Have you ever wondered why doctors seem so stingy with antibiotic prescriptions? I mean, here you are suffering from a nasty cold and you simply cannot be sick right now (what with your crazy, busy life). What’s the harm in taking a few anti-bacterial zappers? They couldn’t hurt, right? Why can’t these stuffy doctors just give in a little? A new patient recently came to see me in clinic. He decided to switch primary care doctors after his previous doctor (who practices in my group) wouldn’t write a prescription for a second round of antibiotics without seeing him in clinic. Initially, the patient self-diagnosed with a sinus infection, called his doctor, was given one round of antibiotics that didn’t seem to work. So he tried to call in for another round but was denied. He was distraught and angry. “I can’t come in for every little thing just because he wants to collect my copay and make money off every visit,” he exclaimed. “So I told him I’m finding a new doctor!" It's a valid question: Why are some doctors hesitant about prescribing antibiotics, especially without a visit? If you've read or listened to my earlier episode Why Is My Doctor Always Late?, you know that there are a lot of misconceptions and problems in the field of primary care. So I can certainly understand his frustration. Let’s reveal the truth behind why doctors don’t like to prescribe antibiotics. (Hint: It's not because they want to charge you an extra copay). What Are Antibiotics? Before we discuss why doctors don’t like to prescribe unnecessary antibiotics, we must learn what antibiotics are in the first place. Antibiotics, along with vaccines, are truly some of the most miraculous discoveries of our time. We can now cure many infectious diseases that previously caused severe complications and deaths. When necessary, antibiotics can be life-saving. But which infectious diseases exactly do antibiotics target? Antibiotics only help to destroy bacteria specifically. This includes illnesses like bacterial pneumonias, strep throat, bacterial ear infections, pertussis (or whooping cough), some STDs (like chlamydia, gonorrhea, and syphilis), tuberculosis - really nasty bugs. Viruses, on the other hand, tend to be much more common than any bacteria that I just mentioned (at least here in the U.S.). Viruses affect almost all of us at one point or another. The common cold and flu viruses run rampant particularly during the winter. Unfortunately, in spite of what you may have heard, antibiotics don’t do a thing for viruses. Why Doctors Don’t Like to Prescribe Antibiotics Without Examining the Patient When prescribing antibiotics, a doctor must determine whether the patient’s illness is due to a virus or bacteria. This is truly not an easy task over the phone or patient portal email. The doctor must ask a series of detailed questions (called a “patient history”) and perform a physical exam before making such a determination. The Exam: For instance, how can a doctor tell if you have an ear infection without seeing pus in your ear? How can they tell if you are suffering from pneumonia without listening to your lungs and possibly performing other necessary tests? How can they tell if you have strep throat without performing a throat swab or looking inside your throat? Even simply looking at the appearance of a patient can sometimes be an indication of how sick they may be – we can’t get that over the phone or email. The History: Also, a detailed history is vital to the decision-making process. For instance, the timing of the symptoms is crucial to determining whether the patient is suffering from the common cold (which is much more common) versus bacterial sinusitis (which often develops after the first 7-10 days of catching the common cold). For most patients, taking antibiotics for the first 7-10 days of developing cold symptoms is likely unnecessary – bacterial growth does not develop this quickly after a cold. Just because you have severe nasal congestion and sinus pressure doesn’t mean it’s bacterial, and in fact, it’s often not during those first 7-10 days. Also, studies also show that 75% of bacterial causes of sinusitis often self-resolve without antibiotics. That means, most of the time, even if it truly is bacterial, your immune system can eradicate it on its own without antibiotics. Therefore, as you can see, making an important decision as to whether or not a patient should be prescribed antibiotics is one that must be done in person. Why Not Just Take the Antibiotics Anyway? Why is making this decision about antibiotics important? What is the harm in prescribing them freely? Antibiotics don’t come without risk, both on an individual and a public health level. If you’ve been listening to the news, you may have heard about a potentially lethal superbug that has recently emerged called “CRE” (Carbapenem-Resistant Enterobacteriaceae). It's resistant to most known antibiotics and difficult to treat. Recently there were several deaths at UCLA associated with this bug, a bacteria that causes death in up to half of those with serious infections. That is astonishing. How did this superbug arise? Antibiotic overuse, no doubt. Here are some other risks of antibiotics you may not know about, but doctors see quite often: Resistance: We all maintain a balance of power of various bacteria that have set up shop in our bodies and skin. Don't panic - this is a good thing. We need these bacteria to keep the peace in our bodies. Taking antibiotics unnecessarily will kill off the wimpiest bacteria, allowing the nasty ones to overgrow and take over. These nasty bugs tend to be more resistant to antibiotics, so when you really need that Z-Pak to work, it just won’t. What can we use to combat bacteria if the antibiotics we currently have are no longer effective? This is a very frightening reality of our time and a process that must aggressively prevent. MRSA (Methicillin-Resistant Staph Aureaus): MRSA is another bacteria that has become resistant to many antibiotics and that has spread widely through the community. It was originally only contracted by hospitalized patients, but nowadays, you've likely shaken hands with numerous people who are carriers of this highly-resistant bacteria that can wreak havoc on the skin by causing pustules and abscesses that need to be drained and debrided surgically. What's worse - they're virtually impossible to eradicate completely. That means, once you become a carrier of MRSA, you will likely carry it for life. How do you catch it? By touching someone who has it. How did it arise? Antibiotic overuse in the community. Clostridium Difficile (C.Diff): This is a bacteria that lives in our colon and overgrows when antibiotics kill off the other good bacteria that keeps it in check. So next time you take that Z-Pak, it may be the one time that C.Diff decides to set up shop in your colon. The result? Severe diarrhea, fevers, weakness, dehydration, electrolyte imbalances, and other dangerous symptoms. Because of its potential for causing serious complications, patients with C.Diff often have to be hospitalized. I’ve even seen patients die from C.Diff. It's very sad. Allergic reactions: Allergic reactions to antibiotics are common. It's possible to develop an allergy even if you weren’t allergic to a certain drug previously. These reactions also have a fatality risk, because although the most common allergic reaction may be an itchy rash, it can occasionally cause anaphylaxis with lip swelling, throat swelling, difficulty breathing, and even “shock.” Antibiotics can also cause a severe and life-threatening rash called Stevens-Johnson Syndrome, which often entails a hospital stay. Source
