonzales, U.S. physicians should write 40% fewer antibiotic prescriptions for respiratory infections. Doctors need to cut the total number of antibiotic prescriptions in half if medicine is going to reverse the growing epidemic of antimicrobial resistance.
According to the CDC, nearly 30% of Streptococcus pneumoniae strains—the leading culprits in community-acquired pneumonia and meningitis—are now resistant to penicillin, while more than 10% are resistant to third-generation cephalosporins.
In addition, the bacteria that cause tuberculosis, gonorrhea and urinary tract infections all show increasing resistance, while cases of Staphylococcus aureus with decreased susceptibility to vancomycin continue to be reported.
To fight the problem, there is plenty that practicing physicians can do. Most of the solutions require little expense or effort to implement.
The 'chagrin factor'
Physicians have no trouble correctly identifying the upper respiratory tract infections (URTIs)—bronchitis, rhinosinusitis, pharyngitis and non-specific URTIs—that account for most of the antibiotics they prescribe. Many clinicians, however, run into trouble distinguishing viral from bacterial infections and deciding which patients need antibiotics based on the symptoms they present.
Part of the problem is that physicians do not always understand the "odds" that an illness is caused by bacteria. Some physicians don't realize, for example, that acute bronchitis in otherwise healthy patients is almost always a viral condition, according to guidelines the College published last spring on prescribing antibiotics for URTIs. (The guidelines are available on ACP-ASIM Online at http://www.acponline.org/sci-policy/guidelines/.)
Physicians prescribe antibiotics to 80% of their patients with sinusitis when only 30% or fewer have bacterial sinus infections, said Dr. Gonzales, who helped write the College's guidelines. And while 75% of patients with pharyngitis receive antibiotics, only 10% of adult patients with sore throats are likely to have group A beta-hemolytic strep.
Dr. Gonzales said he chalks up some of that wide margin of prescribing error to "the chagrin factor," in which physicians try to avoid past mistakes by overcompensating with prescriptions.
"Clinicians live in their own experience," he said. "While it's easy to forget all the patients with coughs that turn into nothing, physicians never forget the cough they missed that turned into pneumonia."
Physicians often put too much emphasis on symptoms they think are sure-fire indicators of bacterial infection, such as tonsillar exudates, even though those symptoms commonly occur in viral syndromes. Another example is purulence, which often leads physicians to prescribe antibiotics—and patients to expect them.
"If patients have anything green coming out of anywhere, whether they're coughing it up or blowing it from their nose, they want an antibiotic," said Richard E. Besser, MD, director of the CDC's campaign to promote appropriate antibiotic use. "But you have to look at the whole time course of an infection as well as other symptoms to decide whether purulence is relevant."
In part, it's difficult to differentiate bacterial vs. viral infections because most physicians do not have reliable—or cost-effective—diagnostic tests. While throat cultures may help you understand what conditions are causing sore throats in your community, for instance, they do not produce the real-time results you need to help diagnose and treat pharyngitis.
To positively identify bacteria in acute sinusitis, you would need to perform a sinus puncture, something that most physicians would not consider ordering for patients who present with sinusitis. At the same time, Dr. Besser pointed out, cultures and radiography "are not much use" either for sinusitis. "Radiographs should be reserved for the patient who isn't getting better or who has an unusual presentation," he said.
Even when they have negative test results, some physicians prescribe based on patients' demands, not data. Studies have shown, for instance, that some physicians will give antibiotics to patients with negative rapid antigen strep tests.
"That fact underscores our need to address the patient-physician dynamic in order to have the best effect on prescribing behavior," said Dr. Gonzales. (For more on how to deal with patient expectations, see "How to say 'no' to patients who demand antibiotics," below.)
Instead of blanketing patients with tests or relying on an isolated symptom to make a diagnosis, keep abreast of community outbreaks and updates from your public health department. Knowing that flu season has started, for instance, can reassure you that you're seeing a viral syndrome and not a bacterial condition.
Take the onset of seasonal conditions into account, particularly those that can trigger allergies. And find out if patients have young children at home or work in a setting with young children, as they run a higher risk of group A strep. (Children also run a much higher risk of being exposed to resistant strains of S. pneumoniae.)
When deciding if a patient needs antibiotics, experts say, consider the constellation and duration of a patient's symptoms.
Patients with group A strep, for example, typically present with two to four symptoms: tonsillar exudates, fever, tenderness in the lymph glands and absence of cough. Physicians should test only those patients who present with at least two of the symptoms. You can skip testing and move to antibiotic treatments (penicillin is the first-line treatment) for patients who meet three or all of the criteria.
Bacterial sinusitis also typically presents with several symptoms, including purulence accompanied by facial or maxillary tooth pain, particularly in the upper canines. "If a patient has tenderness when you tap the tooth, that suggests bacterial inflammation," said James S. Tan, MACP, vice chairman of the department of internal medicine and head of the infectious disease section at Northeastern Ohio University College of Medicine in Akron, Ohio.
When dealing with sinusitis, remember to pay careful attention to how a patient's condition is progressing. "If patients have been sick for more than five to seven days," said Dr. Tan, "you should start thinking about bacterial sinusitis."
But following the timeline of a condition becomes increasingly difficult for physicians—and patients—who are strapped for time. Studies have shown that as patient volume increases, physicians write more prescriptions for antibiotics. Patients are also reluctant to wait several days for relief.
To help reduce inappropriate antibiotic prescriptions, Dr. Gonzales recommended using a good phone triage system. Calls should be handled by a nurse who can discuss symptoms and timelines with patients and help determine who needs to be seen. This type of triage system can also help you get prescriptions to patients you have already seen but who are not getting better.
Choosing the right drug
In choosing which antibiotics to prescribe, physicians need to be aware of the resistance patterns of particular bacteria. Hospital-based physicians can rely on antibiograms from the hospital's infection control staff or infectious disease physicians. Office-based physicians can tap into state or national resistance data through their state health departments.
When you do prescribe an antibiotic, avoid using broad-spectrum ones. That trend is fueling antibiotic resistance, experts say, and threatens to render powerhouse antibiotics obsolete.
While broad-spectrum antibiotics like azithromycin offer convenient dosing schedules, the CDC's Dr. Besser said that physicians and patients alike may have to sacrifice some convenience to cut down on resistance. Both physicians and patients like the broad-spectrum antibiotic because it is taken only once a day. But with pneumococcal resistance to azithromycin on the rise, Dr. Besser continued, amoxicillin—taken two or three times a day—is a better choice.
Physicians may also need to sacrifice some cost-effectiveness. Ceftriaxone is relatively inexpensive because patients take it only once a day. While nafcillin, which must be taken four to six times a day, ends up costing more, experts say it produces far fewer problems with enterococcal and broad-spectrum cephalosporin resistance.
Physicians have also come to depend on broad-spectrum drugs because doctors often hold a scorched-earth policy toward bacteria. Instead of trying to narrowly tailor drug therapies, they decide to kill the broadest-possible range of pathogens. Experts instead urge physicians to target suspected pathogens as narrowly as possible with antibiotics.
In a case of bacterial sinusitis, for instance, which is typically caused by S. pneumoniae or Haemophilus influenzae, experts recommend narrow-spectrum drugs like amoxicillin and trimethoprim-sulfamethoxazole.
Sometimes, however, the most appropriate agent is not so narrowly focused. Dr. Tan pointed out, for instance, that because pneumonia is typically caused by one of six different bacterial agents, the appropriate treatment should target that extended spectrum. The Infectious Diseases Society of America now recommends using any of three different antibiotics to cover all six pathogens: antipneumococcal fluoroquinolones; doxycycline; and new macrolides.
Experts also say that physicians need to stop taking a one-size-fits-all approach. For instance, amoxicillin has been shown to be as effective as newer agents in bacterial sinusitis and is considered to be a first-line agent. Yet "if a patient has had recent exposure to a penicillin drug, starting that patient on amoxicillin at a standard dose doesn't make sense," Dr. Besser said. "You have to go with a higher dose or with something like amoxicillin plus clavulanate."
In choosing the right antibiotic, Julie L. Gerberding, ACP-ASIM Member, said that physicians must consider one other important concern: How sick is the patient? For a minor infection, a first-line drug is called for, said Dr. Gerberding, who is acting deputy director of the National Center for Infectious Diseases at the CDC.
But for a patient with more severe symptoms, "you err on the conservative side and use something with a broader spectrum," she said. "You need to weigh the probability of resistance vs. the probability of harming the patient because you underestimated the need for a broad-spectrum drug."
Physicians say they often overprescribe antibiotics because of patient demand. When patients expect antibiotics for conditions that probably are viral, some physicians think it's easier to write a prescription than to explain the problem of antibiotic resistance.
To help you say 'no,' experts offer the following tips:
- Boost patient satisfaction. Physicians think that if they refuse to hand out prescriptions, patient satisfaction will suffer. Studies on patients with upper respiratory tract infections show, however, that patient satisfaction is more related to having their physician treat them with respect and take the time to help them understand an illness.
Instead of writing a prescription, write down the symptoms patients can expect over the course of their (probably viral) condition and the steps they should take to relieve symptoms. Patients will then have something tangible that will remind them of their office visit and give them a sense of closure.
The CDC sells pre-printed prescription pads you can use to recommend items that patients can buy to relieve common symptoms. You can also use the pads to tell patients when they should call back if they're not feeling better.
- Make it personal. "The message that 'We don't want to increase the risk of resistance in our community by abusing antibiotics' is a big yawn for a patient who's sick," said Richard E. Besser, MD, director of the CDC's campaign to promote appropriate antibiotic use. Instead, physicians should point out that inappropriate prescribing could radically affect that individual patient's ability to fight off a bacterial infection the next time he or she really has one.
- Watch your language. Medical terminology can give patients the impression that a minor ailment is more serious. Patients will expect antibiotics more if they're told they have "bronchitis" instead of "a chest cold," Dr. Besser said. By the same token, telling a patient she has a "runny nose" instead of "early rhinosinusitis" can help temper patient fears and expectations.
- Use samples wisely. Ask pharmaceutical representatives to stock your sample shelves with over-the-counter samples or coupons for over-the-counter medications. Then you can hand patients something at the end of their visit that will at least ease their symptoms.
And if you don't use broad-based antibiotics, toss out any samples you may have around the office. For patients who do need antibiotics, stock generic starter packs instead.
- Use office staff and space for patient education. Train office staff, including schedulers and receptionists, to get the message out about inappropriate prescribing. When patients call for an appointment and say they are coming in specifically for an antibiotic, support staff needs to remind them that many chest colds or sore throats—if that's their complaint—don't respond to antibiotics.
Keep pamphlets and brochures (the CDC's Web site, www.cdc.gov/antibioticresistance, offers several) in your office that explain the dangers of inappropriate prescribing. That way, "You won't have to work so hard to explain the problem," Dr. Besser said. And put posters up in your waiting area to get the message out as well.
- Remember the basics. Hand hygiene, particularly among health professionals, is still a crucial part of preventing infections and therefore of combating drug resistance. Julie L. Gerberding, ACP-ASIM Member, who works with the CDC, urged physicians to use one other key strategy to reduce the spread of infections: "When you're sick," she said, "stay home!"
To learn more about education efforts to reduce inappropriate antibiotic use, see, "Want to change physicians' use of antibiotics? Try educating patients" online at www.acponline.org/journals/news/nov01/lessons.htm.
The College chose emerging antibiotic resistance as its clinical theme in 2000, extending the theme through 2002. In addition to publishing guidelines on treating upper respiratory tract infections (see www.acponline.org/sci-policy/guidelines), the College has offered several Annual Session presentations geared to help physicians reduce inappropriate antibiotic prescribing. New presentations on the clinical theme will be available at Annual Session 2002 in Philadelphia.
For more materials and information, see the ACP-ASIM Online section on emerging antibiotic resistance at www.acponline.org/ear.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of the
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