Thursday, June 23, 2005

Bronchitis Sufferers Can Skip Antibiotics

Via Kevin, MD

CHICAGO Jun 22, 2005 — A study found that bronchitis sufferers who are otherwise healthy do not get better any faster by taking antibiotics. "Antibiotics for the vast majority of people don't seem to make much difference," said Dr. Paul Little, author of the five-year study of patients in England. Moreover, many bronchitis cases are caused by viruses, which antibiotics do not fight...Continue Reading

The article comments that many clinicians and most patients will be probably surprised. To my knowledge, this is not a new finding. Here is what the Sanford Guide to Antimicrobial Therapy(2004 edition), which is a pocket-sized book that most primary care physicians I know have on hand, says about acute bronchitis:
Antibiotics not indicated, use antitussives +/- bronchodilators. Purulent sputum alone is not an indication for antibiotic therapy. Azithromycin (most commonly in the form of a "Z-Pack") was no better than low-dose vitamin C in a controlled trial (Ln 359:1648 2002). Expect cough to last 2 weeks. If fever/rigors, get chest x-ray.

I really think most physicians, are aware of this, but writing a prescription for an antibiotic can be the difference between a pleasant 5 or 10 minute office visit and a 20 minute fight with an otherwise friendly patient in which everyone comes away unhappy. I am more strict about this than most doctors I know, but even I have bad days and give in to the temptation to do the wrong thing for the patient just to satisfy them.

Here is a very discouraging, yet common scenario:
An otherwise healthy patient has a cough for 2 days, this patient is important, busy, and doesn't have time to be sick. He goes to a doctor to try to "treat it early", the first doctor writes a prescription for a Z-pack which is a 5 day course. That gets him to day seven which is halfway through the natural course of a viral bronchitis. He goes back to the same doctor or a different doctor the next day because he is not any better and needs a "stronger antibiotic". Then he gets another prescription for a broad spectrum antibiotic, which he really doesn't need, and finally gets better around day 10-14. Causing the perception that only the "stronger" antibiotic works on them. Here you have, as I see it, a popular pathway to antibiotic resistant microbes.

I love taking care of my patients, but just because they walk away happy doesn't mean I have done the right thing for them or for public health. Sometimes I remind patients that we can put a man on the moon but we can't find a cure for the common cold, they usually either laugh and agree or get more pissed off and don't come back.

ADDENDUM 7/3/05: I noted above and in the comments that I thought most physicians knew that antibiotics did not cure most caes of acute bronchits, but they still heavily prescribed just to improve patient satisfaction as well as their for their own satisfaction. I still believe there is some truth to that, especially among the more recent graduates who were trained in the era of antibiotic resistance. But since then I have had the opportunity to attend a conference where I began to consider that maybe many docs don't know better. The conference was about new drugs. Ketek was the item of consideration and the pharmacologist who was giving the conference stated that we should "just make sure we are treating bacterial infections". At that point one of the physicians mentions the new research findings and then follows it up with "that will put me out of business". The pharmacologist's response was that unfortunately we have enough people who give themselves lung disease by smoking that we won't have to worry about a shortage of patients who fit the criteria for antibiotic therapy. I will also admit here that I have a few friends who are physicians who will treat themselves or their families with new broad spectrum antibiotics, which tend to be readily available as samples, at the first sign of a cold. I mention all this to point out the fact that, physicians as well as the general public need to have this drilled into their heads.

Here is another mention of the subject from Mike the Mad Biologist.



Blogger afarensis said...

I usually wait a week or so before I go to the doctor for that kind of thing. Usually if I am starting to feel better I skip the doctor visit entirely. The one time I went early (cause I had already had several bouts in a short time span) didn't turn out well. Dropped the script off at the pharmacy went home and had several bouts of cough syncopy (not pleasant at all). Called my doctor went to the ER for testing and to confirm it was cough syncopy and was told not to take the antibiotics and was given some kind of high powered cough medicine that, basically, made me sleep all day. I have never gone to the doctor for a cold that early again (I have not had any more bouts with cough syncopy either - which is kind of wierd).
I have heard some pretty high stats on the number of people who don't finish their antibiotics, have you found that to be the case in your practice?

8:35 PM  
Blogger Henry said...

It happens all the time. Usually I find this out becuase a patient will see me after they have already started an antibiotic left over from the last time they were sick, whether they had the same symptoms or not. They tell me about it and I ask them where they got the antibiotic and they admit they didn't finish their last prescription or they got someone else's leftovers. I try not to come down on them too hard because doctor visits can be expensive. What drives me crazy is just the general opinion that antibiotics can cure nearly every acute illness. As I mentioned before, attempting to avoid overprescribing antibiotics is not financially rewarding to physicians becuase it makes office visits last twice as long which limits the number of patients that can be seen. And if you don't write a prescription, they won't come back next time because they can treat their symptoms with OTC's. Usually it is not rewarding emotionally because so many patients leave unhappy and are skeptical. Patients get the opinion that the doctor doesn't care or doesn't want to treat them, which is the opposite of the truth. I'm pretty sure that it is actually costing me some easy income just to go against popular opinion and do what I feel is right.

11:46 AM  
Blogger afarensis said...

You are to be commended for trying!

7:18 PM  

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