Antibiotics need to become controlled substances and regulated

Antibiotics for viral infections are a big pet peeve of mine. No. Make that a huge pet peeve.

Some doctors prescribe antibiotics for coughs and stuffy noses because the patients want them. If you’re one of those patients who think that antibiotics make your coughs go away, or clear up your stuffy noses, or somehow make your sinus headaches vanish, or if you’re a doctor who prescribes antibiotics for these symptoms, this post is for you.

You’re killing people with your dumb demands and/or your inappropriate prescriptions.

MRSA stands for methicillin resistant staphylococcus aureus. There is regular staph aureus — that bug is pretty much fading into the sunset and being replaced by staph aureus on steroids. Because so many people are requesting/using antibiotics for non-bacterial infections, the bacteria in their systems learn how to beat the antibiotics — in effect, making the antibiotics useless. For example, in our area, Levaquin is frequently prescribed by many doctors for obvious viral infections. Then, when people have a urinary tract infection, almost half of the strains of E. coli — the most common urinary tract pathogen — in our town are resistant to Levaquin and Cipro and all the other drugs in that family that would normally kick E. coli’s butt. We have had several patients who had simple UTIs turn into serious systemic infections because they were initially treated with Cipro or Levaquin for their urinary tract infection and the antibiotics didn’t help.

Now there’s a super duper bug that’s coming to a town near you. According to a recent article in Lancet Infectious Diseases, bacteria are now picking up a new gene called NDM-1 that makes the bacteria resistant to almost all antibiotics. Most of the bacterial with this gene were E. coli, but the gene can apparently can be relatively easily transferred to other bacteria. The only antibiotics that bacteria with this gene were sensitive to were tigecycline and colistin. Right now most of the isolates are in India and Pakistan, but it is only a matter of time before the super duper bugs have spread worldwide.

A 2007 JAMA article showed that MRSA infections were abundant (.pdf file). An editorial accompanying the JAMA article noted that “The estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000).” In addition, the editorial noted that if the predicted number of MRSA deaths was accurate, the 18,650 MRSA-related deaths in 2005 “would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States.”

Currently, a study by the CDC is claiming that the incidence of MRSA is declining (I wasn’t able to find the study on the CDC’s web site) by between 17 and 27 percent in the past few years.

Even if MRSA goes away — which it won’t — there are still other resistant bacteria out there that are going to become a greater part of our lives. According to this San Fransisco Chronicle article, there’s “extremely drug-resistant tuberculosis” (XXDR TB). Doctors don’t even know how to treat this disease – or if they even can treat it. Less resistant TB can cost $100,000 per year to cure. Patients with XXDR TB will probably just die.

The San Fransisco Chronicle article also notes that drug-resistant infections killed more than 65,000 people last year — more than prostate and breast cancer combined. In excess of 19,000 of the patients who died from drug-resistant infections had MRSA.

So how do we stop the spread of resistant bacteria? It’s actually pretty simple.

1. Patients need to stop requesting antibiotics for nasal congestion, coughs, bronchitis, and “sinus infections.” Doctors need to stop prescribing antibiotics for these diseases. Norway nearly eradicated MRSA just by restricting antibiotic use. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better.” The slogan on a packet of tissues in Norway says “Penicillin is not a cough medicine.”

If we can’t change the habits of doctors who prescribe antibiotics in this country, then antibiotics need to become controlled substances and regulated by the DEA. It is that serious of a problem.

2. Wash your hands. Patients, doctors, everybody. Wash … your … hands. One friend wrote me and asked whether or not you’ll be viewed as a “trouble patient” if you request that your doctor wash his or her hands after entering your room. My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator.

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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  • Boz

    Is there any merit to the idea that taking antibiotics during a viral infection can protect against secondary infections caused by opportunistic bacteria?

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      No, all that does is culture for resistant bacteria.

  • Mike

    But in our day of patient satisfaction based medicine (especially in the ED and urgent care’s), how are we supposed to say no? I can explain all I went how antibiotics will not help, but patients will complain and then my director will have to deal with it, etc.. And this does not even take into account many doc’s whose salary is affected by “patient satisfaction”. And then they will go to another doctor who until they get what they want. Until this changes, even if making it a controlled substance, nothing will change.

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      Here in Nevada it is even worse. The patients can complain the to board of medical examiners who will initiate a formal investigation of 100% of complaints, regardless of merit. If you have too many complaints they will demand that you appear in front of them which means hiring a lawyer to the toon of $7000 (plus flight costs into reno).

  • SarahW

    Antibiotics are already controlled substances, available only by prescription from trained medical professionals.

    Good grief.

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      So too are narcotics, yet that has done little to curtail abuse. I agree that more needs to be done to stop inappropriate prescribing, which is epidemic here in Reno Nevada, but this is not the way.

    • IMDoc

      SarahW -No, they are not controlled substances in the legal sense to which the author is referring. Narcotics and benzos (among others) are true controlled substances. They require a special DEA license which enables the federal government to monitor prescribing habits. There is no such oversight over antibiotics, allowing them to be prescribed at will without consequence.

      • Dave

        Sadly the only way this will change is through physicians losing more anonymity. Large medical conglomerates (especially ones associated with medical schools) have boards that go through and check on their physicians to see if they are following guidelines (using targeted therapies etc.). There really is no way to do this with private physicians (unless regulations like those mentioned in the article are put in place).

      • ar

        Wow, you in your general clinic 9am-5pm practice complaint about over prescribing atbs, but the pts with pneumonia who were told…’its just a virus’ by zealous general doctors( and I read all day in my practice type),end up in the Emergency/UCC at 2am while you’re passing gas and snoring at home!

  • stargirl65

    Patient want and expect antibiotics. I have had patients transfer out of my office after I refused to give them antibiotics for their viral infections. I have had patients leave my office and go directly to urgent care or the ER “because they’ll give me my antibiotics”. Unfortunately they always do, which further worsens the problem. It creates unreasonable expectations of me and also further propagates the problems with drug resistance.

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      When the local Urgent cares do this, it not only undermines your credibility, it empowers the patients to then complain to licensing agencies about your (APPROPRIATE) care. We need to find a way to ferret out and sanction these providers.

  • Christie B

    It seems that the big problem is that while 90% of illnesses that present in a cold-like fashion are viral, 10% are not and patients would benefit from antibiotics. Of course patients are annoyed to be told that there is a 10% chance that antibiotics could help them feel better in <48 hours but instead their doctor has decided it would be better for everyone (else) if they run a 10% chance of suffering needlessly for two to three weeks to establish a definitively bacterial timecourse (and make a return office visit with time off work and an additional copay). If we had better diagnostic criteria or had more effective palliative measures patients would have an easier time swallowing the restrictions on antibiotic use. How do we expect patients to square their physicians' reluctance to use antibiotics because it is "unlikely" that they have a bacterial infection with their doctors' encouragement to undergo costly and sometimes invasive screenings for cancers they are far less likely to have?

  • everyman

    i face this problem too, the fact is that URI are a large percentage of the business, Just , give the patients things that they can’t get over the counter, ie flonase, allegra, phenegran dm, advair, albuterol.. that will make them feel better,(also make them feel it was worthwhie coming to see the MD), do a culture, strep test and spiro as well to see if anything is actually going on, the other thing is just give the patient a z-pack and tell them to only take if they feel CONSIDERABLY worse after 2 days and most feel better or the same so they end up not taking it so you don’t piss off the patient. I completely agree that docs need to stop giving out levaquin on routine URI that’s just moronic plus expensive for the patient

  • lisasmarie

    If this is made policy, doctors will not decide how antibiotics are prescribed. DEA agents will. You really sure you want that?

    • IMDoc

      Doctors still decide when and how to prescribe controlled substances like narcotics to their patients. The DEA prevents abuse which is precisely what the author is arguing is needed for antibiotics.

      • SarahW

        Disgusting. A new layer of oversight only intrudes on the phsyician patient relationship and the art of medicine.

        Physicians should prescribe as they see fit…for narcotics, too. If their training and expertise is insufficient then it will never be sufficient. Some little government toady going by the numbers breathing down the neck of someone who precsribes often is not going to be a general benefit to mankind.

        The difficulty is that antibiotics are necessary for some -and those some will have to needlessly suffer, even become gravely ill, because of unwarranted delay in the chilled application of the right medicine to the right patient.

        If physicians can not now be trusted to prescribe correctly in the face of patient pressure, how can you trust they will not err on the side of least hassle to themselves if the DEA is applying oversight (likely ham-fisted and by the numbers)?

        That worked out so WELL with narcotics.
        Persons worn out from terrible pain suffer to keep some low life from having a good time, and physicians refuse to treat them because of the grief and paperwork and harrassment from those more interested in restriction than proper treatment of individuals.

        I don’t like your solution, the new layer is redundant and inappropriate.

      • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

        nothing the dea has ever done has slowed down the inappropriate prescription of narcotics, so why do you think that this would help with antibiotics?

    • gzuckier

      well, judging from the DEA’s success, it would certainly lead to antibiotics being freely available to anyone with a few dollars.

  • HCPROF

    We could probably reduce the need for Doctors dramatically or practically eliminate any perceived Doctor shortages, if patients would just not go to see a Doctor for any URI symptoms. Just sit back and take the so called 90% chance that it will pass. If it doesn’t, time will tell and there are always hospitals that can treat you, if it gets bad enough. Norway has far fewer Doctors per capita than the U.S. and a Doctor in Norway earns much less compared to one in the U.S. Patients, you can save yourself some time and money. Do not go to see Doctors, unless you are on your death bed.
    Would cultures to r/o bacterial infections be a wiser idea? Would a study that investigates why patients claim they feel better after taking antibiotics be a good idea?

    • elmo

      = 34 Norway: 3.1 per 1,000 people 2003
      = 34 Netherlands: 3.1 per 1,000 people 2003
      = 34 Slovakia: 3.1 per 1,000 people 2003
      = 37 Latvia: 3.01 per 1,000 people 2003
      = 37 Argentina: 3.01 per 1,000 people 1998
      # 39 Ukraine: 2.95 per 1,000 people 2003
      # 40 Denmark: 2.9 per 1,000 people 2002
      # 41 Ireland: 2.79 per 1,000 people 2004
      # 42 Uzbekistan: 2.74 per 1,000 people 2003
      # 43 Luxembourg: 2.7 per 1,000 people 2003
      # 44 Moldova: 2.64 per 1,000 people 2003
      # 45 Mongolia: 2.63 per 1,000 people 2002
      # 46 Finland: 2.6 per 1,000 people 2003
      = 47 Kyrgyzstan: 2.5 per 1,000 people 2004
      = 47 Australia: 2.5 per 1,000 people 2002
      = 47 Poland: 2.5 per 1,000 people 2003
      # 50 Croatia: 2.4 per 1,000 people 2004
      # 51 Cyprus: 2.34 per 1,000 people 2002
      # 52 United States: 2.3 per 1,000 people 2002
      SOURCE: World Development Indicators database

      Let’s not have the facts get in the way of your doctor bashing

      • HealthCAre PROF

        This is not Doctor Bashing. I am agreeing with a majority of posts on this topic. The theme here is ” Watch and Wait”. Save your time and money.
        And about your facts, are you Kidding ME? You must surely be in favor of socialized medicine. These figures that you so eloquently display are one source. Go to Kyrgyzstan with anything but a priveledged status, and I would bet my life savings that you would not get the care that you would get here.

        • elmo

          In favor of socialized medicine? Hardly
          In favor of factually based statements? Completely

  • Edward Stevenson

    many patients have some “horror story” about how they were once told that it was just a virus and a few days later they were in the hospital for a week with pneumonia, and it all started just like this runny nose and sore throat. its hard to retort, after that story with, “this is *most likely* a virus and there is nothing I can prescribe to make you better.”

    and then there is the cases that do happen just like the story and you didn’t initially prescribe antibiotics and then they come back much sicker. a portion of these patients lose trust in you as a doctor and go to someone that will “get it right the first time” and give them antibiotics.

    when a prescription costs $4 to cover something just to be safe, and a co-pay for a second visit is $40 plus an hour or more of your day everyone is going to want the antibiotic Rx.

  • http://leonardof.med.br/ Doutor Leonardo

    In Brazil we’ve been discussing this for years, but after an outbreak of news about hospital infections, our “FDA” finally decided antbiotics should be sold with the same control we already have with citalopram and such.

  • christy spindler

    what about the millions of lbs. of antibotics that are given to poultry,pigs and beef we eat daily? This is 90% of the problem. Don’t blame the patients and physicians. I don’t hear to much about Mexico as antibiotics are sold over the counter. Are they having mrsa, etc. infections spread through the country of Mexico? I would appreciate your input on this matter.

    • Dave Miller

      Kevin,

      I think that you have hit the nail on the head. We don’t need the federal government regulating yet another aspect of medicine. After all, they’re doing such a fine job with the parts they already regulate. This is an area where the AMA and the AOA needs to decide that enough is enough and establish some community standards and sanctioning docs that misuse antibiotics.

      Additionally, this should prompt a hard look at “patient satisfaction” as a criterion for good medicine. Do they have a right to demand that their doc is not a jerk? Absolutely! Do they have a right to demand inappropriate prescriptions? Absolutely not! An asymptomatic patient demanding an elective appendectomy would be summarily turned away and the doc foolish enough to grant such a request would be strongly sanctioned if not defrocked. Inappropriate prescribing of antibiotics should be viewed just the same. Indeed, it can lead to equally dire sequelae.

      Dave Miller
      Osteopathic Medical Student

      • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

        you are so right on the money.

    • Dave Miller

      Christy,

      Contrary to popular belief, antibiotics given to livestock don’t have much of an impact on MRSA and resistant E. coli in URIs and such. Most of the reason for this is that it’s different antibiotics attacking different bugs. Additionally, you don’t get MRSA or a URI from eating steak or pork.

      Dave

      • ninguem

        Any literature on that Dave Miller?

        I know it’s hard to prove a negative.

        These antibiotics sure look close to human antibiotics:
        http://www.sheepandgoat.com/articles/antibiotictable.html
        Some appear to be identical, and the diseases they are treating, some of the organisms described are the same as human bugs.

        Not expert enough to know if resistance crosses related species. Like human bordatella pertussis versus dog kennel cough, which is another bordatella species (plus viruses, etc.). My dog got amoxicillin./clavulinate (essentially, Augmentin, different dose), for her kennel cough.

        And I don’t know what antibiotics are given routinely to the animals, as opposed to treating a sick animal. Google MRSA in……meat, supermarket, or similar, and you get lots of hits. Problem is a lot of the hits are vegetarian sites, or otherwise have an axe to grind. Just saying I’m not sure of the reliability of their reports sometimes.

        But the concern does not seem to be out in left field. The Brits are concerned about it:
        http://www.bsas.org.uk/about_the_bsas/issue_papers/antibiotic_use_in_farmed_livestock/
        as is the CDC:
        http://www.cdc.gov/EID/content/13/11/1753.htm
        (the report is about a European study).
        This was just a quick Internet glance. Not the last word, of course, and I’m not expert on this, but I don’t think I’d just shrug off the problem.

        • gzuckier

          I think there’s only been one case of human infection where the guilty buy has been identified as having originated in livestock. However, as you say, absence of proof is not proof of absence. As for not getting the disease from eating the critter; people do get infections from undercooked poultry, for instance, but there’s also the question of contact with the animals while live, or the uncooked meat; and the big issue of the huge quantity of untreated sewage runoff from big factory farming of pigs, for instance. A single large pig farm can generate more sewage than a good sized city, and legally requires no treatment.

          Environ Microbiol. 2006 Apr;8(4):667-74.
          Vancomycin- and erythromycin-resistant enterococci in a pig farm and its environment.
          Manero A, Vilanova X, Cerdà-Cuéllar M, Blanch AR.
          Abstract
          A high prevalence of vancomycin- and erythromycin-resistant enterococci (VRE and ERE respectively) in a pig farm and its environment was observed. A similar structure and composition of enterococcal populations was detected between urban sewage and those associated with the pig environment. Enterococcus faecium was the most predominant species among VRE isolates from both animal and human origin. The high population similarity index (Sp) obtained comparing VRE and ERE isolates from urban sewage and pig slurry suggests that there are certain strains circulating through the food chain from farms to humans. Erythromycin resistance was present in a wider variety of clones and species of enterococci in both pigs and humans than vancomycin resistance.

          Note that there is no regulation of antibiotic sales for animal feed, nor any monitoring; so we don’t really know what is being used where, or how much. Although why the practice promotes growth in livestock is unclear, it is tempting to speculate that it is precisely because intensive farming practices lead to a large pool of parasitic microorganisms which would be a persistent drag on growth, and are inhibited by constant exposure to antibiotics; which implies a constant production of resistant organisms.

          • ninguem

            “……..I think there’s only been one case of human infection where the guilty buy has been identified as having originated in livestock………”

            You mean all the warnings about E. coli 0157:H7 that you see at the petting zoo, county fair, etc., the food handling warnings on meat, the undercooked eggs, etc., are all based on one single infection? When the flu breaks out, and you see the Chinese police gathering up all the chickens from backyards and throwing them into the incinerator, it’s based on one case? An ethnic festival in my town ceremonially brings in some livestock. In the old country, they would slaughter the animals for the feast, but not allowed by city health laws. So they get a reprieve, they get sent back to the farm, where I’m sure they’re slaughtered later, but not for that particular fair. The city prohibitions against open-air abbatoirs, based on one case?

            Of course there are bugs going from animals to humans, and vice versa. Viruses, bacteria, parasites, etc.

            Not sure what you mean by one documented case. Whether or not the antibiotics given to livestock contribute to human infections, I don’t know. I’m reluctant to shrug it off as minimal, though.

          • http://Www.twitter.com/alicearobertson Alice

            I think ninguem’s answer was interesting…and it often leads to more thought. Okay…this is pretty ignorant and I know monkeys are not livestock…but the animal to human thing immediately made me think of AIDs and Mad Cow. If you can stand one more ignorant response…a pediatrician once told us that after the county fair meningitis goes up. He blamed farm animals for show at the fair.

  • jim m.d.

    so let me get this straight:
    1) 80% of all antibiotic production goes to the agriculture departments throughout the world. My neighbor’s cattle get cipro direct from ralston purina. Chinese ducks get daily amantadine (and there’s a boatload of Chinese ducks).
    2) It is known that the best way to cultivate resistance is to administer low dose antibiotics for a long duration via the intestinal tract e.g. animal feed.
    3) MRSA has been tracked back via dna to have originated in Danish cattle.
    So, you are complaining that mom wants pen v k for johny’s otitis, when in fact, mom can just as easily go to the local grange and pick up just about any antibiotic she wants in just about any dosage she wants and just not read the part which says “not for human consumption.”
    When the CDC decides that this is an issue important enough to talk with the Agriculture department, and in fact restrict low dose long duration administration in animals, then I will join your crusade. Until then, no matter what we do with the remaining 20% of antibiotic production ( high dose short duration), it will make no difference in the ultimate production of resistant bacteria.

    • ar

      Bravo Jim, well said.

    • http://www.epmonthly.com/whitecoat WhiteCoat

      Little late to the showdown due to work schedule.
      I don’t disagree with any of your numbered statements. People can even go to pet stores and purchase the same antibiotics that the doctors prescribe.
      I still have a problem reconciling the whole issue of “piggy penicillin” or “doggie doxycycline” being the hidden culprit behind MRSA with the story I cited above where Norway nearly eradicated MRSA by restricting antibiotic use by physicians.
      Are you aware of any research showing that eating cooked meats transfers resistant bacteria from barnyard to the dinner plate?
      Are we assuming that people have widespread exposure to farm animal excrement?
      How do resistant bacteria get from animal to human?

    • http://Www.twitter.com/alicearobertson Alice

      Tip for the day…..You can buy antibiotic in some Walmart fish departments. And Middle Eastern stores often have it at the counter for the uninsured….and there is always Mexico if you want to stockpile. But you may have to pay a doc a pittance for a script. Or just order it from India if you want it badly. I ordered some online once when I had two college kids who were uninsured. A huge bottle arrived from an American pharmacy for about a dollar a pill. I just cut the middle man out, and they used it sparingly and rarely. I realize this post will not be popular with the status quo…..but our son was working in a restaurant and they seem to get sick a lot from customers…..I do not want to talk about my fears of the diseases from the staff where some were illegal….you would need much more than antibiotics.

  • ninguem

    I have to say, I feel the same way. The factoid I’ve heard for some time, is more antibiotics are fed to livestock in the State of North Carolina alone, than is used in humans in the entire country.

    http://www.nytimes.com/2010/03/07/opinion/07kristof.html

    Just a mention of it here, in a NY Times editorial.

    I don’t want to give inappropriate anything, but I often wonder if we’re wasting energy trying to divine bacterial versus viral illness in humans, when orders of magnitude more is being shoveled out in agriculture.

    I’ve read, but not sure how true……..if you want to find MRSA, just check out the meat counter in the local supermarket.

    • http://Www.twitter.com/alicearobertson Alice

      Or your gym. Pure food is not easy to come by. We went off meat, and used beans. Mynaturalist friend said it is a perfect food that now has pesticides in it, and if you buy them in cans the plastic lining is bad news. Chemicals everywhere and the “Organic” label often means nothing.
      Our highly educated neighbors decided to grow their own pure food and started a rabbit farm. It was awful. Suddenly, my cats were dragging home dead rats the huts attracted, and because she found their necks hard to slice she would beat them to death with a hammer or drill. The noise was terrible, and the squealing even worse, it was not a quick death.

      We rarely eat meat, but I do eat at Chipotles because of their responsible actions concerning our food. My daughters have not eaten meat in four years and one still developed cancer and the radiation wrecked her immune system. Yet, vegetarianism made my son so sick after two years he decided to risk the steroids and hormones to feel better.

      We watched King Corn and Food, Inc. That did more good than regulation. And Michael Pollen’s books.

  • Dr. J

    The real issue here is that we physicians should be offering patients the best available therapy for upper respiratory tract infection, and not exposing them to un-needed risks and we are doing a terrible job of this.
    Patients with upper respiratory infection come to see doctors because they want symptom relief, or they are worried about developing complications or more serious infection.
    Issue 1; symptoms. Even in the setting of confirmed strep pharyngitis antibiotics perform about as well as NSAIDS and less well then steroids for symptom control. If we want patients to feel better we should be giving them a single dose of steroid and NSAIDS (I like liquid dexamethasone and liquid ibuprofen, pills are brutal to swallow with pharyngitis). This is superior therapy for symptom control to antibiotics.
    Issue 2; complications. The natural history of viral URI is that basically everyone gets better and a few people develop rare complications. The natural history of bacterial URI is also that virtually everyone gets better with no therapy and there are few rare complications. A few patients will develop specific complications and the number of pharyngitis patients who need to be treated with antibiotics (NNT) to prevent one case of each complication is known; peritonsillar abscess NNT 125, Rheumatic fever NNT 40,000, glomerularnephritis NNT>40,000, PANDAS NNT >40,000. This should be contrasted with number needed to harm (NNH) with antibiotics for known side effects; diarrhea NNH 6, yeast infection (women) NNH 5, anaphylaxis NNH 1250.
    The only thing we can even pretend we are trying to prevent with antibiotics is peritonsillar abscess, which is pretty easily treated if it develops anyways. The idea that we are preventing rheumatic fever or AGN is nonsense and we harm and injure far more patients than we help if this is really our goal.
    In summary we should take good care of patients, we should make them feel better and we should not expose them to needless risk. Patients who are otherwise healthy and who have upper respiratory infection and pharyngitis in particular should receive aggressive symptom control. It makes no difference if they have a bacterial infection, they will get better anyways. The reason we should not be handing out antibiotics is because they do little for symptoms, are generally unnecessary for recovery, do little to prevent complications (except a small effect on peritonsillar abscess), and have significant associated danger (diarrhea, yeast infection, anaphylaxis).

    • Dave Miller

      Dr. J,

      While I, in principle, agree with your argument, the notion that we shouldn’t give antibiotics for strep throat because of the NNT for Rheumatic Fever is a bit wrong-headed. Before wide-spread use of antibiotics, when RF was fairly common, the costs were pretty high in terms of Rheumatic Arthritis and Rheumatic Valvular Disease. Considering your NNT of 40,000, at $4 for a course, the $160,000 needed to prevent a single case of RF is pretty much chump-change compared to a single valve replacement, not to mention the life-long costs of the sequelae of RF.

      • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

        While I also agree that we should treat strep throat and thus avoid Rheumatic Fever regardless of the NNT, nothing precludes doing a rapid strep and thus avoid giving antibiotics to patients who don’t have group A strep.

      • Dr. J

        Dave, the economic analysis is not nearly as simple as that. There are costs associated with the 30 cases of anaphylaxis, 8000 cases of diarrhea and 4000 yeast infections you will cause in the process of treating those 40000 patients in order to prevent 1 case of RF as well.
        It is also not at all clear that antibiotic use is the reason for declining RF rates in the modern world. The last available CDC data on RF (since they no longer consider it enough of a public health concern to track) is that there about 300 annual cases in the US. This number has fallen steadily to this very low baseline over the last 100 years, not in direct parallel with our antibiotic use and in fact the incidence began falling before antibiotics were widely available. Since as many as half of people with pharyngitis do not even seek medical treatment the actual incidence of RF has likely declined substantially based on factors other than antibiotic use (the background rate of RF in untreated pharyngitis is almost nil).
        In the huge existing cumulative RCT data sets on pharyngitis there are no significant sequel of GN or PANDAS (not to say they don’t happen, just that they didn’t happen in that set of >10,000 total patients), meaning that they are also exquisitely rare.
        It is medical dogma that wide spread antibiotic use for pharyngitis is the reason RF is almost non-existent in the western world, but this is not really supported by evidence. Antibiotics do a little bit for symptoms of pharyngitis (less than steroids, equal to NSAIDS), may prevent a virtually non-existent disease (RF) and have an unknown role (no good level 1 data) in 2 other very rare diseases; GN and PANDAS. Antibiotics have known harms as outlined above including death.
        Having looked at this evidence in detail I have no problem at all treating bacterial pharyngitis symptomatically (because symptoms are why the patient came to see me anyways) and feeling fully supported by the evidence. I caution the patient about peritonsillar abscess as that is the only real potentially viable target of care if antibiotics are used.
        I will also note that in using this approach I don’t find myself in conflict with patients, probably because it is the longest pharyngitis visit they have ever had with a doctor and I try to validate their reason for visit (your throat looks terrible, that must hurt, I’m going to use the best medicines I have based on the research to make you feel better.)

        • Dave Miller

          Dr. J,

          Regarding the drop in the incidence of RF with the use of antibiotics, you are correct that the incidence dropped before widespread use of antibiotics. However, the reason is not at all mysterious nor does it negate the use of antibiotics. At that time, when a child was diagnosed with acute pharyngitis they were immediately and aggressively quarantined. This lowered the incidence of pharyngitis overall. Thus, assuming that the conversion rates remained constant, there was an apparent decrease in the incidence of RF. However, as PCN arrived on the scene, the NNT was about 20. In Mexico today it remains at about 50.

          As far as the costs of the adverse rxns you mentioned, the diarrhea and yeast infections are a vanishingly-small cost to treat as most are treated with OTC remedies. Moreover, if a pt has a history of penn allergy, they will be given erythromycin, lowering the overall incidence of anaphylaxis. Even if you figure in a few scripts for anti-diarrhea and anti-yeast meds, added to the $160,000, you still a far cry from the cost of valvular replacement or even the cost of an ICU visit for an acute rheumatic flare up.

          You cite the drop in incidence of RF in America as a reason for not treating aggressively. This is analogous to a person not wanting to vaccinate their child against polio because “no one gets polio anymore.” As we have enjoyed the benefits of treatment and not experienced increased disease burdens, it’s pretty easy to shun the treatment that provides those benefits. Herd immunity plays a huge role here. You don’t stop treating simply because no one gets the disease anymore. No one gets the disease anymore because of the treatment.

          • Dr. J

            Dave, I imagine that you are just trying to get a rise out of me by insinuating that my argument is the same sort of drivel as the anti-vax movement. In fact my argument is based on a review of the available literature, I have tried to present real numbers, and my interpretation of them in the interest of discussion. As a fellow clinician I respect your right to interpret this data as you will and do what you think is best for your patients. Personally I don’t think the risk vs. benefit shows that antibiotics should be used for strep pharyngitis, but you are welcome to your interpretation (and I obviously hope to sway that with my evaluation of the evidence).
            I think the economic numbers are less simple than you state, particularly for anaphylaxis and c. diff diarrhea.
            Finally your herd immunity hypothesis is interesting. In fact group A strep remains endemic in the US and there is no functional herd immunity to it. The presumed purpose of antibiotic therapy is to blunt an immune response thereby blunting a potential immune disease (RF). In studies patients with strep pharyngitis treated with antibiotics have had subsequent higher rates of strep pharyngitis (presumably due to blunted immune response when treated with antibiotics).
            I point this out not because it is terribly relevant in the decision to use or not use antibiotics, but to show that your characterization of me as an anti-vaxer is a straw man type argument and that antibiotics do not result in personal or herd immunity.
            Finally it certainly not clear that ‘no one gets the disease anymore because of the treatment’. By some estimates fully half of patients with pharyngitis seek no medical care at all (difficult to estimate but a substantially large group), yet the background rate of RF remains at 300 cases per year in the US. This implies that factors other than antibiotics are playing a role in the decreased disease prevalence.
            There are many areas of medicine where practice is primarily dogma based and this is one of them. It is important to explore these practices and challenge them when the evidence says something other than what we were taught in medical school. An early post on this subject by a DO student said something along the lines of ‘obviously we should treat strep pharyngitis to prevent RF no matter the NNT’, my point is that we should not obviously do anything simply because it is long-standing dogma, rather we should critically analyze the data in oder to make rational clinical judgments.

        • http://www.epmonthly.com/whitecoat WhiteCoat

          Right on target, Dr. J. Here is a previous post I made on my blog regarding the strep throat issue:
          http://www.epmonthly.com/whitecoat/2009/03/antibiotics-more-harm-than-good-for-strep/

    • ninguem

      I’m going to try the dexamethasone trick, how much you you use? Single-dose?

      • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

        in pediatrics we use 0.3-0.6 mg/kg single dose IM or PO

      • Dr. J

        Agree with Kevin I use 1 dose of 0.6 mg/kg to a maximum dose of 10mg usually po occasionally IM if the patient has lots of pain with swallowing.

    • http://Www.twitter.com/alicearobertson Alice

      This is so interesting. It feels like I am witnessing the comic book style cloud with words contained in it of what is clicking through the doctor’s mind when you are there. This a great summation…but as a patient you think…why bother going to the doctor if I can’t get antibiotics? They will head to the drug store to treat the symptoms. But patients need educated on what symptoms not to ignore (thinking about the inability to put your chin to your chest). It does seem ear infections are another malady that can usually heal without a doctor”s visit, and UTI”s, but again more patient education on when the ordinary symptoms change into something unordinary that needs medical attention.

      Pediatrician’s used to say they prescribed an aspirin for mom…..it works like that with antibiotic too.

  • jenga

    Until they ban it’s prophalactic use in livestock such talk is laughable.

  • Michael F. Mirochna, MD

    Animals and us both need antibiotics because of our living conditions. So much of modern medicine is just making up for the modern way of life. Cities cluster us and our diseases together, our lifestyle requires we exercise since rarely do we have a job that requires much labor. Animal conditions are so terrible… take a look at Omnivore’s Dilemma and I also believe Fast Food Nation has some discussion of the animal conditions as well.

  • Dr. G.Patino MD.,

    Kevin, here in Mexico we recently enacted a Federal Law that one must have an authorized prescription for an antibiotic; previously one would just walk into any pharmacy and order any dose and amount of antibiotics they felt necessary.

    Hope this helps our hospital systems with MSRA….

    Dr. Gp. MD.,

    • http://www.epmonthly.com/whitecoat WhiteCoat

      Interesting. Thanks for that information.
      Just curious – what is the rate of MRSA in your area?

    • ar

      Mexico enacted a ‘law’
      What does that mean?
      I’ve been to Mexico and let me assure you that there’s not such a thing as a meaninful ‘law’ n medicine and, especially when it comes to the use of antibiotics.

      ra

  • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

    Also when looking at NNT, are you looking at Number of patients with pharyngitis needed to treat or the number of patients with Rapid Assay/culture positive Group A strep needed to treat? The ratio in the second group will be more compelling than the ratio in the first group.

    • Dr. J

      40,000 is the number of strep positive patients you need to treat to prevent 1 case of RF. Is that to many to treat to prevent a case of RF? To me it is because the treatment (IM penicillin being the treatment that would be evidence based, but also macrolide antibiotics) carry small serious risks that occur at rates that far exceed the rate of benefit.

      I will also comment that this approach is not at all applicable in an area where RF is endemic (ie. much of the developing world) where we would expect to see excellent results from antibiotics mirroring the earliest RCTs which were conducted in environments where the disease was in fact endemic (a single military base in particular).

  • christy

    A few years back I remember feeling achy,my throat hurt and I would take tylenol every 4hours to relieve my symptons. at that time I worked at an elementary school and strep was making the rounds. I knew I caught strep because of the symptoms I was experiencing, fever, chills, sore throat. I had had it before and felt the same way. I went to my clinic which was only a block from the school I worked at. I had a rapid strep test which tested negative for strep. The problem was I had to catch a plane early the next am. so if the 24 hr. test came back positive for strep I would not have been able to get my prescription filled. I was quite ill getting up at 3am getting ready to catch a flight to Colorado skiing. My children were young and I had to help them get packed,clothes, ski gear etc. I told the clinic my dilemma and asked if they could prescribe antibiotics even though the rapid test was neg. They would not. Wow! I was very ill by the time we got to our ski lodge! My husband immediately brought me to the clinic in Breckinridge. I explained my situation to the attending physician,he checked my throat,said he would be right back. A few minutes later he returned and gave me antibiotics. I was in bed for 3 days at the lodge and missed ski time. I did recover but felt weak . When we got home I called my clinic and told them what happened. The 24 hour strep test was positive. They tried to reach me so I could start antibiotics but apparently forgot that I was out of town. After all it was spring break. I had another similar incident happen much like the one I jusy explained. I guess no one listened to me.

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      Your story is the typical reason for over prescribing. What you don’t realize, because you never studied microbiology and pharmacology is that starting meds a day earlier would not have made any difference. You still would have been sick for three days. If you had been inappropriately started on antibiotics and had a complication like Stevens Johnson Syndrome when you were in Colorado you would have died.

      • Nerdy but not a clinician

        A number of years ago I was having a lot of respiratory symptoms – cough, congestion in the chest, frequent fevers, etc. I thought it was a virus but I was wrong, wrong, wrong. It turned out to be a tumor in my chest.

        Patients can make educated guesses on their diagnosis. This doesn’t always make them right. There’s a danger in forming biases and preconceived notions on the basis of previous experience – “I had something similar before so I’m pretty sure that’s what’s wrong with me.”

        That said, I recently had an experience similar to yours, with an extremely sore throat and white blotches on my tonsils (only no fever). Urgent care dx’d it as a virus and sent me home sans antibiotics, which was actually fine with me. There’s no point in incurring extra costs and side effects with unnecessary drugs. Two days later they called back and said the throat swab had cultured positive for strep.

        I’m not trying to sound unsympathetic here, but your clinic did you a favor by not prescribing antibiotics before confirming your dx. They practiced good medicine. Would you want a clinician to just rush ahead and do surgery before confirming the patient had appendicitis, or rush ahead with chemotherapy before confirming the patient has cancer? Actions in medicine need to be based on facts, not on what-ifs and guesswork.

        I think one of the real issues here is that the rapid strep test may not be all that accurate. I’m not sure if anyone has studied the rate of false negatives – any researchers out there looking for a project? Maybe what we also need is a better algorithm for treating sore throats.

        • Dr. J

          Nerdy and Christie are both falling into the same trap, they think that doctors are giving antibiotics for strep pharyngitis so that they will get better. That is not the case, doctors are giving antibiotics to prevent rheumatic fever as a sequelae to strep pharyngitis. It makes no difference if antibiotics are given right away or in 48 hours when a culture returns, inasmuch as RF is equally prevented in both groups. I think prevention of RF is a lousy target of treatment as I have outlined above.

          So do antibiotics make you feel better even though that is not why the doctor gave them to you? The short answer is maybe a bit. In terms of symptom duration for strep pharyngitis antibiotics make a difference of hours in an illness that lasts days. Even with antibiotics the expectations is for many more days of sore throat. Antibiotics do little for your symptoms, and little for the duration of your illness. For symptom contrl, as I stated above, antibiotics are equal to NSAIDS (eg. ibuprofen or naproxyn) and inferior to single dose steroids (eg. dexamethasone).

          If you want to feel as good as possible as fast as possible, the next time you have strep throat ask your doctor for a dose of steroid, and then take NSAIDS regularly for a few days. If you are concerned about a rare illness that is far less risk to you than the antibiotics themselves then ask for antibiotics.

          • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

            Let me give a second opinion regarding the steroids and NSAIDS- Absolutely.

            Let me give a second opinion regarding antibiotics not making the symptoms better faster- Demonstarted time and time again in multiple studies, Dr. J isn’t making this stuff up.

          • christy

            It was not just the slight sore throat i was experiencing,it was the fever,aches and chills. when I have experienced strep, the sore throat is not the main complaint,but that’s where the results come from. You must think out of the box and look at the whole picture. Not everyone is a textbook example. Along with knowledge common sense also plays a part in medicine. enough said

    • stargirl65

      So I am assuming that you did not have a cell phone? Or you were unable to call the clinic to confirm that your test was negative the next day?

      My office follows up with people on vacation all the time by cell phone or we have them call us to get the results.

      • Nerdy but not a clinician

        Wait… what? So the real reason antibiotics are prescribed for strep throat is to prevent complications rather than to knock down the bacterial infection? I’ve never had it explained to me like that.Thanks.

      • christy

        Actually, no I did not have a cell phone at that time. I got the prescription I desperately needed,but in fact I did have strep and I recovered 100%

  • imdoc

    Maybe rather than restricting the antibiotic from the screaming kid or the ill patient awaiting a strep culture, the place to start is to stop allowing corporate farming to shovel industrial doses of antibiotics at penned up animals. Farms dispense antibiotics indiscriminately in order to continue raising livestock in crowded conditions. Also, while we in the U.S. would be poring over new onerous “guidelines” for antibiotic use, the third world will continue to permit over the counter sales, eclipsing any efforts we make to reduce resistance. The other place which is a source of resistance is dialysis units. Renal patients get lots of antibiotics. That is because they get a lot of infections and I am not sure we have a good solution to that.

  • christy

    Kevin, I totally do not agree with you .I knew what was wrongwith me and do not agree that antibiotics a day earlier would not have made a difference. I’ve seen my daughter at 5 years old pop back to life after 24 hours on antibiotics. If she hadn’t had that penicllin when she did I was told my daughter would probably have ended up in the hospital as she came down with pneumococcal pneumonia. Our family is very rarely ill but we had some life changing experiences with health professionals that are very negative. And the negative experiences all include antibiotics,or should I say the lack of prescribing them. Until you’ve experienced these negative experiences first hand, of course you wouldn’t understand

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      You disagree with me based upon how many years of scientific study in the areas of microbiology and pharmacology? What peer reviewed literature have you read? You knew what was wrong with you based upon what training?

      Wait till you or your child gets clostridium dificil from inappropriate antibiotic treatment. Then I’ll tell you “I told you so.” These drugs are not innocuous. I’ve seen too many people almost die from inappropriate use. Good luck to you. It will happen.

      • ninguem

        I saw a case of C. difficile colitis from a single dose antibiotic, a patient of mine, prescribed by a dentist for some routine dental work. To the hospital with abdominal pain, the surgeons got involved, laparotomy was considered for a while. In the hospital a couple days, determined stable enough to send home and follow as an outpatient.

        “Are you sure you haven’t had antibiotics?”

        “None”

        “How about a dentist?”

        “Oh, yeah, I had to take one amoxicillin before……”

        I don’t remember, a root canal or something. The timing was about right.

        Two samples for C. diff, the first was negative, the second was a little delayed, came back positive when the patient was in my office.

        • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

          I recently discovered that c diff has reported 20% mortality rate. Wow.

          • anon

            Could this be due to the fact that most people who get c. dif. are hospitalized in the ICU? Thier mortality rate is usually higher to begin with.

          • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

            Yes the high mortality could be due to other complicating factors in the ICU. Regardless, the disease makes you horrifically ill. To quote my cousin who got it after 1 dose of doxycycline for mastitis postpartum, “I wanted to die, kev.”

  • christy

    I just want to make a comment ; Aids patients are also prescribed antibiotics and propholatic? drugs more often than not.

    • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

      AIDS patients have no functioning immune system, they are very different from you, Christy. They also die more often from the complications of their bactrim than the diesease itself. Is that what you want for yourself, death from Stevens Johnsons Syndrome. Not a pretty way to go.

  • christy

    I have never insisted for a dr. to prescribe antibiotics.What the average person feels is th doc should know what he is talking about. Most people would never question their physician as you are the professionals. My daughter is 24 years old and has never been sick since the age of 5. Thank God for my instincts as a mother!

    • http://www.epmonthly.com/whitecoat WhiteCoat

      Unfortunately, your experience with “average people” is not representative of many patients seen in doctors’ offices and emergency departments who demand antibiotics for coughs, scratchy throats with negative strep tests, or because their runny noses “always turn into pneumonia.”

  • christy

    A website to inform everyone regarding overuse of antibiotics in our pork,poultry and livestock is “The union of concerned scientists. They speak the truth of what is really going on in our country and world wide overuse of antibiotics in our food. The regulation on this is not enforced well in the US. Big money talks and the hype and media suck it up. What is wrong with doing the right thing?

  • ckay

    My 13 yr. old started coughing six days ago with no fever. I gave him over the counter cough syrup as it was instructed and did not help his coughing over a four day period. I also gave him extra C, honey, and fluids. He had a little bit of a stuffy nose and sore throat. Day four his primary Dr. office was closed and took him to a medical facility and he was seen by a Dr. and diagnosed with Upper Respitory Infection (Viral) and prescribed C Phen to help relieve coughing. He still had no fever. Day five I took him to his primary Dr. since they were open for a re-check and was prescribed antibiotics. The first Dr. checked him out way more than the primary one did. I told the primary Dr. the diagnosis from the Dr. who seen him the day prior. Primary Dr. still prescribed antibiotics and I left not knowing why. I didn’t feel comfortable but still got the prescription for a 5 day course antibiotic. Today I gave him one does of it and a half hour later he was fevered and his chest hurt. He never had a fever with this cold until after one does of the antibiotic or chest pain. I don’t want to continue the course and want to stop giving it to him and just move forward w./ the first Dr.’s diagnosis. The primary Dr. never gave a diagnosis. Am I right to follow my gut? Also, would it be alright to stop after one does?

  • ar

    Dear CKay,
    the answer you’ll get here depends on the doctor’s agenda and especialty: a pediatrician/gp who spends 8hrs M-F in a out patient clinic would likely argue against giving antibiotics despite pertinent signs and symptoms(by the way, I can diagnosed a strep g-A infection just by the breath smell f the pt). On the other hand, chances are that a physician who sees,receives sick patients in acute center, 2,3 days post PCP check with bronchitis/pneumonia, will likely use antibiotics. In regards to your son and fever after one day of antibiotics, I doubt the fever was caused by the antbiotic.

    ra