Patients demand them when they don’t need them, doctors prescribe them when they shouldn’t. We need to join forces to defeat a common enemy
‘Antibiotics are neither an entitlement nor a panacea but a valuable treatment that should be dispensed prudently.’ Photograph: Don Wilkie/Getty Images
“I need antibiotics.”
“You have a common cold, which will get clear by itself.”
“But I am bringing up yellow stuff.”
“A virus can do that. You are otherwise well.”
“But it’ll turn bacterial. Can you give me a script just in case?”
“I’d prefer not to but come back if you’re unwell.”
“I know my body, and the last doctor gave me a script.”
The young woman walked out in a huff and crossed the road to an adjoining clinic.
The doctor continued with his other patients. An infant with a runny nose, another with a painful ear. A builder who had aches and pains for two days. A retiree with a sore throat. Each received the same thorough explanation about why antibiotics weren’t necessary. The young mother was nervous, the builder was unimpressed and the retiree was sceptical but they all left without antibiotics.
US reports first case of bacteria resistant to antibiotic of last resort
Then, a call came from the first patient, irate and wanting her money back, because the second doctor had written her a script.
At this, the doctor threw up his hands. What followed was a dejected, often bitter discourse about how difficult it was to practice responsible medicine when patients made unreasonable demands and there was always someone to satisfy them. His efforts at patient education felt insignificant though they were in keeping with his belief in the mission of medicine.
He summarised his dilemma. “Do I prescribe antibiotics inappropriately and keep the patient or do I adhere to principle and lose business?”
I was a young medical student at the time hearing all this, unable to appreciate all the nuances of the story but twenty years later, the exchanges seems all too familiar, which is all the more depressing.
In fact, it plays on a loop across every general practice and every emergency department. Patients with viral symptoms present with a fixed opinion that they need antibiotics and doctors, willingly or unwillingly, prescribe them. After a few days, the patient feels better, credits the antibiotic, stops the course midway and tucks away the rest of the pills in a drawer, to be used the next time. Or to give to a family member who “desperately” wants to get over a cold.
These are some of the behaviours that led to 46% of the population receiving antibiotics in a year according to the first national report of antimicrobial use and resistance conducted by the Australian Commission on Safety and Quality in Health Care. No doubt patient expectations play a large role in determining inappropriate prescription but the survey shows just how widely doctors share the blame.
On any given day in an Australian hospital, 38.4% of patients were being given an antibiotic. Of these, a slight majority were either noncompliant with guidelines or plainly inappropriate. Antibiotics used in surgery were often not required or were given for too long. A striking 40.2% of antibiotics given prior to surgery were inappropriate. Reasons included incorrect dose, duration and indication – hardly explained by “the patient wanted it so I gave it”.
Why do we use so many antibiotics? The reasons is patient consumerism and medical uncertainty. In line with other modern needs, patients expect a quick fix for their infective symptoms regardless of cause. “Mate, I don’t care give a toss what bug it is, I want it gone,” complained a man with a sore throat. This patient was offended that his GP advised rest and fluids and grumbled at having to leave his bed for this “rubbish” advice.
Antibiotic prescription at the end of life is rife. A recent American study found that 90% of patients with advanced cancer received antibiotics in the last week of life and 42% of advanced dementia sufferers got them in the last two weeks of life. Despite evidence to the contrary, continuing strong (and expensive) antibiotics retains a powerful connotation of hope. In an already fraught situation, sometimes it seems easier, and kinder, to continue the antibiotic than upset a family.
Uncertainty, too, is never far from a doctor’s mind. For the thousands of patients that an experienced doctor might dissuade from having antibiotics, there may be the one who is brewing symptoms of something serious, like meningitis. This will be the devastated patient with his amputated toes splashed across the front page of the newspaper, accusing the doctor of having ignored his symptoms and ruining his life.
The doctor will face years of legal action, lose income and friends, especially professional ones. It’s understandable that the mere thought of a rare but devastating mistake makes both GPs and hospitals err on the side of caution. After all, how much individual harm could a course of antibiotics do?
As it turns out, a lot. One of the gravest misconceptions about antibiotic overuse is that it is people who become resistant, not bacteria – this ignorance extends across poor and rich countries. If you believe resistance is a human attribute you might think yourself as safe, especially if you only take the occasional antibiotic. You might think that not finishing a course is protective, whereas it’s actually detrimental because it allows resistant strains to fester. But if you understand that resistance is a bacterial characteristic and inappropriate antibiotic use puts you personally at risk of acquiring a deadly strain and that the risk of death from sepsis is significantly higher, you might be more conservative.
A recent Wellcome Trust review found that worldwide, 700,000 people die each year from infection caused by drug-resistant pathogens and parasites. That figure is projected to be 10 million in the next few decades if we continue with our current ways. Rampant antibiotic usage in livestock is a critical problem. In the United States, 70% of antibiotics sold are used for cattle and fowl but the resistant bacterial genes they engender could end up affecting humans.
UK doctors told to halve inappropriate antibiotic prescriptions by 2020
No one is immune to the scourge of antibiotic misuse and it will take a concerted effort to tackle the problem. Doctors would be helped by better diagnostics that allow them to distinguish a bacterial infection from self-limiting viral ones and provide early reassurance. Better and more targeted drugs would help, even though the real temptation for pharmaceutical companies lies in moonshots for cancer. Hospitals should pay more attention to hand hygiene, antibiotic stewardship and education and demand greater accountability.
But these attempts will be insufficient unless our patients realise that antibiotics are neither an entitlement nor a panacea but a valuable treatment that should be dispensed prudently.
A doctor who is judicious with antibiotics deserves commendation for being thoughtful rather than condemnation for being unhelpful. In a world that wants a fix to every ailment right away, this is a big undertaking – but not impossible if doctors and patients join forces to defeat a common enemy – the drug-resistant bacteria.
By:Dr.Ranjana Srivastava is an Australian oncologist