Posted tagged ‘antibiotic resistance’

Urgent care centers lead the way in unneeded antibiotic prescribing

July 23, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Urgent care centers are way ahead in prescribing unnecessary, potentially harmful antibiotics that are doing no one any good – at least no patients any good. The owners of the urgent care centers are the ones who are benefitting. And you and your family are being bilked, misled, and harmed.

A July, 2018 study published in JAMA Internal Medicine looked at the proportion of antibiotic prescriptions that were made for viral respiratory infections – things like the common cold and bronchitis. These are viral infections, caused by viruses (sorry if I’m hammering that too much – but obviously it bears repeating.) The researchers looked at over 150 million visits to emergency departments, urgent care centers, retail pharmacy clinics, and medical office visits to compare the rates of inappropriate prescribing between these settings.

Why is this important? Because antibiotics will not help anyone who has a viral infection. But they can lead to allergic reactions and serious complications like C. difficile colitis. They also contribute to antibiotic resistance, or the emergence of so-called “superbugs” that we can’t kill with any antibiotics. This is not just a theoretical problem – it’s a huge a growing nightmare occurring in hospitals all over the world. Some bacteria have figured out how to evade all of our antibiotics, and it’s entirely our fault.

Big differences were found in the rates of inappropriate antibiotic prescriptions. In ordinary medical offices, 17% of respiratory viral infections were treated with antibiotics. That’s way too high, and we need to work on that. But even worse: emergency departments prescribed antibiotics for about 25% of these viral infections. And topping the list was urgent care centers, where 46% of viral respiratory infections were treated with antibiotics. That’s about three times as bad as regular office visits.

The best prescribing habits – and they deserve credit for this – was found at the retail pharmacy clinics, at about 14%. They often use protocol-driven clinical pathways which leave little “wiggle room” for the nurse practitioners that usually are on staff. I’ve been critical of these quick-minute-clinics before, and I still don’t think they’re a good place for children to be seen, but give them credit for not throwing around antibiotics.

But those urgent care centers – why are they so quick to write for an unneeded and potentially harmful antibiotic? Though this study didn’t look at potential reasons, one potential driver may be profit. Urgent cares may be especially quick to write antibiotics because they make more money that way.

Some urgent care centers sell the antibiotics (and other medicines) that are prescribed, so there’s a direct profit there. But more commonly, antibiotics are prescribed because it’s a quick way to give patient what they want, to get them out the door so the next patient can be seen. It takes much more time to explain why an antibiotic isn’t needed than it takes to write the prescription. And writing that prescription seems to feed a cycle of dependence – now, the patient thinks every cough needs an antibiotic. Repeat business!

It’s not just antibiotics that fly off the shelves at urgent care centers. They make money from lab tests and x-rays, too. I spoke with one urgent care center physician who had this to say:

Our pay was a small base compensation and all the rest was a percentage of our billing. The more patients you saw, and the more lab, x-ray and meds you ordered, the more you got paid. Plain and simple. So not only was prescribing an antibiotic lucrative, not wasting time explaining why was also lucrative.

Now, many urgent care physicians are good doctors who genuinely want to help people. And it’s convenient to have them nearby for quick visits. But their employees may be under financial pressure to over-prescribe and over-test – and that can affect the care that you get.

How can you protect yourself?

  • Tell the physician, plainly, that you don’t want an antibiotic if it’s not needed. The doctor may be assuming incorrectly that everyone wants a prescription. Tell her that’s not the case.
  • Have reasonable expectations about ordinary illnesses. Coughs and cold symptoms rarely need antibiotics, even when they make you feel miserable. Most sore throats are caused by viral infections. We know you want to return to work and feel better, but an antibiotic isn’t going to help.
  • Use your primary care physician’s office as your main site of care. Get to know your doctors, and let them get to know you as someone who isn’t there just to get a prescription. If your own doctor is one of those that’s quick to prescribe, think about why that might be the case, and think about getting a new doctor.
  • Prevention is key! Wash your hands, stay away from sick people, get a good night’s sleep, and get all recommended vaccines. Remember, immunizations are the real immune boosters.

Earlier:

Keeping the world safe from antibiotics

Fighting back the superbugs

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Antibiotic overuse: Still a lot of room for improvement

June 22, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

We’ve heard it before: antibiotics just don’t work for viral infections. Docs know this, and I think most patients know this, but it’s an addiction we’ve had a hard time shaking.

Docs overprescribe because it’s fast, it’s easy, and it (might) increase patient satisfaction and return visits. That’s led to a cycle of reinforcing expectations from patients – who, after all, keep feeling better after the antibiotics. Of course they do. The minor viral infections that have been treated would have gotten better anyway. Still, it’s hard to shake that impression that it was the drug that made the illness go away. So next time, the patient expects and antibiotic, and doc is even quicker to prescribe it.

What’s the harm? Briefly: we’re encouraging the emergence of super-resistant super-bugs that, to put it bluntly, might just kill us all.

A study from 2015 illustrates some of the craziness and superstition that still guides a whole lot of antibiotic use:

The most-popular, most-prescribed antibiotic in the USA is “azithromycin”, known commonly as Zithromax. This top antibiotic is not recommended, first-line for ANY common infection—it’s not a good choice for ear infections, strep throat, or sinusitis. Not recommended for the top 3 reasons for antibiotic use, yet it’s still the top antibiotic*. Crazy.

Antibiotic prescribing varies tremendously by state. In Alaska, 348 scripts per 1000 patients per year; in Kentucky, it’s about four times that. Do they get four times as many bacterial infections in Kentucky? I don’t think so. Antibiotics, overall, are much more commonly prescribed in the southern states.

Another factor: counties with the most doctors – or the highest “per capita” number of people licensed to prescribe meds – have the highest rate of prescriptions. More docs doesn’t mean more preventive care, more access to good medical information, or better health. It does mean more prescriptions for antibiotics. (Why? I’d guess because it makes a practice more competitive and increases repeat business to write a lot of scripts.)

Current data shows that about 58% of antibiotic prescriptions handed out to human patients are for viral respiratory infections, including common colds or “upper respiratory infections”, viral sore throats, or ordinary “bronchitis”. None of these benefit from antibiotics in any way. Perhaps now’s a good time to revive the “Just say no” campaign.

There is some good news. There’s been about a 25% drop in antibiotic use since the 1990s, and I’m hearing from more and more patients who say right up front “we don’t want an antibiotic if we don’t need it.” That’s a very powerful message, and it’s something you ought to think about saying to your own doctor. You might think we’d only prescribe antibiotics if we genuinely thought they’d help… but the question is, who are they really helping? Probably not you.

*If you’re curious – why is Zithromax so popular, even though it doesn’t work well for any common infection? I think it’s because it can be prescribed with a very quick wave of the hand as a “Z Pak take as directed”. It’s so quick to write! So easy! Other meds need milligrams and instructions and things like “once a day” – who’s got time for that?! It also has a cool name. ZITH. Ro. Max! You may think I’m joking, but I’m not.

Medicine

Medicine

Keeping the world safe from antibiotics

December 8, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Intellectually, we know it’s true. Antibiotics are becoming less able to protect us from infections, and it’s our fault. Exposing microorganisms to antibiotics “selects out” the ones best able to survive. Over generations of life the germs that are left become craftier and hardier – and they can even share their genetic material with other unrelated microorganisms, giving nearby pathogens a protective power boost.

This is no surprise. We’ve known this since the first early antibiotics started to lose their power in the 1950’s. But the hope had been that we would keep inventing new antibiotics, so we’d stay ahead of the evolutionary learning curve. We think we’re clever. But we’re now losing the war. The pipeline of genuinely new antibiotics has been running dry, and those persistent and patient bugs are quickly catching up.

To make matters worse, we continue to shoot ourselves in the foot with policies and attitudes that seem designed to make sure the bacteria win:

 

#1: We pump farm animals full of antibiotics they don’t even need

In the US, 80% of the total antibiotics sold go into farm animals, literally about 32.2 million pounds each year. The vast majority of this, about 94%, is added to animal feed or water to be given to healthy, non-infected animals. We’re not talking about animals that are sick with infections, examined by a vet, and prescribed a therapeutic course of medication to help them get healthy—we’re talking about tons of antibiotics, sold legally without a prescription or a veterinarian’s input, directly to farming companies to give to all of their animals. This is entirely legal, and is thought to promote faster growth of animals or allow them to be raised with less feed.

Antibiotics given to animals unquestionably changes the resistance pattern of bacteria on farms, in consumed meat, and in people. And active antimicrobial agents can be found in runoff and wastewater from farms, and in groundwater nearby. These are often the same antibiotics used to treat people with infections.

This problem has a relatively simple fix: we should ban the use of non-therapeutic antimicrobials for agricultural use. Antibiotics should only be given to animals who have infections, under the supervision of a veterinarian, similar to how antibiotics are used in people in the USA. Though, even then there’s still far too much antibiotic overuse, in part because….

 

#2: We expect antibiotics for viral infections

Ask any practicing physician—it’s a daily struggle. Our sloppy prescribing has led to an expectation from many patients that an antibiotic be given for almost any ailment. People think “bronchitis” needs antibiotics, and sore throats, and fevers, and upper respiratory infections. It’s quicker to just write a prescription than to fight about it. And if we don’t give them antibiotics, our “satisfaction scores” will suffer. (Which often means we’ll lose our bonus, or even lose our jobs.)

The fix, this time, has to come from a few different angles:

  • Patient and physician education should stress when antibiotics are and are not helpful.
  • Physicians need to be protected from patient complaints when their recommendations are appropriate.
  • At the same time, physicians need to have the time to evaluate and explain and develop rapport. If we’re expected to prescribe fewer antibiotics, we need the time to explain why.
  • Patients should speak up, too. Physicians often assume that patients “want” antibiotics—but, in truth, many really just want a good careful exam and recommendations. Start your visit with “Doc, I don’t really want antibiotics unless you really think they’re help.” Watch how that statement changes the tone of the encounter. Make yourself an ally in the decisions about your own medical care.

I don’t think these fixes are very difficult, but they’re both going to take some changes in the minds of regulators, doctors, and patients. We can do this, together, but time’s running short. We can still beat the bugs, but it’s not going to be quite as easy as we expected.

 

Alexander Fleming

Fighting back the superbugs

September 9, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Antibiotics are not wonderdrugs that can treat any illness. They can only treat certain  bacterial infections, and each antibiotic has a different “spectrum” of bacteria that it can kill effectively. Every time bacteria are exposed to any antibiotic, there’s the potential for the bacteria to become resistant. We had once thought that infectious diseases were a thing of the past, but it’s become clear that at least for now the germs are winning. Currently, hospitals are swarming with resistant C difficile; in some parts of the world gonorrhea is now resistant to all antibiotics; and the emergence of the resistant staph MRSA has completely changed our approach to common skin boils and abscesses.

All of this is our own fault. We’re hosing down our kids, our hospitals, our farm animals, and our planet with antibiotics.

So which patients really benefit from antibiotics? Take this fun quiz to find out!

  • A 15 year old with a sore throat.
  • A 12 year old with a cough.
  • A 30 year old with bronchitis.
  • A 10 year old with 7 days of nasal congestion that’s turned green.
  • An 8 year old with an ear infection.
  • A 6 month old with a fever.

The answer: none of them. None of these patients is likely to benefit from antibiotics; in fact, antibiotics are more likely to make them sick with side effects (like diarrhea), possible allergic reactions, and resistant bacterial overgrowth.

There are caveats, of course: some of these patients might need antibiotics. A child with a sore throat should have antibiotics if a strep test proves that it’s a bacterial infection (most sore throats are viral, and a doctor can’t reliably tell the difference without an objective test.) Almost all cough illnesses are viral, including bronchitis, unless the lungs have been damaged by years of cigarettes or other problems. Cold viruses will cause green snot—that doesn’t mean there are bacteria—and most cold virus illnesses will last 7-10 days. Most ear infections in children past age 2 will resolve on their own without antibiotics, and if symptoms are fairly mild it’s very reasonable to “wait and see” before prescribing. A 6 month old does need a good evaluation to see what’s causing the fever, but in the developed world among immunized children most fevers are caused by viral infections that have to run their course.

In an evidence-based, good medical practice antibiotic prescribing should be the rare exception. Unfortunately, that’s just not what’s happening in the real world. 50% of inpatient antibiotics are unnecessary; for typical outpatient prescribing, it’s been estimated that 75% of antibiotics are not needed.

Why are so many antibiotics being prescribed?

In some instances there is a genuine knowledge gap. Some physicians were trained in an era when the effect of antibiotic overprescribing were less-well understood. But honestly, as physicians we’re hearing about this issue constantly. It’s not a believable excuse anymore.

There is a perception that patients will demand antibiotics. While it’s true that some patients will not leave happy without a prescription, most people prefer a good, honest assessment and a plan that will help them feel better. Of course, discussing other treatments and why an antibiotic will do more harm than good takes time… which brings us to what I think is the most significant reason for antibiotic over-prescribing: it’s quicker. And in an odious way, it’s better for business to prescribe than yak about why you’re not prescribing.

That’s right: market forces, for now, seem to favor the docs who whip out the pad and give patients a prescription. It’s quicker, so those docs can see more patients and bill more encounters. And it makes a careful and thoughtful history and physical exam less necessary—hell, I’m going to put ‘em on antibiotics anyway, so why do I need to clear the wax out of those ears? And it creates repeat business, because the patients of these doctors quickly learn that they need to come in for a prescription for every illness.

I will tell you: I personally know pediatricians right here in my community who see twice as many patients as I see in a day and who essentially always prescribe antibiotics. And their patients love them, because they think they’re getting good care. They’ve been trained with certain expectations, they’re happy to get antibiotics, and their doc is  making plenty of money. Meanwhile, the germs get smarter. The resistant bacteria spread to other children. Your child may end up with a resistant infection, even if you’ve been careful about antibiotic overuse. Resistant bacteria affect the whole community, not just the patient on the unnecessary antibiotics.

What can parents do about this?

  • Prevention is better than cure. Prevent common illnesses with good hand washing and common sense. Keep your children up-to-date on vaccines (including a yearly influenza vaccine.) Any illness prevented is one less potential antibiotic course. Breastfeeding and avoiding cigarette smoke also help prevent many childhood infections.
  • Make sure your pediatrician knows you’re not one of those parents who wants antibiotics. If you’re getting the impression that your doc is quick-to-prescribe, change doctors to someone who uses good careful judgment.
  • If you do have an antibiotic prescription, follow the directions. Take it for the full course. Do not hoard antibiotics or start them on your own without very specific instructions from a qualified health provider.
  • Avoid going to urgent-care clinics, ERs, or quickie health clinics in retail stores. Because they don’t have long term follow-up, these sorts of places are more likely to knee-jerk prescribe (remember: what’s good for their business isn’t necessarily good for your health.)

For now, the bugs are winning: they’re defeating our antibiotics quicker than new ones can be discovered. It’s a problem that’s mostly self-inflicted. Indiscriminate use of these medications (in humans and in agriculture) is the best way to make sure that they won’t work when we need them. The germs are patient, and have been around a long time. Are we smart enough to stay ahead of the race?