Wednesday, February 8, 2012

Antibiotic Stewardship is Everyone’s Responsibility

Since Alexander Fleming discovered penicillin in 1928 the world has been fascinated by this miracle drug that had the potential to save countless lives. When Dr. Fleming was awarded the Nobel Prize in 1945, about the time penicillin was being introduced into modern medicine, he warned of its potential dangers as well, but the enamored medical community was not listening. By the time that I was born in 1951, penicillin was being used for just about everything. It did not take long for antimicrobial resistance to occur. This miracle drug started to become less of a miracle.

Pharmaceutical researchers, in an on-going battle to combat emerging antibiotic resistance, scrambled and searched for new antibiotics. The battle continues to this day. Microorganisms naturally survive by complex adaptations. If just a few bugs survive an attack by antibiotics, those resistant organisms will multiply…and multiply…and multiply.  Soon, the original antibiotic will become less effective and, eventually, worthless.
Who is to blame? The simple answer is: everyone. In the past two decades, antimicrobial resistant organisms have risen to alarming levels due to a number of factors, but the primary reason has been the inappropriate use of antibiotics for acute viral infections (colds, influenza, viral sore throats, etc.). We have improved on this “treat ‘em all with antibiotics and let the body sort out the need” attitude over the last decade but we still have a long way to go.

 Strep throat – a bacterial infection – can present with some characteristic signs after you have had it a few days. The throat becomes bright red, covered in tiny hemorrhages called petechiae, and the breath smells awful. The person may have a fever, and children tend to have upset stomachs and malaise. (Incidentally, the “white stuff” that people see on the tonsils is NOT a characteristic sign of Strep.) Earlier in the course (the first few days), the throat may look normal, so the only way that you can be sure is to run a diagnostic test. A rapid Strep test, even taken carefully, is not a 100% accurate, but it is pretty darn good. A throat culture for Strep takes 2-3 days and is 100% accurate, but few people want to wait anymore.  Some medical providers do both; some don’t use tests at all. They feel they can diagnose Strep just by looking at it, but studies have shown that even the best clinicians are wrong 50% of the time. They might as well flip a coin in front of the patient. They just shell out the antibiotics, just in case, and just because a patient demands or expects them. This is a dangerous, on-going practice.

Children under the age of 14 or so are usually the ones who get inappropriately treated with antibiotics. Adults will wing it for a week or so with a nasty respiratory infection, but they rush the kids right to the doctor at the first sign of an illness, like a fever, sore throat, or a cough. Since most of these respiratory illnesses are due to self-limiting viruses, antibiotics would be futile.  Medical providers often find it easier, less-confrontational, and faster just to prescribe an antibiotic that is probably worthless than to take the time and effort to educate the patient.

Not to over-simplify the issue at hand, but it can be narrowed down to two causes: Inappropriate prescribing by medical providers who should know better, and patients who demand or expect antibiotics. There are three simple, logical steps that can make things better for all of us:
  1. Clinicians should follow evidence-based practices. No longer can medical providers afford to shoot from the hip when it comes to treating infectious diseases. Patients deserve to be treated on sound, scientific principles not clinical suspicions.
  2. Education may be preferable to Medication. Medical providers need to learn to say NO. If an illness is clearly viral, then forego antibiotics. Stop routinely treating middle ear infections with powerful antibiotics. The evidence is there. Read it. For patients, take time to educate yourselves about standard medical practices. Work with your medical provider as a partner, not an adversary. Stop demanding, begging, or soliciting treatment that is not needed.
  3.  An accurate diagnosis is essential. ER doctors cannot diagnose a middle ear infection in a child whose ears are full of wax, so why give antibiotics based on ear pain alone? Since most middle ear infections resolve on their own without antibiotics, parents should not demand, expect, or accept them. Insist on a Strep test to confirm a diagnosis rather than just randomly using an antibiotic.
Over time, this more judicious use of antibiotics will result in a turn-around. Not only will many of the super-bugs lose their acquired resistances, our improved immune systems will become stronger. If we do need to use antibiotics, we may be able to return to less-potent antimicrobial agents again. Antibiotics have been precious gift to mankind, but we cannot take them for granted anymore.


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