Urgent care centers lead the way in unneeded antibiotic prescribing

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

Protect your kids from the “new” respiratory virus

The Pediatric Insider

© 2014 Roy Benaroch, MD

Facebook and other social media sites are all a-twitter (ha!) about a “new” respiratory virus, sweeping the country and sickening thousands of kids. There is something new, or new-ish, out there, and it looks like the infection can get pretty bad. But now is not the time for panic. We’ll get through this, like we get through other spikes in viral infections. With some common-sense steps, your kids will be OK.

As reported officially by the CDC this week, in the last month hospitals in Illinois and Missouri reported an increase in emergency department visits and hospitalizations for respiratory symptoms. Since then, reports of similar illness are coming in from many other states, scattered across the country. Most (but not all) of the cases with more severe illness had pre-existing lung disease (like asthma).

The illness seems to be mostly affecting children. Most cases begin with ordinary, cold-like symptoms—and it’s likely that most cases actually never develop into anything more than that. The reported cases, so far, may well be a “tip of the iceberg” effect, where only the sickest children get tested and identified. These are the kids who develop trouble breathing and low oxygen levels, and often need intensive care. It’s quite likely that most children with this infection quickly recover after a cough, sniffles, and runny nose. Of the cases reported so far, only about 1 in 4 or 5 runs a fever. Probably, most children and adults who have this infection don’t seek medical care, and very few of them (so far) are even being tested for the likely viral cause.

Most of the reported cases are testing positive for a specific virus, called enterovirus D68. That virus was first identified in California and 1962, and until now had rarely been a reported cause of illness. The enterovirus group, as a whole, contains a lot of other viruses that cause a whole bunch of different symptoms—fevers, respiratory illnesses, GI problems, heart disease, rashes, and neurologic problems. Pediatricians and others who take care of kids are used to seeing tons of enterovirus, which usually strikes in the summer, most typically as hand-foot-and-mouth disease, or as a fever. So we’re used to these kinds of viruses, even though this specific one is a newly-recognized member of the family. We’re not 100% sure, yet, exactly how D68 is transmitted, but other enteroviruses spread though respiratory drops and in stool, and can remain infectious for a long time on contaminated surfaces.

As with many viral infections, prevention is the best strategy. Common sense things can really help: keep your kids home when they’re sick, and don’t send your kids off to play with sick children. Encourage your kids to wash their hands and use hand sanitizer frequently. Get a good night’s sleep and moderate exercise. Keep your child up-to-date on vaccines—though there is no specific vaccine for this enterovirus*, bacterial and viral coinfections with influenza and pneumonia can be prevented. If your child has asthma (or any other respiratory problems), make sure that you’re keeping up with all prescribed treatments, so things are less likely to spiral out of control when an infection strikes.

If your child does get sick with cough, look out for these symptoms:

• Having trouble breathing. You may see individual ribs poking out with each breath, or the depression at the bottom of the neck sinking in, or bobbing up and down. Children with trouble breathing usually breathe fast, and sometimes breathe noisily.
• Having trouble speaking. If you can’t get good breaths in, you can’t typically complete sentences and talk normally.
• Seeming listless, with low energy. Children with serious respiratory compromise may not be getting enough oxygen to their brains. They can seem “foggy” or “out of it.”
• Drinking poorly. Younger children and babies may have a hard time eating and (especially) drinking when they’re really ill.
• Looking blue or pale.

If you’re seeing those kinds of symptoms, take your child to the doctor right away, or head to the emergency department. Even if things don’t seem quite that bad, if you’re worried, don’t hesitate to call for help.

Most children who are getting enterovirus D68 infection will do just fine. Some of you have probably already had children with this, and didn’t even know it. Every year, we see spikes of infections like this, caused by a variety of viruses like RSV, metapneumovirus, or influenza. Though there is no specific therapy for most of these, we’re pretty good at recognizing who needs extra help, and we can provide good supportive care when it’s needed. It sounds scary when you see news of a new, bad infection—but in truth, this isn’t very different from other infections we’re used to dealing with. We need to stay vigilant and keep our eyes on whatever’s out there making our children sick, but there’s no reason to get too worked up over this latest challenge.

*Fun trivia challenge: we routinely vaccinate against one other enterovirus, one that historically caused infections in the summertime. Guess!

This was adapted from a post I wrote for my practice website.

Keep your child safe from antibiotics

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.

Do we need more naked doctors and nurses?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Those scrubs and white coats worn by your friendly doctor and helpful nurses? They might just be loaded with germs.

This month researchers published a simple study looking at about 240 samples collected from physicians’ and nurses’ uniforms at a hospital in Jerusalem. They found that over 60% of the swabs were contaminated with disease-causing bacteria, including many that were resistant to multiple drugs. Previous research has shown that doctors’ neckties can also harbor nasty infectious organisms.

These studies have not shown that the bacteria on clothes can make their way to patients and cause infection, but they do illustrate how difficult it is to create a truly germ-free environment.

The best defense seems to be to fight the most direct path that bacteria take to get to you and cause infection: though your hands. Germs on the doctor’s coat (or even, heaven forbid, on a naked body) won’t make you sick until they get through your skin. That usually means via the mucus membranes of your mouth, eyes, and nose when you touch your own face. Keep washing those hands!

And just to be safe, I’d stay away from the naked doctor, too.

Infections now, or infections later: Does day care keep children healthier in the long run?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Tracy has a good question: “My 4 year old is not in day care – he stays with Granny. I heard that once you get a cold, you never get that cold again, and I am worried he isn’t exposed to enough germs now to keep him healthy later. Should we be trying to infect him with more colds now that he has the luxury of staying in PJs all day instead of hitting him with all these new viruses when he does start school?”

For many viral infections, it’s true: you get it once, you won’t get it again. Think about chicken pox, measles, or hepatitis A—suffer through the infection, or get the vaccine, and you’re pretty much protected for life. Second infections or breakthrough disease after vaccination can happen, but it’s uncommon. This doesn’t hold true for bacterial infections like pneumonia, whooping cough, or ear infections, but for many viruses immunity can last the rest of your life.

But the common cold isn’t caused by one virus, or even one family of viruses. Common cold symptoms occur with hundreds of kinds of rhinoviruses, coronaviruses, and the recently-discovered metapneumovirus, to name just a few. Each cold may earn you immunity from one variety of one virus, but there are plenty more of them lurking out there.

What about the cumulative effect of the dozens or hundreds of viruses kids in day care? Do day-care kids earn lasting protection from enough viruses to keep them healthier once they’re in school? And does that mean that kids who spent more time in their PJs with Granny will get sicker once they start kindergarten?

A study published in December 2010 tried to figure that out. Researchers followed about 1300 families in Canada over eight years to record the frequency of infections in children through their years of day care and school. They looked at upper respiratory infections, ear infections, and “tummy bugs” that caused vomiting and diarrhea. Their conclusion was actually quite satisfying: children, whether or not they attended day care, suffered through approximately the same number of infections over the course of the study. But day-care kids got more of their infections when they were younger, especially when they first started in group care, while kids who didn’t attend day care got more infections later when they started school. The piper gets paid, either way: get your infections over with early, or get them later.

It’s reassuring to know that overall, neither group of children was really sicker than the other. Whether or not children attend group care when they’re young doesn’t seem to affect the total number of infections, but rather only the timing of their infections. Parents can choose whether their children will get more infections now or later, but the total number of infections is going to be about the same either way.

Humidifier versus dehumidifier smackdown!

The Pediatric Insider

© 2010 Roy Benaroch, MD

Shannon wrote in, “I just recently read in a magazine that a humid environment as opposed to a dry environment is more hostile to viruses. It sounds a little counter-intuitive to me, however, if it’s true would it be best to run my children’s humidifiers all winter long to stave off the flu and other viruses as this article recommended? I tend to run them more in the winter anyway because my kids tend to have more runny noses or their nasal passages are drier and bloodier. What are your thoughts?”

I’m not sure the viruses, themselves, would even care. Viruses are just little teeny packets of genetic material, with a small handful of protein. They’re not cells, so they won’t “dry out”, and I doubt that their survival would depend much on humidity.

I would guess, though, that a dry environment might make it easier for viruses to invade the nasal lining to make your children sick. Viruses can’t penetrate normal intact skin, and even moist surfaces like the lining of a mouth or nose does a pretty good job repelling these little monsters (the viruses, I mean, not the children.) But once the lining of a nose gets dried out and develops cracks and fissures, the viruses can grab hold and jump right in.

By preventing dry air with a humidifier, you’ll also keep whatever mucus is around nicely wet and runny—that’s good, because thin and runny mucus is less likely to plug up noses and sinuses and get infected with bacteria. Thick and sticky mucus just sits there, an inviting bacterial playground. Thin and runny mucus drains, carrying infection away.

If you do run a humidifier all winter, you’ve got to keep it clean. That warm, moist environment can also become a playground for mold. Once a week, take the humidifier apart, wipe it down with diluted bleach (1 capful per gallon) and let the pieces dry before re-assembling.

What kind of humidifier is best? The ultrasonic ones are easiest to clean, so those get my vote. The kind with the big fabric wicks are just about impossible to clean well, and the ones that use a heating coil could cause burns when Junior pulls it over onto her head.

More articles about mucus, which has apparently become a favorite topic at my blog. Momma would be proud:

Out, Damn’d Snot

Control your mucus

Too many colds

A cold lasts longer than you think

Cough and cold medicines don’t work, updated here

Icky toys

The Pediatric Insider

© 2010 Roy Benaroch, MD

Look around my waiting rooms: not a toy in sight, unless parents bring ‘em themselves. You can bet shared toys in preschool rooms and day cares are covered with a sticky sheen of snot—and the toys in a pediatrician’s office have the added bonus of being handled by kids who are sick. Mmmmm mmmmm good!

Researchers published a somewhat-nauseating study in February (summarized here) examining swabs from toys in pediatricians’ offices. About 30% of the toys had disease-causing viral particles; even after disinfection with commercial wipes, about 20% were still loaded with germs. In fact, some of the toys that were “clean” prior to their rubdown with disinfectants actually had more germs after they were sanitized.

Toys handled by sick kids get icky and germy, and are very hard to clean well. Bring your own toys along next time you visit the doctor’s office—or you might have a worse infection on your way out than on your way in!