Says Whitecoat, ranting about the indiscriminate use of antibiotics, and I couldn’t agree more. In the last five years I’ve seen cipro transform from a “big gun” to a throwaway antibiotic, useless against skin infections and ineffective (at least locally) in one of four UTI’s.
So I too try to do my part. No shots of rocephin or Z-paks for the various ways viruses decide to show up in my ER: bronchitis, sinusitis, gastroenteritis, or my personal favorite: the all encompassing “viral syndrome.” Strep throat? Penicillin works just fine, thank you very much. Ditto amoxicillin for toddler pneumonia. No you don’t need anything “stronger,” there’s really no such thing, what you think of as stronger is really broad-spectrum, killing more varieties of bacteria, but unnecessary when we have a pretty good idea of what’s causing the infection.
So I feel good about my practice of medicine in this respect. Then again, I also feel good about taking the recyclables out to the curb, but for neither do I harbor any illusions of making a real difference. Just as your spouse might cancel out your vote this November, so too are my puny efforts negated many times over across the country in various pediatrician’s offices, family practice clinics, urgent care centers, and ER’s.
Not to mention there are ways of getting antibiotics without a prescription (my professional advice: don’t take fish antibiotics). But despite all the leaks in the system, and all the problems it has spawned, at least we still have some regulation. Many African, Asian, and Latin American countries sell antibiotics directly to the public, no script required. My eyes were opened to this long ago, during a spring break trip to Matamoras where I saw dozens of antibiotics available over the counter as if I was channeling directly into some uptight soccer mom’s wet dream. (I also saw a stand where you could buy ten tacos for a dollar, but that’s another story.) I would never profess to be any kind of expert on Mexican culture, but when you live in a county where one person out of every three is Latino you are bound to learn a thing or two. And what I’ve learned, not surprisingly, is that when antibiotics are readily available they are taken with alarming frequency. Throughout life for every symptom imaginable or even just for general health maintainance they are a country stuffing themselves with antibiotics like farm raised cattle.
But the problem with too many people is if they’re not ignorant, then they just can’t see past the boundries of their own skin to the greater good. And as bacterial resistance increases at ever alarming rates, new antibiotic technology emerges slower than ever (guess what: pharmaceutical companies care about developing drugs that you take for a lifetime, not for a week). We may very well be headed back to the abyss Alexander Fleming pulled us from eighty years ago, where people die from routine infections as we, despite all of our 21st century technology, can do nothing but stand idly by.
May 8, 2008 at 3:51 pm
I know. In Guatemala a mom brought in a 6 week old who she’d been giving bactrim liquid to for a week because the kid was feeding less per feeding (but more feedings per day). Ugh.
May 8, 2008 at 5:02 pm
Last night:
Me: Why were you prescribed amoxicillin?
Patient: Oh, the doctor said I have a virus.
Me: Well, amoxicillin doesn’t work on viruses.
Patient: Yeah, but he said he just gave it just in case.
Why was the patient in the ER? Yep, you guessed it. No improvment from amoxicillin with non-specific aches, pains, and intermittent fever.
May 8, 2008 at 9:42 pm
ER the show today had a woman dying from septecemia that wasn’t responding to antibiotics.
Me: “This is why I yell at you for not finishing antibiotics or taking them unnecessarily.”
Mom: “That has nothing to do with it.”
Me: “It has everything to do with it.”
May 8, 2008 at 10:23 pm
Here’s a good question:
Will FDA put humans at risk with cow drug?
By Rick Weiss
The Washington Post
The government is on track to approve a new antibiotic to treat a pneumonialike disease in cattle, despite warnings from health groups and a majority of the agency’s own expert advisers that the decision will be dangerous for people.
The drug, cefquinome, belongs to a class of potent antibiotics that are among medicine’s last defense against several serious human infections. No drug from that class has been approved in the United States for use in animals….
The American Medical Association and about 12 other health groups warned the Food and Drug Administration that giving cefquinome to animals probably would speed the emergence of microbes resistant to that important class of antibiotic, as has happened with other drugs. [emphasis added by http://enigmafoundry.wordpress.com/2007/03/04/stupid-question-but-at-least-my-cow-is-well/EF Those supermicrobes could then spread to people.
Find the answer here:
Agreed, big problem that I didn’t even address.
May 9, 2008 at 4:21 am
Ok, from a strictly non-medical point of view…I love my doctor, we discuss stuff and he knows I’m VERY reluctant to give my kids antibiotics unless we flat out know for sure they have to take something. Most of the ones you listed except the rocephin, my kids are sensitive to. Oh yeah, rashy hivey goodness up in our house. The Cipro just causes massive, uncontrolled vomiting. And so they are limited in what they can take. And it chaps my heinie to no END when people don’t finish their meds or just take ‘em for no reason. It puts my kids at major risk. So rant on, Doctor.
May 9, 2008 at 4:34 am
Sadly enough, underdeveloped countries are not the only places where antibiotics are sold over the counter. In poorer communities, where people do not have insurance or the time to visit the doctor, the pharmacist becomes the physician and he will listen to complaints and sell what should be prescription drugs to the uneducated consumer. I think it’s an overall public health education issue and a mainstream media issue.
May 9, 2008 at 5:22 am
10/10,
The public health guilt I feel when a patient browbeats me for days into a course of amoxicillin for a cold quickly turns to anger when I see my colleagues throwing around Levaquin for 2 days of sniffling.
Keep the faith, man. And keep recycling.
(Fist bump)
May 9, 2008 at 8:19 am
Thanks for holding your ground. I work as an RN in a large pediatric clinic, and our docs are the same; no antibiotics for viruses, plain old PCN for strep, and Amox is just fine for toddler pneumonia.
Bacteria-resistant Cipro is very scary to me personally. I have Polycystic Kidney Disease, and occasionally get infected cysts. 3-4 weeks of Cipro is usually what it takes to clear it up; if not, a Nephrectomy would be in my future (I just got a transplant last week, so I’m not worried about losing a native kidney; I just don’t want to have to go through a Nephrectomy).
I’ve started using Keflex for UTI’s because our local sensitivities are showing so much Cipro-resistant E Coli. Best of luck to you, I hope you manage to avoid the surgery.
May 9, 2008 at 9:59 am
My kid has never had antibiotics, ear infections, serious colds or flus. Although we do have regular HMO insurance, we pay out of pocket to see an old-fashioned osteopathic doctor (the kind who does adjustments), who would probably rather have toothpicks shoved under his nails than prescribe antibiotics. Thank goodness there are still doctors like him. He’s worth every penny.
May 9, 2008 at 11:29 am
The easiest way, IMHO, to descourage unnecessary use of antibiotics is to put more emphasis on potential side effects, especially bad ones, however rare they might be. Think about how much of a public outcry there is about side effects of a serious but very rare side effects emerging from drugs prescribe for chronic conditions. All of the antibiotics have potential for serious side effect which while rare are not any rarer (correct me if I am wrong, I am not a doctor) than side effects of biophosphates or HRT or Vioxx. I don’t know the actual incidence of hearing loss or kidney damage with some antibiotics, but it can happen.
Most people care about themselves more than about “greater good”. For many people who ask for antibiotics for colds, brinchitis, etc. antibiotic resistance is an abstract concept that happens to someone else. An immediate risk, however small, of hearing loss or kidney damage is a whole lot scarier.
BTW – I don’t bother going to a doctor for colds and such and try to get over it without drugs; if a doctor prescribes antibiotics I ask if it is really needed. In my childhood the only time I had antibiotics was for pneumonia, and that was penicillin; although I managed to avoid ear infections, so I cannot say anything about those. The only times when I had antibiotics as an adult was on the request of my periodontist before/after periodontal surgery. I don’t have enough knowledge to know if this is necessary -just found some studies that say it might not be, but I didn’t want to question my periodontist. It seems to me that if there is indeed evidence that such a use of antibiotics is not needed, it should be some guidelines that need to change.
Pointing out side effects is a staple of my “you don’t need antibiotics” speeches.
May 9, 2008 at 12:01 pm
So interesting! Thanks for sharing this info, I love learning more about the medical issues of the day and this was really insightfull!
May 9, 2008 at 12:57 pm
So I guess you’re doing nasal swabs for pertussis and gram stains of sputum prior to discharging these patients with their “viral” illnesses?
Or do you have a rapid viral test for viruses other than influenza?
Nope, you’re making a clinical diagnosis. Good luck with that.
I make clinical diagnoses every shift and so do you and so do all doctors. I will take all the good luck I can get though, even the sarcastic kind.
PS: RSV
May 9, 2008 at 1:37 pm
Scalpel – why do you have to rule out viral disease; isn’t it bacterial disease that has to be ruled in?
If you are going to perform some positive action (in casu administring antibiotics), you must give a reason (in casu demonstrating that antibiotics will cure the disease in question). The negative, doing nothing, needs no justification.
May 9, 2008 at 1:51 pm
The potential consequence of delayed treatment of bacterial disease is less than the potential consequence of overtreating viral disease.
I don’t recycle either.
Those are some words that will ring hollow fifty years from now.
May 9, 2008 at 2:07 pm
The problem, in general, is that many people don’t go to a physician to take antibiotics.
May 9, 2008 at 2:32 pm
As a patient that caught one of the antibiotic resistant superbugs during a “routine” procedure and barely survived: keep up the good work! I wish all doctors shared your belief.
May 9, 2008 at 3:33 pm
“The potential consequence of delayed treatment of bacterial disease is less than the potential consequence of overtreating viral disease.”
Only problem with that logic is…your not over treating. Anti-biotics don’t treat viruses. Using them incorrectly like this just lead to more resistant strains of bacteria…
May 9, 2008 at 11:03 pm
How do you know it’s a virus?
I’m just saying that there is a spectrum of unnecessary antibiotic use, and the blanket denial of the practice by any working ER doc is disingenuous at best.
Do you culture every urine with a few WBCs and make patients wait until the culture is positive before treating? I doubt it, and if you are that sort of hardass as a practicing ER doc then you are eventually going to get burned. We don’t have the luxury of close followup.
Do you eagerly give a broad spectrum antibiotic (or two!) to every patient in triage with a hint of atelectasis on their CXR in order to meet the mandated 4 hour window for “pneumonia?” Without even examining the patient, perhaps? Then you are being hypocritical.
Few of us would give antibiotics to a runny-nosed three year old, but if you withhold antibiotics from every 80 year old with a cough and low grade fever (whether their X-ray and CBC are abnormal or not) then you are perhaps being a bit reckless.
In between is the working mother who has patiently fought off a bad cough for a week and doesn’t want to miss any more work than necessary.
May 10, 2008 at 12:10 am
Scalpel, have you ever read a journal?
If you’re a real doctor, you need to do yourself a favor and start working by evidence and not bullshit. You’re as good as a mom treating her infant’s cough with paregoric – seems like a good idea, as long as you ignore evidence and logic.
May 10, 2008 at 1:31 am
Sometimes I do.
May 10, 2008 at 8:42 am
The drug, cefquinome, belongs to a class of potent antibiotics that are among medicine’s last defense against several serious human infections. No drug from that class has been approved in the United States for use in animals….
The American Medical Association and about 12 other health groups warned the Food and Drug Administration that giving cefquinome to animals probably would speed the emergence of microbes resistant to that important class of antibiotic, as has happened with other drugs.
What will the FDA do?
Sorry, the link above didn’t work, here’s one that does:
http://enigmafoundry.wordpress.com/2007/03/04/stupid-question-but-at-least-my-cow-is-well/
May 10, 2008 at 9:40 am
This is a very interesting, but less publicly known, problem.
On the handing out of antibiotics, one of the paradoxes in treatment include illnesses where the body was weakened by the non-specific bacterial cleansing of antibiotics. Then, the only traditional method of treatment consists of more antibiotics!
This automatically causes an added complication for the patient, which sometimes is more dangerous than the original condition. This also encourages antibiotic resistant strains from
1) the original antibiotic dosage
2) the additional antibiotics to treat the bacterial infection
May 10, 2008 at 9:57 am
Scalpel, I agree with your entire comment up until the last paragraph. Using your examples I do give antibiotics when not necessary because the UA ended up being misleading or in the case of an 80 year old with a fever/cough because being wrong would lead to them quickly decompensating.
But I just don’t see a mom with a cough for a week as inbetween. Do you believe that antibiotics will get her better faster? There is no objective evidence for this, only to the contrary.
I’m not suggesting recklessness, and I’m certainly not breaking new ground, all I’m advocating is withholding antibiotics from relatively healthy kids and adults with a viral-type picture, a group that any practicing clinician knows sees tons of antibiotics thrown its way.
May 10, 2008 at 11:27 am
Studies do indeed suggest a marginal benefit from antibiotics to individual patients with bronchitis, but the concern of the industry is that the risk of antibiotic resistance outweighs the (admittedly subtle) individual benefit.
Some individual patients may get more benefit from antibiotics than others. I’m not treating society, I’m treating a patient who has probably waited 4 to 6 hours to see me and paid a $100 copay. If she really wants a freaking Z-pak even after I explain that it might not help her much if any, then I’m probably going to give it to her.
You might be interested in checking out the CDC recommendation for treatment of sinusitis too:
“Patients with moderate or severe symptoms may benefit from antibiotics. Use a narrow spectrum agent that covers S. pneumoniae and H. influenzae. Amoxicillin remains an appropriate choice for uncomplicated infections. Consider second line agent if no improvement or worsening after 72 hours.”
I submit that waiting 6 hours in an ER self selects for “moderate to severe” symptoms in many cases.
May 10, 2008 at 11:58 am
I wonder if you prescribe antibiotics to kids with otitis media. If you want to be consistent in your practice, the benefit of antibiotics for acute OM in children is about the same as that for bronchitis.
You basically have to treat 8 kids to see one patient who improves with treatment. Is it worth it? Probably not to “Doctor Dan.”
May 10, 2008 at 3:30 pm
This is exactly why I cringe every time I see a script for antibiotics for things like URIs, bronchitis, ear infections, and viral pneumonia. I’m just a mere HIM gal, but even I know the potential disaster from this kind of overuse. I’m not blaming the docs, I’m blaming the stupid people who insist the docs give the abx for a likely VIRAL infection. (I only blame the docs for giving in to these idiots, but that only shows that they’re human, so can’t rag on the docs too much!) Crazy world we live in…
May 10, 2008 at 7:11 pm
This is why I feel guilty when I am given antibiotics. I have one of those fun life-threatening allergies to beta-lactams, and while the adrenaline rush from the epipen is all good and fun, the not breathing and tight throat and other stuff bites it big time. So when my MD determines that I actually do need antibiotics, I’ll admit to squirming a little as I walk away with a Z-pac.
Oh, and just so all of you know, in vet school they do push the public health aspect of antibiotic therapy for animals. We unfortunately have plenty of MRSA and MRSI in the VMTH.
May 11, 2008 at 5:14 pm
Re bronchitis: fair enough, I recend my previous statement, should have said there’s evidence that antibiotics don’t help and no strong evidence that they do.
Re sinusitis: per Hardwood-Nuss, antibiotics are reserved only for cases not improving after 7 days duration.
But I feel like we’re nitpicking. It would be foolish to say that patients with bronchitis or sinusitis NEVER need antibiotics, but most of the time it is my opinion that they do not. I think there are practitioners who overprescribe for these conditions, and I think it would be beneficial if they stopped.
Finally, I discuss the watchful waiting thing for otitis in kids (and parents) in which I think it would be appropriate. But for all I know, every single mom could be heading straight from the ER to the pharmacy.
Thanks for your comments, it’s always a good thing to reread and think hard about why I’m doing what I’m doing. I think I remember someone telling me one time that obviously there’s more than one way to do this job
May 11, 2008 at 8:37 pm
woah, I didn’t realize a little pill could be so darned controversial!!
May 11, 2008 at 11:43 pm
“I think I remember someone telling me one time that obviously there’s more than one way to do this job.”
And I think it’s important to keep it that way. Protocols and guidelines are fine, but I don’t pray to them.
Here’s another consideration: patients in randomized, placebo-controlled studies are at least getting the benefit of a placebo effect. I’d like to see a study comparing outcomes between a Z-pak prescription and a “sorry, you get nothing but a 6 hour wait and a huge bill discussion.”
Like with narcotic-seekers, if a patient is convinced they need some medication to feel better then that’s pretty much what they are going to require.
Maybe we should bring back placebos.
May 12, 2008 at 11:33 am
It’s not just the patients who demand antibiotics.
As an urgent care physician, I am getting pressure from my employer, the hospital administrator, to prescribe unnecessary antibiotics in order to make patients “happy” and thereby increase volume and revenue in the urgent care. He is also unhappy that I am not prescribing narcotics, thereby losing potential patient revenue and visits from drug seekers. I never expected that I would lose my job because I was trying to practice good medicine. I am being blamed for the decreased volume in our urgent care because of these issues, in spite of having nothing but positive feedback from patients both verbally and on patient surveys.
May 12, 2008 at 12:33 pm
That is a very interesting point. I remember doing a month rotation during my fourth year of med school at an urgent care clinic in an affluent suburb. There were maybe 8 or so of these clinics in the area, and the doctor I was assigned to owned all of them. I remember even so early in my education being struck by how much he pandered to the wishes of his patients.
You seem to be in an impossible position, it’s hard to practice good medicine when the only way to keep you job is to practice bad medicine.
May 14, 2008 at 9:19 am
It is a tough one. Hold the fort 10/10!
A FM resident now doing internal, I am shocked at how the IM people treat levaquin as first line for pneumonia. Erythro, people. It’s 33 cents a dose! And it works!
On the upside, if you check out the stats for MRSA, cultures show it’s quite often sensitive to one of the simpler, older antibiotics.
All you can do is what you can do. There are others working to reduce indiscriminate abx use.
May 17, 2008 at 7:36 pm
I teach biology (both high school and community college) and I address this issue several times in the course (when we talk about bacteria as a taxonomic group; when we talk about evolution especially population genetics; when we discuss the immune system).
I also have my AP kids read a great article in the ecology section published in either Scientific America or Natural History which argues that we should treat and manage our antibiotics in the same way as any other natural resource.
Just so you know that I’m trying on my end
I haven’t taken an antibiotic since the 10th grade (and I’m almost 40) either.
May 17, 2008 at 8:17 pm
Very interesting topic! Thanks for the read.
I have a young son who had tubes put in his ears at 10 months. It seemed like he had one big long ear infection from about 3 months (when he entered daycare) until 10, when the tubes went in (and yes, I breastfed). He was constantly on anti’s, and I was sick of it, but didn’t know how sick I should’ve been (and wanted to sleep again), so we went with tubes.
Now he still gets ear infections, but we put drops in, which are combo antibiotic/steroid (ciprodex), after his ears leak.
I try to avoid getting oral antibiotics, but the doctors seem to prescribe them–even if I don’t ask. If they prescribe–should I ask if I could wait? What if my son has been sick for a month? Should I ask for something simpler, like amoxicillian, versus augmenten?
Uh, sorry for all the questions. I’ve just never found a community that questions it like this. I’ve always had doubt in the back of my mind, but I wasn’t sure what to do with it. Would love other opinions.