To Rx or not to Rx
That is the question as physicians navigate patient need and public health when considering antibiotics
Almost as impressive as the ability of antibiotics to treat some of the most threatening infections humans face is the ability of bacteria to develop resistance to those drugs. While drug resistance has always caused concern, the pace of pharmaceutical innovation had, for many years, outpaced microbial adaptation.
As antibiotic use continued unabated, however, and most pharmaceutical companies began to abandon antibiotic development due to increasingly staunch regulations and to pursue the more lucrative business of chronic disease medications, resistance reached unprecedented levels. The World Health Organization now cites microbial resistance among its top three global problems after lack of clean water and malnutrition.
While the ramifications are global, the roots, and potentially the solutions, are decidedly local.
Susan K. Rowe, MD ’80
“Antibiotics, which are still a wonderful tool in our armamentarium to treat illness, unfortunately are a tool we overused,” said Susan K. Rowe, MD ’80, a family practitioner at Midelfort Clinic in Eau Claire, Wis. “We trained the public to think there was an antibiotic to treat all infections. We overprescribed. Some of that overuse was considered good medical practice at the time.”
Ear infections are a good example, Dr. Rowe said. Physicians used to treat even fluid in the ear with antibiotics. Now, they more often try to educate patients, provide treatment for the pain and let the body resolve the infection on its own, knowing it can be revisited if needed.
Is it a virus or isn’t it?
Determining between viral and bacterial infection is a daily charge of the general practitioner, who constantly needs to balance the wider public health concern of antibiotic resistance with individual concern for providing appropriate care to a patient. The infectious disease community has consistently beat the drum for more judicious use of antibiotics, as they have long recognized the correlation between increased use and increased resistance.
Gary Doern, PhD ’74, is Professor Emeritus of Clinical Microbiology at the University of Iowa and an expert on antibiotics resistance.
Photo courtesy of University of Iowa
“Antibiotics are a double-edged sword,” said Gary Doern, PhD ’74, Professor Emeritus of Clinical Microbiology at the University of Iowa, “You have to use them to treat infections, but their usage is going to lead to their obsolescence and create resistance. So what does that mean? It means that we simply have to be a little more circumspect about when we use antibiotics.”
Dr. Doern is an expert on antibiotic resistance and estimates more than half of antibiotic usage in community-based and ambulatory practice is not necessary. This includes prescriptions ordered not just by physicians, but other health care providers. Hospitals contribute, Dr. Doern said, not through overuse but by reliance on broad-spectrum antibiotics. Since it is unlikely that new antibiotics will be developed at any reasonable pace, he says practitioners must ask themselves two questions:
“Are you going to use an antibiotic in the first place, and if the answer to that is yes, which drugs do you choose?” he said. “And there is a whole lot of improvement on both fronts to be gained and together, we can hope to solve the problem.”
One of the key challenges is overcoming the lack of adequate diagnostic tests for many infectious diseases or the cost involved with those that do exist, doctors said.
“Unfortunately, the clinical manifestations of infections are notoriously imprecise,” Dr. Doern said. “Patients don’t just walk in the door with a neon sign reliably defining themselves as having a bacterial infection that merits antibiotics vs. any of the other things that look exactly the same. So what we have long been taught is that when in doubt, do no harm.”
Practicing physicians say an emphasis on clinical-based medicine can help make these judgments more objective and hopefully, more precise. Knowing the prevalence of a viral vs. bacterial cause for cough, for example, is useful information as is a primary care provider’s knowledge of a particular patient’s history, including frequency of infections, said Michael R. Miller, MD ’89, GME ’93. Dr. Miller practices family medicine in Hubertus, Wis.
“I really try, if it’s borderline, to see if we can go without antibiotics and see if they improve with simple measures,” he said. “If not, we can always fall back on them. Some patients come in and it’s pretty obvious they need antibiotics, but for those that aren’t so obvious, it’s using evidence-based medicine, clinical judgment and leaning toward not using antibiotics if possible.”
Patient expectations can also be misaligned with clinical wisdom. While some patients visit the clinic just looking for answers, others arrive with predetermined motives and demand antibiotics because they are convinced of their necessity.
“Some patients just want to make sure they don’t have strep,” Dr. Miller said. “It’s those coming in who are expecting antibiotics where I have to take more time to explain why they don’t need them.”
Dr. Rowe said patients often see a cause and effect relationship between antibiotic use and getting better, and it is hard to convince them otherwise, that their illness could or should resolve on its own. Robert J. Werra, MD ’57, a family physician in Ukiah, Calif., said patients in general aren’t concerned with the big public health picture; they are concerned about their own health.
“People want to get an antibiotic because they want to be cured, and they know antibiotics cure infections, and they have symptoms of infection,” he said. “So we always have the dilemma of are we going to give these people antibiotics or do we think it’s a virus and we’re not going to give you antibiotics and create drug resistant germs?”
Dr. Werra said he works to strike a balance between the individual and not contributing to the problem of resistance and relies on his clinical experience and observations to determine if antibiotics are justified or not.
“We’re torn between what science says is well documented and good for society and what we have as a primary obligation to our individual patient, and I admit that I tend to come down on the side of the individual,” he said.
Teaching the public
Jennifer Thomas, MD ’93, GME ’96
Jennifer Thomas, MD ’93, GME ’96, a pediatrician at Lakeshore Medical Group in Franklin, Wis., said she sees every contact with her patients and parents as an opportunity to educate about such topics as antibiotic use and resistance. She even operates a Web site, drjen4kids.com, that receives 70,000 hits a week and provides tools and information to help guide parental decisions and proper expectations.
Dr. Thomas, like many of her alumni colleagues, believes that educational efforts – particularly one-on-one dialogue between provider and patient – has had a positive effect on patient awareness of antibiotic resistance as well as when antibiotics are effective. She has seen expectations for antibiotics decline, but also has observed a new cycle beginning.
“I don’t see as much demand for antibiotics like I used to when I started 10 years ago, but during the H1N1 outbreak, everyone wanted antivirals,” she said. “The time it took to explain who was eligible reminded me of my early days in pediatrics. The same principles apply – we don’t need Tamiflu-resistant H1N1 because we overused it.”
Dr. Rowe said H1N1, interestingly, has helped reinforced the message that antibiotics are not a cure-all. The public health message for H1N1 has emphasized that it is a virus and there is no treatment for it (save for at-risk patients). The best therapy is to stay home, don’t risk infecting others and the illness will resolve with time.
Still, it is difficult to change practice patterns and patient expectations, Dr. Rowe said. Sending a consistent message to patients and providers is important, and making careful, educated decisions about antibiotics is essential.
“You don’t have to use a cannon if a water pistol will take care of it,” Dr. Rowe said. “We have to make sure we are appropriately selecting the right drugs for first-line drugs and saving the big guns for down the road. And of course, treating what needs to be treated, and not treating what doesn’t.”
Gary Doern, PhD ’74, Professor Emeritus of Clinical Microbiology at the University of Iowa, provides a brief history of antibiotic development and resistance. (mp3 audio file) Click to play or right click and save to desktop or device.
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