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

How to treat congestion in babies

The Pediatric Insider

© 2013 Roy Benaroch, MD

Life isn’t easy for babies. You can’t talk, and to get anywhere you have to wave your arms around and hope someone carries you. Perhaps worst of all, when you’ve got a cold your little nose gets so stuffy, it’s miserable.

Face it: no matter how smart your baby is, she probably hasn’t figured out how to blow her nose. Are there any practical ways to help unstuff congested baby?

• Keep the room humid, using a cool-mist humidifier or a warm vaporizer. Moist air prevents mucus from getting stick and sticky and harder to move.

• Try using a few drops of nasal saline. You can buy a little bottle at the drug store, or make it yourself.  Squirt or drip a few drops of this up each nostril to loosen mucus. You can repeat this as often as you’d like.

• A nasal bulb aspirator can help pull out at least some of the mucus. Remember, first squeeze it, then gently press the tip against the nose opening, then let go so it sucks out the yuck.

• Gently inclining the bed can help, but it’s not a good idea to routinely let babies sleep in a car seat, bouncy seat, or other device that holds them upright.

• Vapor-rubs like “Vicks” might help some with congestion, though good studies haven’t been done, especially in young babies. If you want to try a product like this, it’s essential that your baby NOT be able to eat or lick any of the rub. It’s very toxic if ingested.

Fortunately, even the most congestion baby usually feels much better in a day or two. If your congested baby is acting ill, having trouble nursing, having any trouble breathing, or isn’t improving in a few days it’s a good idea to head to the doctor.

Idiotic attendance policies, part 2: The preschoolers

The Pediatric Insider

© 2012 Roy Benaroch, MD

I’ve written about stupid school policies before—schools that set up carrots and sticks to prevent even genuinely sick kids from staying home. Dumb, dumb, dumb. But it did give me the opportunity to write, “If absences are outlawed, only outlaws will have absences.” I’m not sure exactly what that means, but it seems wise. Someone ought to put it on a bumper sticker.

Now I’m noticing more and more little kids being sent home (and often sent to my office) for equally dumb reasons. I don’t know why, but while the high schools seem to want to keep genuinely sick kids in the classrooms, child care centers for little ones want to send them home for next-to-nothing illnesses. Both extremes aren’t helping keep kids healthy.

The AmericanAcademyof Pediatrics has tried to offer guidance about sensible, science-based pre-school policies to protect the health of children. They’re summarized in this book, also available at Amazon. Owners and operators of preschools and government bodies that make health policies really ought to read that book, and keep it under their pillows at night to help absorb its wisdom. Instead, they seem to be making things up.

School exclusion rules ought to be designed to protect the health of children and staff. Children, in general, ought to stay home if:

• They can’t comfortably participate
• Their presence poses a health risk to themselves or others
• Their presence requires more support than the staff can offer

The AAP has specific suggestions for certain health problems that may surprise you. They certainly run counter to what I’m seeing from day cares in my community. Some of their recommendations:

Kids with the common cold, even if there is green snot, don’t need to be excluded from school. This is because the period of highest infectivity is before symptoms become obvious. Once a child has obvious cold symptoms, they’re no longer very contagious anymore—no matter the color of their snot. As long as they’re comfortable, they can go to school.

Fever, itself, isn’t a reason to keep kids home. Now, most kids with fever are uncomfortable—those kids shouldn’t go to school, since they can’t participate. But some kids with fevers, especially those with viral infections, feel just fine after a dose of ibuprofen. Excluding these children is unlikely to reduce the spread of disease, since most viral infections are spread by children who have no symptoms at all.

Pink eye? This seems to be the biggest boogeyman at preschool. Like the common cold, pink eye is contagious, but there is no evidence that treatment of pink eye reduces the spread of the bacteria or viruses that cause this common infection. The symptoms are quite mild, and will resolve in 5-6 days with or without treatment. The schools freak out, but kids do not go blind from garden-variety pink-eye, and most of them feel fine. As with other illnesses, if the child really feels bad she ought to stay home. Note that there are rare, more-serious occasional outbreaks of more-serious pink eye caused by adenovirus, so a classroom with multiple cases of severe pink eye needs to be reported to public health authorities. But the vast majority of pink eye that’s referred “emergently” to my office are very mild, nearly symptom-free infections.

Infections that really ought to stay home are those that include diarrhea that can’t be contained in a diaper or requires frequent changes, or vomiting. These symptoms really can’t be managed safely or comfortably in a group care setting.

Wrongheaded day care policies probably drive a lot of my business. Many centers seem to require a “note from a doctor” to return to school. Still, wrong is wrong. What we need is a more sensible approach to group care and school illnesses, rather than knee-jerk policies that keep children and parents home or send them to my office. Sick kids ought to stay home, but most kids with mild illnesses who feel pretty well can go to school safely.

Preventing colds: Kids show us how it’s done

The Pediatric Insider

© 2011 Roy Benaroch, MD

Want to get fewer colds, skip the flu, and avoid using the toilet face-first? One of the most effective ways to prevent infectious diseases is to stay away from mucus. Other people’s mucus, that is—the infectious toxic goo that sick people can’t seem to avoid spreading all over the place.

Two recent studies illustrate that it really is possible to stay healthier thru goo avoidance. But the kids seem to be better at it than we are.

I wrote earlier about the first study, where adults were observed during, let’s say, events of mucus production. Surprise! The vast majority of adults did nothing to limit the spread of their sneezes, and even helped further spread their germs by wiping their snot-covered hands on doorknobs and other surfaces. Look around you. If you see adults, they’re trying to make you sick.

Compare that to a more recent study of children, summarized here. Danish schoolchildren underwent special training in hand washing, and were required to follow good hand hygiene while in school. Over the following months, compared with kids in other schools without the special training, the children in the handwashing groups had about 25% fewer illnesses and missed days of school. Even better—the following year, when the special training and requirements were dropped, those same children still continued to wash their hands, and continued to have a reduced rate of illnesses. The kids learned, and it worked, and it stuck! Take a lesson from these kids: good hand hygiene is a habit that we can learn, and a habit that really can keep us healthier.

If it makes you sick, it probably likes mucus. Try to keep your mucus to yourself, especially when you’re ill. When you’re sick, sneeze into your elbow and wash your hands! If you don’t want to become ill, wash your hands before eating or especially before touching your own face. In fact, you might be able to prevent many infections by developing a new habit: don’t touch your eyes, your nose, or your mouth without first washing your own hands. The germs on your skin won’t make you ill until you rub them in your eyes or up your nose. With the kids back in school and winter approaching, now’s a good time to work on those anti-mucus, staying-healthy habits. Let’s all keep our snot and germs to ourselves.

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

A cold lasts longer than you think

Here’s a simple question: how long should symptoms of a common cold last? Three days? How about five? Maybe a week?

A study published in January, 2008 sought to answer that question. School-age children were followed for several months, and kept records of the onset and duration of common cold symptoms like fever, congestion, cough, sneezing, and runny nose. During the study period, 81 colds occurred. The investigators also collected mucus from the kids during their colds to test it for viruses and bacteria.

Cough and cold medicines don’t work

Health authorities are reporting that commonly-used cough and cold medications are not safe and are not effective. Since colds are so common and affect all of our children at least a few times a year, parents ask me every day about the new guidelines, and about the safest ways to help their children feel better.

First, some details. The medications that are commonly suggested to relieve the symptoms of the common cold fall into just a few groups. Within each group, the available choices are all essentially the same. Often, medications from several groups are combined to make what is optimistically sold as a “multisymptom cold reliever.”

Decongestants include products with the active ingredients pseudoephedrine and phenylephrine. They are supposed to work by shrinking the lining of the nose and decreasing nasal mucus secretions. Decongestants also raise a child’s heart rate and blood pressure, and may cause hyperactivity, agitation, and sleeplessness. Good studies have never shown decongestants to be effective in children, and even in adults their clinical effect is probably very small.

Cough suppressants are another group of medications purchased to help with the symptoms of the common cold. The most widely used over-the-counter product, dextromethorphan, has become a drug of abuse among young adults. Good studies have never shown that dextromethorphan is effective in stopping a cough; in fact, a recent study showed that in children, honey may be just as good or better than this medication. There are some prescription-strength cough suppressants as well. These are usually narcotics with strong sedating effects and some potential for abuse and addiction. Even these potent drugs, with all of their side effects, are very effective at actually helping a child who has a cough.

Antihistamines can certainly help with symptoms of nasal allergy, and are often used for colds as well. If you’re not sure if your child has allergies or a cold, a safe dose of an antihistamine may be worth trying. But it won’t help if your child’s runny nose is caused by a cold. Some families may find that the sedating effect of antihistamines can allow better sleep, at least for the parents. Newer, non-sedating antihistamines like Claritin and Zyrtec are expensive and offer no benefit whatsoever to children with the common cold.

Expectorant medications include those with the active ingredient “guaifenesin”, sold under the brand name Robitussin. These are supposed to thin secretions and help clear mucus. Unfortunately, no studies have ever shown that these medications actually work; and the liquid forms taste horrible. Among the medications reviewed so far, expectorants are the least likely to cause any side effects. Even though they’re unlikely to be effective, at least they’re safe enough to be worth trying in some cases.

The medicines reviewed so far—decongestants, cough suppressants, antihistamines, and expectorants—are collectively called “cold medicines.” They’re combined in all sorts of ways in products marketed to children, including common brands like Dimetapp, Triaminic, Pediacare, and many others. These are the medications that have generated some increased controversy over the last years because of questions of their safety and effectiveness, and the way they’re marketed to children.

In 2004 and 2005, about 1500 children less than two years of age were treated for adverse events triggered by cold medications. While many of these reactions were mild, more serious reactions including seizures, stroke, and death have occurred. Though industry representatives feel confident that these more severe reactions are not possible if the medications are dosed correctly, safe doses of these medications are not well-established or agreed upon by pharmacists and pediatricians.

In August, 2007 an FDA advisory panel recommended that cold medications not be used under age six, citing both a lack of evidence that they work and concerns about their safety under age two. Shortly after that, several large manufacturers of these products voluntarily recalled cold medications that were packaged for use in babies and toddlers. In January, 2008, the FDA formally announced that they advised against the use of these products under age two, and that later this year they will make recommendations for older children.

So what can a parent do to help the miserable symptoms of the common cold in a child? First, several non-medicine approaches can really help. Frequent use of non-medicated saltwater (also called saline) drops can help clear mucus from the nose and is safe at any age. You can buy these drops over-the-counter, or mix them up inexpensively yourself. Other methods to keep nasal secretions runny and loose will also help. Encourage a child to drink more fluids, use a humidifier, and sit together in a steamy bathroom. Honey can be used safely in children past their first birthday to help settle a child’s cough. (Honey should never be given to infants less than one year of age.) Though these are many other alternative or “natural” medicines that are marketed for children with cold symptoms, many of these have unknown safety and effectiveness. If you’re interested, we can cover more details about these products in a future post.

Medicines that reduce fever and relieve aches and pains are safe and effective, and can help with some of the symptoms of a cold. These include acetaminophen (found in Tylenol, and safe at any age), and ibuprofen (found in Motrin and Advil, and safe for use in babies six months and up.) Confirm the correct dose for these based on your child’s weight with your pediatrician.

In summary, many of the medications commonly sold to reduce symptoms of the common cold just don’t work, and they can be unsafe especially if used under age two. To help your child feel better, rely on simple home remedies that thin secretions and help clear out stuffy noses. If you do want to use a medication, follow the dosing guidelines of your pediatrician or pharmacist closely, and always keep medicine bottles away from children. As miserable as it can be, a cold is going to get better all on its own. It’s not worth it to use approaches that might lead to far more serious consequences than a cold itself.

© 2008 Roy Benaroch, MD from www.PediatricInsider.com