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!
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).
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.
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).
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