May 2000 • Volume 6 • Number 5
Too many antibiotics
To the editor:
I would like to continue the dialogue on antibiotic misuse and overuse initiated by Dr. John Hickner in a March FP Report story and continued by Dr. Steve Kriebel in a letter in April.
I sympathize with Dr. Kreibel, who complains of "being bullied in the literature for doing too much of one thing and not enough of something else." However, I detect skepticism about the results of randomized trials. Randomized trials sometimes seem to contradict our experiences with patients. That doesn't mean the studies are wrong. More likely, it is a reflection of our limitations as observers and as processors of information. Think about it -- do you really know what happened to the last 20 patients that you treated for bronchitis? I bet some got antibiotics, and some didn't. Do you know how they were all doing one week later and whether the antibiotic-treated patients got better faster?
In Iceland, community physicians prescribed a lot of macrolide antibiotics in the early 1980s. Resistance rates of common community-based infections to macrolides increased. A campaign to reduce inappropriate use of macrolides in the outpatient setting reversed that trend and significantly decreased those rates of resistance. We should support campaigns that reduce inappropriate use of antibiotics in our country, not jump to the defense of outmoded prescribing practices.
Mark Ebell, M.D., M.S.
East Lansing, Mich.To the editor:
Your recent article on the over-prescribing of antibiotics by primary care physicians gave me an idea. Instead of the academics of our profession bashing the community-based doctors for their practices, why don't they come up with a more objective method, a "virometer," so to speak, to determine whether some commonly seen infections are really bacterial?
"We didn't study all the sciences to become fortune-tellers" I can test cardiac patients with an electrocardiogram and enzymes, a diabetic with a blood sugar or someone who is injured with X-rays. But while my patients trust me, it's harder to convince someone that Johnny's green nasal drainage for two weeks or Susie's injected tympanic membrane doesn't need more than just symptomatic treatment.
On the other hand, I've rarely had patients with sore throats who've had a negative strep test or people with urinary symptoms who've had a negative dip stick complain about not being treated with antibiotics. Those of us on the front lines need more tools, not just criticism. We didn't study all the sciences during medical school to become fortune-tellers.
Bruce Greenberg, M.D.
King City, Calif.To the editor:
I am distressed that a letter (by Steve Kriebel, M.D.) in the April FP Report cites "I have seen no studies" as evidence that it's OK to use antibiotics in upper respiratory infections. One reference is sufficient to refute such an argument: an article by H. Seppala et al. on macrolide antibiotics in the August 1997 New England Journal of Medicine.
Unfortunately, Dr. Steve Kriebel does not cite his "several studies" which show that URIs have statistically significant improved outcomes, so I cannot discuss the quality or clinical significance of those studies.
Perhaps Dr. Kriebel has been practicing long enough to remember that we used to use ampicillin to treat uncomplicated gonorrhea. This is no longer considered adequate therapy. Much of the reason is due to the importation of penicillinase-producing Neisseria from Thailand during the Vietnam War. Thailand allowed (and, I believe, still does allow) over-the-counter use of antibiotics. I once visited a Bangkok pharmacy seeking a decongestant for a URI, and the pharmacist tried to sell me erythromycin as the preferred treatment.
I agree that antibiotic use in hospitals is an important source of bacterial resistance. This can be partially alleviated by measures designed to reduce nosocomial transmission.
Richard Lamson, M.D.
Baltimore
Match results
To the editor:
The April FP Report article regarding the decline in family practice matching quotes our AAFP president, Dr. Bruce Bagley, as stating, "The health of the public will be hurt -- this trend must be reversed." To imply such a devastating effect from this decline is perhaps not only a bit grandiose but also demonstrates an element of denial as to the state of our specialty.
Could the decline have anything to do with relinquishing hospital privileges to hospitalists or relinquishing direct patient care to a variety of midlevel practitioners, or perhaps relinquishing other medical-political privileging issues within hospitals and universities? Or is the new fad of Med/Pedi residencies really a ruse to avoid the conflict our specialty often feels with obstetrics? Or are the insurance companies making the business of medicine so hostile that the romance of medicine has evaporated, directly affecting our lifestyles, especially considering the debt burden students incur? Perhaps the bull market in family practice really is over. It may actually now be time to plan for a bear market by diversifying our specialty adequately to help it remain a viable, valuable option for career planning as well as for acquiring patient confidence.
Jerry Behal, M.D.
McAllen, TexasTo the editor:
I would like to comment on AAFP President Bruce Bagley's statement in the April FP Report that "family practice involves a high degree of commitment." He seems to be implying that family practice requires a higher degree of commitment to patient care and that this is discouraging medical students such as myself from applying for family practice residencies.
I disagree with Dr. Bagley. In my experience, family practitioners frequently had a great deal more family time than, for instance, internists or surgeons, not only in residency programs but in private and academic practice settings as well.
I think the move away from primary care by medical school graduates has more to do with the increasing complexity of care and the reality that a physician cannot stay current in internal medicine, pediatrics, obstetrics/gynecology and psychiatry. Subsequently, the quality of care suffers.
Ward Naviaux
Seattle
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