SOME things that you’re sure to see every winter include children with coughs, office workers seeking medical certificates, football fever and … articles preaching to doctors about their overuse of antibiotics.

The articles in question dance to the same three beats: “naughty” doctors, you overprescribe and superbugs are your fault. The typical fillers for such articles are infectious diseases academics, patients in hospital for serious infections and alternative practitioners who love launching attacks against doctors.

It is time for a more nuanced approach to this phenomenon. While this criticism of doctors is often not based on a true understanding of the realities of clinical practice, we do need to admit that there are areas where we need to improve. In this article, I present the 10 problems with antibiotic prescribing, while in Part 2 (to be published on 21 August), I will discuss the solutions.

As I see things, there are five shades of clinical antibiotic problems.

Prescribing an antibiotic when one is not needed (a very common problem)

Not all fever means bacterial infection. Not all pus is bacterial. CRP (c-reactive protein) does not stand for “give me antibiotics”.

While the microbiologists are becoming faster and cleverer at isolating organisms, the process can still take days. Therefore, we sometimes have to make judgment calls and treatment decisions without all the information and we don’t always get it right.

Overprescribing the correct antibiotic choice (a common problem)

This manifests as keeping patients on antibiotics too long and using maximum (or higher than maximum) recommended doses.

The classic example of this is adult female uncomplicated urinary tract infection. Three days of trimethoprim is ample, but we often prescribe longer courses, perhaps out of habit, perhaps because that is what we were taught as trainees.

Prescribing the incorrect antibiotic (a common problem)

I have self-inflicted brain damage from the number of times I have banged my head against the wall on this point.

Hospital doctors can be among the worst offenders, with a tendency to overprescribe antibiotics starting with the letters “cef-”. Other antibiotics may be effective, and they need to be considered more often. For GPs, the tendency can be to prescribe amoxicillin as a fix for everything – it’s time to think again!

Antibiotic guidelines are widely available, for a fee, but not used well.

Underprescribing the correct antibiotic (a less common problem)

In my opinion, some of our kin like taking an each-way bet – prescribing an antibiotic, but dropping the dose. The danger of that, of course, is that when we don’t give enough, we are left wondering if treatment failure is due to incorrect diagnosis or undertreatment.

Current trends towards shortening antibiotic treatment times do not justify prescribing lower than recommended doses or shorter than recommended courses. When new evidence is in, the treatment time recommendations will change.

Not prescribing an antibiotic when one is needed (an infrequent problem)

These can really turn nasty. Missing the meningitis and not covering the compound fracture are examples that easily come to mind. The fear of missing these potentially serious conditions may often drive overprescription. If a bone sees the light, it also sees antibiotics.

The five clinical shades can be coated with good doses of education to give us brighter outcomes.

What aren’t so easy to coat are the following five shades of cultural antibiotic problems (pardon the pun).

Time pressure

In my experience, this is the commonest excuse.

Example 1: GPs may say they’re so busy that this is the most efficient way to handle things. If they don’t give antibiotics now, the patient will be back in a few days for the antibiotics anyway, they think.

Example 2: junior doctors may say it takes too long to track down the boss, so giving antibiotics is just the quickest thing to do.

Convenience

Doctors spend years learning the art of clinical history and examination. In my opinion, if a doctor is prescribing an antibiotic for a patient they haven’t thoroughly examined, then that is really disappointing.

Defense against litigation

Taking a conservative approach is something we often do, with the aim of avoiding litigation in the back of our mind. Defensive medicine’s legacy is overinvestigation and overtreatment, and antibiotics are easily the chief overtreatment.

Pacifying the patients and parents

We’ve all had those patients that won’t leave the consultation room without a script for antibiotics. They believe that they and Dr Google know best, and often we end up bowing under the pressure. Surely Dr Google has a script-printing app for these folks?

Being seen – our glamorous egos

We can blame the system, blame the Pharmaceutical Benefits Scheme, blame the hospitals, blame the patients and blame every quack in the universe.

At the end of the day, we only have ourselves to blame. We write the scripts. We sign the medication charts.

We are humans and love to assuage our egos. We’re doctors and we love to be seen to be doing something.

Can someone hand me a script pad?

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

(In Part 2 in a fortnight, he will offer some solutions to the 10 shades).

 

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.

 

7 thoughts on “The 10 shades of antibiotic problems

  1. Anonymous says:

    Thanks for bringing this up. Yes its a minefield sometimes to navigate to or not to give antibiotics
    Wait and risk sepsis or give and risk resistence.
    Therapetic guidelines are god sent but common sense should prevail as well, parts of body affected and possible culprits/bugs should give us an idea for choice of antibiotics.agree with amoxil commonly prescribed for all infections by GP.
    Thanks again for highlighting this issue will definitely await part 2.
    Cheers

  2. Antibiotic Steward says:

    Thank you for your refreshing and honest take on this topic – in particularly for pointing out that undertreatment/ wrong antibiotic selection can be just as problematic as overtreatment.

    One of the contributing problems in my opinion is separating cause from effect. A great number of people will state that because they got better after having antibiotics for their cough/cold/flu (very likely they would have recovered just as quickly without the antibiotic), they will want/expect an antibiotic again for future coughs/colds/flu. This seems to drive the belief that antibiotics are beneficial/needed.

    Is it time to develop a placebo antibiotic? Or increase public knowledge of the microbiome and the impact an unnecessary course of antibiotics can have on it? Looking forward to the solutions in Part 2.

  3. Randal Williams says:

    Doctors generally are blamed for antibiotic overuse, and some of the blame is justified, but the light is rarely shone on veterinary practitioners, who use them frequently. Animals can’t give a history so antibiotics, and NSAID’s / corticosteroids are frequently prescribed to cover most clinical situations. We must also remember that VRE developed from the farming practice of giving pigs vancomycin to prevent enteric infections and so fatten them up. Human viral illnesses sometimes can be alarming, especially to parents, and the pressure to prescribe an antibiotic can be high, remembering the clinical and medico-legal consequences of missing bacterial infections such as meningococcal disease. It is easy to sit in an academic ‘ ivory tower ‘ and pontificate, not so easy if you are a GP on the front line. ( I am a retired surgeon ,not a GP )

  4. Former Medico says:

    With the new additive combined medications in one tab similar to anti hypertension meds, why not try
    a combination of appropriate anti viral + low dose penicillin for the common acute URTI in a tab – likely reduction of duration and severity of the URTI, that could be viral and bacterial induced.
    May be the sophisticated drug companies need to trial on it, just an opinion of mine.

  5. Dr Tony Marshal says:

    Getting a diagnosis wrong, is something we all do and it happens from time to time. But getting priorities wrong, especially on important issues, is altogether another kettle of fish and should not be forgiven. Imagine a doctor concentrates on dealing with a sore throat, and neglects prompt treatment of a lung cancer.

    Alarm bells have been ringing recently regarding excessive use of antibiotics, and the risk of antibiotic resistance and the doomsday scenario that all the bugs may become resistant to all the antibiotics. It is an aside that, as usual and as you guessed it, this is blamed on the most obvious of culprits i.e. the GPs!

    In the last few months, all the weekly medical magazines that I came across, have had articles on the topic (Medical Republic, 20/04/17, page 31; Australian Doctor, 28/04/17; & MJA, online, April 2017 and now this article).

    In one article, the expert (Prof Cheryl Jones) sounded “alarmed” (as if not expecting it at all, (Australian Doctor 28/04/17 page 6), that an American woman had died due to being resistant to all available types of antibiotics .

    Alarming as it may be, however, it appears that the alarmists have been missing the biggest elephant in the room.

    According to sustainabletable.org and as also articulated in a recent documentary episode in RT (Russia Today TV), over 80% of all antibiotics in the USA are used on animals. It is also known that for instance, in 2012, pigs accounted for over three quarters of antimicrobial agents consumed in Denmark (DANMAP, 2012). It can be reasonably presumed that the trend in the rest of the so called “developed world”, including Australia would be very similar.

    The sad fact is that these antibiotics are not used for treatment of or even prevention of infection, the prime reason for their existence, but, but to increase animal productivity (so-called “production-purpose uses”), i.e.to fatten the animals, in order to enhance meat production.

    Apparently this is achieved by antibiotics changing the animals’ gut flora, so that they digest and excrete not in the usual way but in a way that they retain most of what they eat. Simply put, antibiotics are used by clever capitalists to produce cheap meat. We can reasonably assume that none of them have even scant regard to the long term effects of this abuse of science on the immediate health of the entire population of earth.

    This is in addition to indirect and longer term effect on global warming and so on; as approximately a quarter of global warming is said to be due to methane gas produced by farmed animal for meat production.

    Given that this “International community”, of which Australia is an integral part, are the biggest consumers on the planet not only of antibiotics for production-purpose uses, but also in many other areas (energy consumption and so on), the point cannot be over emphasised.
    We also know the ill effects of excessive consumption of meat on many other aspects of human health, ranging from obesity to high cholesterol and cardiovascular diseases.

    Despite this, here we are filling pages and pages of “scientific” articles and opinion pages regarding the hazards of using antibiotics for respiratory infections by GPs.

    While the argument here is not to deny the virtues of evidence based medicine, the evidence based practitioners appear to have lost sight of real priorities.

    Would it not be wiser, perhaps, for us to try to enlighten the business leaders and the politicians, who are their ultimate enablers, of these dangerous practices?

    http://www.sustainabletable.org/257/antibiotics

    https://www.ers.usda.gov/webdocs/publications/err200/55529_err200.pdf

  6. Anonymous says:

    I’m acutely aware of a young patient with totally untreatable Gram-ve negative enteric pathogens (x2) that live on some linked kidney stones, and try to kill this patient every time one of these stones tries to pass via the ureter. These pathogens are clearly derived from the inappropriate use of antimicrobials in humans; albeit, in another part of the world. This is not to say that the vets and primary producers are not contributing to these problems, but why do we feel so threatened by the true reality?

    Indeed, sadly as a medical practitioner, prescription of antimicrobials in humans still remains the biggest ‘elephant in the room’. It’s also something that we can directly influence. We have been required to address this issue in hospital clinical practice as a quality and safety issue, through comprehensive antimicrobial stewardship programs. Painful, that’s certainly true, but it’s SO much better than have a young patient die of untreatable sepsis – short of getting all of their associated kidney stones removed, asap. I have had similar outcomes in the past, so I’m comments that appear to be rare anomalous cases found overseas, are found in our own backyards. Could these sorts of Q&S initiatives be incentivised from within primary care frameworks (or perhaps via the MBS schedule)? Hopefully that could be improved for us all, because GPs won’t be the people directly looking after young people with untreatable sepsis, at least in the near future. Plus, we all ultimately become patients one day, ourselves.

    In a perfect world, these totally untreatable Gram-ve negative enteric pathogens would be attached to a business leader and/or a politician. Sadly this is currently not the case! In the interim, I’ll keep on asking my colleagues when they ask for advice re: some antimicrobials, just in case of….xyz, etc. My response is usually: Just in case of what? It’s really a very revealing question to ask, re: the key practical issues involved, although clearly never enjoyed by my colleagues at the other end of the phone! Although our business leaders and politicians are clearly enablers to this very complex and fraught issue, however, why don’t we feel so defensive about the reality of our current position re: antimicrobial resistance? Perhaps everyone has heard this message for way too long now and/or still does not believe that it’s real entity, and that patients like this truly exists within contemporary Australian health-care settings??

  7. Dr Tony Marshal says:

    It is a sad day that MJA Insight has joined the band wagon of political correctness and allows the comments such as above to be published in the first place, and more particularly “anonymously”.
    I can not believe that the above comments are made by some doctor practising in Australia who can not even put few sentences together correctly in English.
    No wonder our politicians are trying to impose English tests on all the new immigrants.
    I for one do not understand what the point is, that the above commentator is making in pigeon English.
    Being so as it may be, I believe the moderator should check all the comments and only publish them, if they were comprehendible by an average doctor such as myself.

Leave a Reply

Your email address will not be published.