Gimme my antibiotics!

Dr. Emily Gibson calls it the “Z-pack pas de deux.”

Dr. Gibson, who blogs at Barnstorming, describes the dance this way:

I’m really miserable and need that 5-day antibiotic to get better faster.

Ninety-eight percent of the time it is a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and decongestant nose sprays.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And so on and so on, until the patient finally complains, “That’s all you can offer?” and leaves Dr. Gibson’s office to go find “a real doctor” who presumably will do what the patient wants and prescribe that Z-pack.

There are many issues on which doctors and patients can clash, and the use of antibiotics is surely one of these flashpoints. Growing concern about overuse and the development of antibiotic resistance has only sharpened the potential for conflict.

But who’s the villain here – patients for being unreasonable and demanding? Doctors for caving in and whipping out the prescription pad? As it turns out, it’s a little more complicated than this.

Although a number of studies suggest that inappropriate use of antibiotics is mostly driven by patient demand, there’s evidence this might not be the driving force everyone assumes it is.

Take this study, which appeared in the Archives of Family Medicine more than a decade ago and involved a survey of parents and adult patients at three Minneapolis clinics who sought relief for symptoms of a cold. Barely half of the adults and only 30 percent of the parents wanted a prescription for antibiotics – and when they did, it was often because their symptoms were more severe and they were worried about coming down with something more serious.

The researchers also uncovered a couple of interesting facts: The adult patients who expected antibiotics were more likely to have been prescribed antibiotics in the past to treat a cold, and many of them were unaware of the rising concerns over antibiotic misuse. This suggests that past experience, coupled with a lack of current information, may be an important factor in patients’ attitudes – perhaps more so than “demand”. “Clinicians incorporating a discussion of the patient’s previous cold-related medical management and drug resistance into the educational component of the visit might preserve a positive doctor-patient relationship while reducing antibiotic prescriptions,” the researchers wrote.

Another study, carried out in Belgium, found that teens and adults who visited the doctor for a sore throat often were in search of pain relief rather than antibiotics per se.

Other studies have found that physicians are more likely to prescribe antibiotics when they perceive the patient wants them – but that these perceptions are often inaccurate. As for the doctor’s fear that patients might complain or become upset at not receiving antibiotics, most of these studies determined that the quality of the time spent with the doctor was the most important predictor of patient satisfaction.

A review in Emergency Medicine News a few years ago sums it up this way:

The preponderance of evidence strongly suggests that physicians should not attempt to base their antibiotic prescribing practices on perceived patient expectations. Not only is this a bad way to practice medicine, but we do a lousy job of guessing what the patient wants. Furthermore, contrary to our assumptions, receipt of an antibiotic (whether expected or not) is not a significant factor in determining whether the patient will be happy with his visit and his doctor.

When to appropriately prescribe and when not to prescribe isn’t always clear-cut, however. The patient’s bronchitis is most likely viral, but what if it’s among the 5 to 10 percent of cases that are bacterial? What if the doctor sends the patient home without antibiotics and the patient gets worse? Are there subgroups of patients who are more at risk – and if so, how should they be identified? Should every patient with bronchitis be tested first to weed out the viral infections and ensure antibiotics are only being prescribed to those who truly need them?

These aren’t easy questions to answer. Guidelines have been emerging to help make more rational, evidence-based decisions, but patients don’t always fit neatly into one-size-fits-all formulas. Clinicians sometimes just have to use their best judgment, and sometimes this means falling back on the familiar habit of issuing a prescription.

Has the increased focus on appropriate antibiotic usage made a difference? Earlier this month the CDC reported on a national sample of antibiotic prescriptions issued in doctors’ offices for children 14 and younger and noted several trends: From 1993 to 2008, the overall number of antibiotics for children in this age group fell by 24 percent. The largest decrease was for sore throats, 26 percent, and colds, 19 percent. Unfortunately there was little significant change in the number of antibiotic prescriptions that continue to be written for children with ear and sinus infections and bronchitis.

The CDC’s rather dispiriting conclusion: This is still “inappropriately high” and indicates that more work is needed to reduce the overprescription of antibiotics to children.

What can the public do? First, it’s helpful to understand the difference between viral and bacterial infections. Antibiotics are designed to knock out bacteria and have little, if any, effect on the viruses responsible for colds, sore throats and other common respiratory ailments. Second, patients can ask more questions in the doctor’s office. If the doctor prescribes an antibiotic, is it necessary or is the physician doing this out of habit? Finally, antibiotics should be taken as directed for the full course of the prescription – no quitting while there are still five pills left, no hoarding for future needs, no sharing with others in the household. Although overprescribing has been one of the major contributors to the worrisome antibiotic resistance spreading across the globe, improper use is a significant factor as well. Hard as it may be, old habits need to change.