Much has been made of antibiotic overuse, and it’s potential effect on the rise of drug resistant bacteria. Ben Brewer wrote a timely piece today on community-acquired MRSA, which is a symptom of indiscriminate antibiotic prescribing.
Determining whether upper respiratory infections are viral or not has always been a challenge. In today’s practice environment, providers simply prescribe antibiotics to meet both patient expectation and to expedite care. Spending time to counsel patients on the consequences of antibiotic overuse is becoming less feasible.
A recent study in the Archives of Internal Medicine caught my eye, where an objective test can be taken to determine whether upper respiratory infections were bacterial or not. Procalcitonin is an inflammatory marker that rises in cases of bacterial infections. Antibiotic prescription rates were 72 percent lower for doctors who treated patients guided by procalcitonin levels, without a significant change in outcomes.
That’s a significant finding, but there are concerns about cost and delay of results. I would certainly use it if the results were immediate, like a rapid strep test.
Today’s patients are conditioned to favor objective studies, like blood tests and x-rays, over physician opinion. An applicable procalcitonin test can satisfy this need, as well as reduce unnecessary antibiotic use.
A win-win situation for everyone involved.
Related posts:
- Primary care is a lousy term
- Too many doctors are calling in antibiotics over the phone
- Why free antibiotics are a terrible idea, and what drug and grocery stores should give away instead
- What Mozart can teach us about suberbugs and antibiotic resistance
- Door-to-antibiotics time for pneumonia
- Who are more likely to inappropriate prescribe antibiotics?
- Bacterial infection and cancer
{ 6 comments }
Wow – now that I have to look into!
As a family practitioner, I try to “walk the walk” with antibiotics and URI’s; however, it ain’t easy. In this era of 30 dollar copays, the patient expects more “bang for their buck” and wants a souvenir, in the form of a prescription, from the visit. I frequently give the scrip but encourage them to wait at least a week before starting.
I also find that urgi cares in particular give out z-packs for minimal reasons. No one studies that, just pcps. And this scenario makes pcps look bad: patient gets seen early in week, told it is viral and antibiotics not needed, goes to urgicare later in week and is given an antibiotic. Even the notes don’t make sense: impression is viral uri, plan is z-pack. The patient is left with the impression that the pcp was somehow deficient.
One of the big problems that I have with this procalcitonin test is how it may be used. I fear that I will be used as a substitute for practicing the art of medicine. Part of this art includes being the bad guy and explaining to patients that they don’t need antibiotics. Most cases of URIs don’t need a lab test to tell me if someone needs an antibiotic. Most people need to be re-educated and shown that they will get better, they just need wait.
I have been practicing for about 5 years and I can think of maybe a handful of cases where I would need to use a test like this. Whatever happened to the waiting for 7-10 days, in the case of sinus infections? Also the AAP as stated that it is acceptable to do watchful waiting for most kids over 2 with otitis. Never mind that 100% of viral conjunctivitis and 50% of bacterial conjunctivitis will resolve spontaneously. We providers have become a bunch of spineless wimps that cave the moment someone breaths loudly.
With that, I’ll go back to watching “House” where everything has an answer…If you haven’t found it, you just haven’t ordered enough tests.
@Anonymous – the FP
you are right on urgent care/ER providers making PCP look bad by prescribing antibiotics. Plus, and even worse, this reinforces the patient’s expectation of receiving an antibiotics for a URI. This is the exact opposite behavior we are trying to reinforce.
It’s just the same as a parent saying no to candy for their child, the child then throws a tantrum, so what happens… the parent given the child the candy thereby reinforcing the idea that if the child throws a tantrum he will get candy.
I think a good use for it would be someone who comes back after 4-5 days of not getting better. Then, instead of saying “you may have a bacterial URI since you are not better”, you can now come closer to proving it.
Hi Dr Kevin.
Doesn’t ESR cover everything in terms of diagnosing a bacterial infection? Our doctors say that if ESR is not raised, no infection, the end. Does procalcitonin pick up on infections that do not raise the ESR?
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