Posted tagged ‘antibiotics’

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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Most kids with penicillin allergies aren’t actually allergic

July 6, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

It’s a common problem: an infant or child has a rash or another symptom while taking antibiotic, so he’s considered “allergic.” The chart is so marked, and the child isn’t allowed to take that antibiotic anymore. But a new study adds to growing evidence that many children thought to be allergic actually aren’t. They could take that same drug again, and they’d do fine.

This isn’t a minor issue. Second like drugs used when there’s a reported allergy tend to be less effective or more broad-spectrum, leading to more side effects. And some kinds end up with a whole lot of alleged allergies, making it difficult to treat them with anything.

In the current study, the authors looked at children (age 4 to 18) showing up to an Emergency Department with a history of any penicillin allergy (this includes amoxicillin, Augmentin, and other penicillins.) Parents were asked to fill out a questionnaire about their child’s previous reactions, and most of the common reactions reported were considered “low risk” for true allergy – symptoms like any rash (hives or not hives, any rash), itching, diarrhea, comiting, runny nose, nausea, cough, headache, dizziness, or allergy suspected based only on a family member being allergic. If a child’s symptoms were one or more of these items, they were considered “low risk” to be truly allergic. When 100 of these “low risk” patients had formal allergy testing, ALL of them tested negative. Not one of them was allergic to penicillin.

Reported “high risk” symptoms included facial or lip swelling, difficulty breathing, wheezing, throat swelling, skin blisters or peeling, or a drop in blood pressure. These children were not tested for penicillin allergy, and were presumed to be really allergic.

This was a small sample – despite their “100% not allergic” finding, I don’t think anyone’s prepared to say that all amoxicillin rashes can be disregarded as non allergic. But it’s clear that most children (and adults) labeled as penicillin or amoxicillin allergic are not allergic, and could safely try the medication again. If you or your child is thought to be allergic, talk with your doctor about the exact reaction, and see if either a rechallenge or a referral to an allergist would be a good idea.

 

 

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

Keep your child safe from antibiotics

April 3, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here are some facts:

Antibiotic use is the direct cause of the rise of untreatable superbugs that are killing people.

Antibiotic use is also the cause of most cases of C diff colitis in kids, a potentially life-threatening, difficult-to-treat gut disorder. Antibiotics have also been linked with recurrent wheezing  in infants and inflammatory bowel disease. They can also trigger allergic reactions that can be severe or life-threatening. (I was going to link to photos of Stevens Johnson Syndrome, but decided not to be cruel. Go ahead and Google at your risk. Don’t say I didn’t warn you.)

Here’s some more facts:

Most infections in children are caused by viral infections. This includes all common colds, most coughs, most sore throats, most nasal congestion, and most fevers. It includes most bronchitis, most pneumonia, and most wheezing. Croup, laryngitis, tonsillitis, upper respiratory infections—they’re all viral. They are caused by viruses.

There is no circumstance where any antibiotic medication helps anyone with a viral infection get better. They don’t make viral infections go away faster, and they don’t prevent the development of later bacterial infections. They just don’t work.

Even “bacterial” infections often don’t need antibiotics to get better. Most ear infections will resolve without antibiotics, and good studies have shown that antibiotics, overall, are not effective in treating sinus infections.

So: the potential for great harm. And no upside. If you’ve got an accurate diagnosis of a viral infection, you know that the antibiotics aren’t going to help. Zero benefit. Some real risk. You’d think this would be a no-brainer kind of decision.

And yet, every single day I feel this struggle with some parents who just want antibiotics. It’s really strange, in a way— I listen to the story, I do a careful exam, and if possible I get a confident diagnosis. I talk about what will help the child feel better, and red flags to look out for to contact us if things get worse. And I get back a stare. “Can’t I just get an antibiotic?” or “He needs an antibiotic for his sinus” or “My doctor just gave me an antibiotic. He has the same thing.”

It’s our own fault, I know. Doctors have been way too quick to write antibiotic prescriptions. It’s much faster to whip out the prescription pad than talk about viruses and bacteria. And, more nefariously, writing antibiotic prescriptions creates a culture of dependency that guarantees future business. Patients, at least some of them, seem more satisfied if they just get a magic antibiotic prescription. Why anger people, why fight it, why not just give out the pills and move on to the next patient? Happy parents, happy cash register.

Besides: I know there’s a good chance they’ll go right to the QuickieClinic in the drug store across the street and get their peniwondercillin prescription anyway. (And then I’ll be the one called with the weird allergic reaction or when Junior didn’t get better because he needs a “stronger” antibiotic. QuickieClinic doesn’t offer 24/7 access to their doctor. They don’t offer any access to any doctor. But I’m getting off topic here.)

Why fight it? Because I’m your kids’ doctor. I’m not here to make you happy, or give you what you think you need. I’m here to try to get an accurate diagnosis and to do the best thing for my patient. I’m here to give solid advice about how to help your kiddo feel better, and to tell you when to worry, and when not to worry. I will not always get it right, but I’m going to try my best every time, even when that means I’m not giving you the prescription you want. And I’ll be here to help when things take an unexpected turn, because symptoms and diagnoses change. I can’t guarantee when your child will get better, but I’ll do my best to do the things that can genuinely help.

You want a burger your way? Go to Burger King. You want a quick antibiotic prescription? Go to the retail clinic in the drug store, or one of those docs or practitioners who see 60 kids a day. You want someone to use their professional skills and judgment to help your child? Find yourself physicians who’re stingy with the prescription pad.

Antibiotics may do more harm than good

November 19, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Add to the growing list of reasons antibiotics might not be good for you and your children: a recent study showing a statistical link between early ear infections and inflammatory bowel disease (IBD).

Researchers in the UK analyzed data from about a million children, looking specifically at the 750 who developed IBD (Crohn Disease and ulcerative colitis, mostly.) They then compared the kids with IBD to children without that diagnosis, and looked back at the frequency of prior ear infections. Ear infections are the most common diagnosis leading to the use of antibiotics in young children, so it was figured that more ear infection diagnoses were a good marker for more antibiotics.

Their analysis found that early ear infections increased the risk of IDB substantially, probably by about 80%. The highest risk was among children with the most ear infections, and among children with the earliest diagnoses. So more antibiotics, and earlier antibiotics, seem to be predictive of the later development of IBD.

IBD is a complex illness. It seems to be related to altered immune regulation in the gut and other tissues. It’s been speculated that the normal bacteria in the gut help with the early formation and control of the immune system.  Early antibiotics could indeed interfere with that process, and are a plausible trigger for IBD, at least in people who are genetically predisposed. There are probably other factors at work, too.

Indiscriminate antibiotic use is bad news. It contributes to the development of resistant superbugs, and may play a role in the development of obesity, allergic disease, and asthma. Insidious forces can sometimes encourage the perceived “quick fix” of an antibiotic prescription—including rushed doctors, exasperated parents, and a health care system that rewards “satisfaction” over health. If you want to protect your child from unnecessary antibiotics, you have to ask a few questions:

  • Is this antibiotic really necessary?
  • Are there other options?
  • Is it safe to wait?
  • If we do need an antibiotic, what’s the safest one to use?

And, of course, remember that prevention is always better than cure. Keeping your child up to date on vaccines—including influenza vaccination—prevents both bacterial infections and some viral infections that predispose to ear infections and other antibiotic temptations. Nursing, avoiding group care, avoiding second-hand smoke, and not bottle-propping—all of these can help prevent at least some ear and other infections.

There will be times when an antibiotic is a good idea—I don’t want parents to be afraid of them when they really are necessary. But parents and doctors both need to take an active, thoughtful role in deciding when antibiotics are really a good idea.

Patient satisfaction versus good health

August 20, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

There’s a quiet tug-of-war going on behind the scenes in medicine. Patient satisfaction is important for business, and increasingly it’s being measured and incorporated into physician scores, salaries, and employment decisions. Doctors are being employed by clinics and groups whose administrative pygmies call the final shots—and to them, the customer is always right. Maybe this isn’t always a good thing.

What administrators look for, mostly, is happy customers and quick visits. See more patients, keep ‘em happy, and you’re a successful doctor. Patients know how to complain, and believe me: those complaints do come back to the doctor.

Take antibiotics, as an example. It’s widely known that most sore throats, coughs, fevers, and runny noses do not benefit from antibiotics. Bronchitis, upper respiratory infections, and most other ailments that make kids and adults feel bad are caused by viral infections, and will not improve any quicker with any prescription. Yet: patients and parents are more happy when antibiotics are prescribed. Not all parents, of course, but many. And it takes far more time to explain why an antibiotic isn’t needed than to write the prescription. So time pressure and administrative pressure and the pressure to make patients happy all conspire against proper medical judgment.

What’s the harm? In the case of antibiotics, you’ve got a real risk of encouraging the development of antibiotic resistance. And allergic reactions, some of which are very serious. Add to that a growing risk of complications like C diff colitis and other adverse reactions. Antibiotics are not placebos. They can genuinely harm you, your children, and your community.

A more-subtle consequence: unnecessary antibiotic prescriptions reinforce the need for more antibiotics in the future. Once the expectation is created that a cough needs a pill, it’s very difficult to break the easy cycle of cough -> doctor visit -> prescription. In the short run, this pattern helps the doctor make money and helps the patient feel like they’re being taken care of. In the long run, it costs money and does far more harm than good.

It’s not just antibiotics that are the problem. Patients sometimes seem to want extra tests and procedures that have their own risks, including radiation exposure and pain. And misleading test results, which happen so often after unnecessary tests, lead to more tests and more-invasive procedures, ratcheting up the anxiety. Again, it’s easier and quicker to just order the test rather than explain why it’s not necessary. And at least the perception is that it makes patients happier.

Are happier patients necessarily healthier patients? No. A 2012 study in The Archives of Internal Medicine, called “The cost of satisfaction”, looked at a sample of about 50,000 adults and tracked health expenses, health status, and satisfaction. The happiest patients were the ones who spent the most money on health care. And they were the most likely to die.

Patient satisfaction is important, but it ought to be fostered through good communication, honest dialog, and a partnership with a primary goal of good health. Quick prescriptions, in the long run, are costing us money and lives. We need to ask: are health care economic incentives encouraging the profitable thing, or the right thing?

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?