“I’m at a level of very concerned,” said Dr. Jeffrey Linder, lead author of the study and chief of the Division of General Internal Medicine and Geriatrics at the Northwestern University Feinberg School of Medicine in Chicago. He presented early results from his work at the IDWeek conference at Moscone Center. That antibiotics are often inappropriately prescribed is not new information. But the Northwestern study is among the first to carefully describe prescribing behaviors in outpatient settings, which are the source of roughly 80 percent of all antibiotic prescriptions. The U.S. Centers for Disease Control and Prevention in the past has estimated that a third of outpatient prescriptions are unnecessary. Linder’s study looked at prescriptions given at 514 outpatient clinics in the Northwestern health system from November 2015 to October 2017. Forty-six percent of the prescriptions were given without an infection-related diagnosis for which antibiotics would help. It’s possible that in some cases the antibiotic was appropriate and the prescriber just didn’t write down the diagnosis, Linder said. But the percentage of antibiotics given without good reason is too high for that to be the only explanation, he added. “The problem is actually bigger than we thought,” Linder said. “We continue to be pretty cavalier about overuse of antibiotics. It’s sort of a collective indifference to the harms.” The main fear around antibiotic misuse is that it can cause drug resistance. Every time someone takes an antibiotic, there is a risk that bacteria that are able to fend off the drug will survive and multiply. Those antibiotic-resistant bacteria can be passed from person to person, or the bacteria can share that resistant trait with other microbes in the body. So when patients take an antibiotic for a common cold or sinus infection that’s caused by a virus, for example, they may be inadvertently promoting drug resistance. For decades that wasn’t much of a problem, because if bacteria became resistant to one antibiotic, doctors could always try another. But there are a limited number of antibiotics, and some bacteria are close to developing resistance to every one of them. A case was reported earlier this year of so-called super-resistant gonorrhea in the United Kingdom, and infectious disease experts say it’s just a matter of time before cases arrive in the U.S. That’s the public health concern, but patients also could be hurting themselves by overusing antibiotics, experts say. The vast majority of bacteria in human bodies are not disease-causing, and some contribute to overall good health. Antibiotics can wipe out even the healthy bacteria. “There is risk for personal harm and risk for public health problems. And as we move into a more modern era of antibiotics we should consider both,” said Dr. Ami Bhatt, an assistant professor of medicine and genetics at Stanford who studies host-microbe interactions. Bhatt said she’ll be interested to see more results from Linder’s study, which could help infectious disease and public health experts identify the types of conditions in which health care providers are most likely to misprescribe antibiotics. The study found that 20 percent of outpatient antibiotics were given without the patient being seen by a doctor or other caregiver. In most cases the antibiotics were prescribed after a phone call with the patient, and again, Linder said, sometimes that may be appropriate — for example, for women with recurring urinary tract infections. But there’s no doubt that antibiotics often are prescribed when doctors or other caregivers know they’re unlikely to be useful, said Linder and other infectious disease experts. A lot of the reasoning comes down to culture. Doctors believe that patients have come to expect antibiotics to treat all kinds of maladies, and certainly many patients do demand the drugs. A paper published last week found that patient satisfaction rates go up when doctors prescribe antibiotics. Earlier studies have found that doctors are more likely to prescribe antibiotics in the afternoon than in the morning — a concept labeled “decision-fatigue,” because doctors get tired of explaining to patients why they don’t need the drugs, said Dr. Stan Deresinski, an infectious disease expert at Stanford. He’s worked with a colleague, Dr. Marisa Holubar, on training videos to help doctors learn how to communicate appropriate antibiotic use with patients. Part of the reason patients may prefer to get antibiotics is that it’s validating — they feel like they’ve been heard and their condition is being taken seriously. But doctors can accomplish the same thing by appropriately diagnosing patients, explaining why antibiotics aren’t helpful and may be harmful, and then giving people information that will help them recover, Holubar said. Some public health experts say just handing out informational pamphlets at the end of a visit can increase patient satisfaction. “A lot of times patients just need to know what’s going to happen to them,” Holubar said. “They need to know what their illness is due to, what they should expect, and what they should do if they don’t get better.” Linder said he recognizes that the doctor’s office can feel like a battleground in the “antibiotic wars,” and that can make it challenging for physicians to rein in their prescriptions. But with that in mind, patients can help keep the peace, he said. “The doctor’s default thought is, ‘The patient wants an antibiotic and I don’t want a debate,’” Linder said. “As a patient, as someone who’s concerned about your own health, the best thing you can do for yourself is tell your doctor you don’t want an antibiotic unless you need it.” Source
