Antibiotic Overuse: Both Physicians and Patients to Blame

Today physician blog KevinMD posted a guest post written by Dr. Michael Kirsch, a blogger and gastroenterologist with whose opinions I frequently align myself.  In his post, Dr. Kirsh discusses the ever-present battle of antibiotic overuse and the reasons for the abuse of these medications prompting me to discuss the topic as well.

Whether you work in acute care, pediatrics or family medicine, nurse practitioners are well aware of the struggles surrounding antibiotic prescriptions.  Patients want them, you may not know for sure if the patient needs them... So ultimately, most of us err on the side of caution or on the side of pacifying our patients.  What are the most common reasons we unnecessarily prescribe antibiotics and how can we change our behavior as well as that of our patients?

Uncertainty Surrounding A Diagnosis

Sometimes a diagnosis is not clear.  Is that gout or cellulitis?  One requires antibiotics while the other does not.  Should I wait for that culture to come back or preemptively treat?  Often, uncertainty surrounds the diagnoses we make.  We must wait for further testing or watch and wait to see if a patient improves on their own.  It can be very tempting to go ahead and prescribe antibiotics to patients in these situations even if ultimately they may not need them.

Patient Preference

Even patients who are well aware of the threat of widespread antibiotic resistance want to leave a provider's office with a prescription.  People tend to think they are the exception rather than the rule or that if they cheat the system their personal behavior will not have global effects.  It is OK if they are the one who takes a Z-Pack 'just in case' when they get the sniffles.  It can be very difficult to change these attitudes as well as very inconvenient.  You are busy.  It takes about 10 minutes to calm an angry parent upset about leaving your office without a prescription for a child with croup or bronchitis but only 10 seconds to write and sign a prescription.  Then, you must repeat this process multiple times each day.  Exhausting.  No wonder many of us reach for our pen in this situation. 

How Do We Change Behaviors Surrounding Antibiotic Use?

We must change our prescribing behaviors in regards to antibiotics as overuse of these medications is rendering them less and less effective.  One of the most effective methods I have found personally in preventing over-prescribing of antibiotics in my practice is to quickly educate patients about the dangers and side effects associated with antibiotic use.  Although widely regarded as harmless, antibiotics do come with some unwanted effects.  The New York Times recently published an article outlining the risk of sudden death associated with azithromycin.  I think fewer patients would request Z-Packs if they were aware of the minute but real risk of cardiac arrest.  

How do you advise patients of the risks associated with antibiotics in an efficient manner?  When treating a child with a cold, for example, I will tell the parent "Unfortunately, I think your child has an upper respiratory infection caused by a virus.  Antibiotics will not be effective for this; all they will do is cause him to have diarrhea in addition".  Nothing strikes fear in a parent more than the threat of diarrhea.  Or, in female patients requesting antibiotics I will inform them I believe antibiotics will not help and may also result in a yeast infection.  No woman wants to deal with a cold in addition to an itchy crotch.  Warning patients of the dangers and side effects of antibiotic use causes them to think twice and increase their willingness to stick it out and get better on their own.