May 2001 • Volume 7 • Number 5
Battling a growing dilemma
AAFP joins in developing new antibiotic use guidelines
BY CINDY McCANSE
You've heard it before, and you'll hear it again: It's just not smart medicine to routinely prescribe antibiotics for every child's acute otitis media or every adult's acute pharyngitis.
The fallout from overuse and inappropriate use of antibiotics is the emergence of scores of antibiotic-resistant pathogens.
Witness the virulence of Streptococcus pneumoniae, the leading cause of community-acquired bacterial pneumonia, bacterial meningitis, bacterial sinusitis and otitis media in the United States. Penicillin-resistant strains of this ornery little critter now abound, and resistance to doxycycline, macrolides, second- and third-generation cephalosporins and trimethoprim-sulfamethoxazole is on the rise.
In response, the Academy recently teamed up with the CDC, the American College of Physicians-American Society of Internal Medicine and the Infectious Diseases Society of America to create a set of evidence-based clinical practice guidelines on evaluating and treating adults with acute respiratory tract infections. The guidelines appeared in the March 20 Annals of Internal Medicine and will also be published in a series in American Family Physician. Currently, you can access them online by going to http://www.annals.org/issues/v134n6/toc.html and scrolling through the table of contents.
The guidelines present practical strategies for limiting antibiotic use to patients most likely to benefit from it. Specifically considered are acute sinusitis, acute pharyngitis, acute bronchitis and nonspecific upper respiratory tract infections. The majority of such infections, the guidelines conclude, are of viral origin and, therefore, warrant symptomatic rather than antibiotic treatment.
What's the reality?
But how do these recommendations translate into hands-on patient care? What do you tell a busy father who pleads with you to give him something -- anything -- that'll clear up a three-day-old sinus infection and get him back to work?
"We do respond to pressure from patients," says family physician Susan Hawn, M.D., of Jefferson, Ga.
Many patients don't want to be educated, says Hawn. "Some of them get hostile about it. I have patients who come in and say, 'I have a green nasal discharge' or 'I'm coughing up green mucus.' They've been told for 50 years, 'Oh, you need an antibiotic.' Who do you think they're going to believe?"
Lee Green, M.D., M.P.H., of Ann Arbor, Mich., a member of the Academy's Commission on Clinical Policies and Research, agrees it's a problem that physicians have largely brought on themselves.
"What was it Pogo said?" he muses. "'We have met the enemy and he is us.' There is a widespread perception on the part of doctors that patients demand antibiotics and can't be dissuaded, or that explaining the new thinking takes more time than we already-overburdened docs have."
But in truth, Green notes, that may not be the case. According to a recent study conducted by researchers at the University of California, Los Angeles, most parents who had been informed about the downside of the routine use of antibiotics in their children accepted their physician's explanation. Better yet, it added an average of only 31 seconds to the patient encounter.
Getting the word out
Granted, some patients already avoid taking antibiotics. They've read about the resistance problem and want reassurance that the drugs are necessary.
But those folks are in the minority, Hawn says. "Most people's concept of biology comes from shows like ER, where everybody who doesn't get the 'right treatment' is dead in three hours."
"They do try to make us earn our pay," agrees Theodore Ganiats, M.D., of La Jolla, Calif., chair of the AAFP commission. "But I've been shocked by the number of times that I've started trying to talk a patient out of antibiotics, and they've stopped me and said, 'No, I'm not asking for them. I'm just asking if I need them.' So the message is getting out to patients."
Help in delivering that message is on the way. HHS has already initiated a four-pronged attack on antimicrobial resistance; increasing patient awareness plays a major role (see the story "Feds, insurers step into the fray.")
Such a plan can create a culture in which patients don't expect an antibiotic prescription for every cold or sore throat, Ganiats believes. But then, he adds, it's up to physicians to enforce that culture.
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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