I suspect that almost every physician in theUnited Stateswould agree that antibiotics are over-prescribed. Unfortunately, since the total number of antibiotic prescriptions in theUnited Statesgiven to people with “cold” has been estimated at 44 million per year, it would seem that most physicians have not actually decreased their own prescribing habits. I can see how this would be the case. Physicians are stuck in the inertia of “I have always done it this way.” Also, “my patients expect an antibiotic when they come in and they won’t be happy if I don’t prescribe one.” Finally, “The antibiotic can’t hurt and it might help!” Multiply each incident of an unneeded prescription by, oh, a few million, and it adds up.
Of course, inappropriate antibiotic use can and does hurt. It hurts every patient who has an adverse effect from inappropriate antibiotic prescriptions, stuff like diarrhea, yeast infections, nausea or an allergic reaction. It hurts the community by breeding antibiotic resistant bugs. And it hurts because inappropriate antibiotic use is expensive! 40 billion dollars a year expensive! How much of that money is being wasted at your facility?
One of the neatest things that I have discovered about the evidence-based medicine movement is that using evidence-based principles almost always saves money. There is no better example of this than in the area of antibiotic use.
Three years ago, the Centers of Disease Control published evidence-based guidelines for the appropriate use of antibiotics for upper respiratory infections. The guidelines were developed by a panel of experts which included representatives from infectious disease, family practice, emergency medicine, internal medicine and from the CDC itself. The panel used evidence-based principles to review the huge amount of literature on these subjects. In the end, they came up with guidelines entitled “Principles of Appropriate Antibiotic Use for Acute Respiratory Tract Infections in Adults.” The finished guidelines can be found in the March 20, 2001edition of the Annals of Internal Medicine or online at www.cdc.gov/ncidod/dbmd/antibioticresisance/. The final report included pharyngitis (which I reviewed in the last issue of CorrectCare), acute bronchits, and rhinosinusitis.
Acute Bronchitis: A patient presents to your medical clinic complaining of a cough, productive of green sputum that she has had for three days. She should get an antibiotic, right? Not so fast!
The CDC panel defines acute bronchitis as an acute respiratory tract infection with prominent cough, with or without sputum production. As we all know, complaints of cough that we diagnose as “acute bronchitis” are common. The CDC panel’s recommendations apply to otherwise healthy adults without other complications, such as COPD. In other words, they apply to the vast majority of the patients we see. With that in mind, here is a summary of the CDC’s recommendations regarding bronchitis:
Viruses cause the vast majority of bronchitis. The only significant non-viral causes of bronchitis are Pertussis, Mycoplasma, and Chlamydia.
- The main clinical objective for the practitioner evaluating a patient with cough is to rule out pneumonia. In healthy adults, this can be accomplished by finding symmetric breath sounds and normal vital signs ( no fever, a respiratory rate less than 24 and a heart rate less than 100). Chest x-ray should only be ordered in those with cough of greater than three weeks duration or asymmetric breath sounds or abnormal vital signs.
- Antibiotics should not be prescribed for routine, uncomplicated acute bronchitis. If the patient is a healthy adult who does not have pneumonia, do not give antibiotics! The CDC points out here that a long series of meta-analyses and randomized trials consistently fail to show any benefit of antibiotics when given for uncomplicated acute bronchitis.
- Finally (and this is important), the CDC notes that patient satisfaction with physicians’ care for acute bronchitis depends more on physician-patient communication than on whether the patient received an antibiotic. If you will explain to your patient why they do not need an antibiotic, they will most often be happy with your care. I have found it helpful to refer to the CDC guidelines when talking to patients.
Let us now return to our patient who has been coughing up green sputum for three days. She was found in clinic to have normal vital sounds and symmetric breath sounds. The PA on duty explained to the patient the CDC criteria for antibiotic use and then discharged her without an antibiotic prescription.
Rhinosinusitis: The next patient who comes to the jail medical clinic complains of “sinusitis.” He has “stuff running down the back of my throat” and a stuffy nose for three days. He states “my doctor on the outside always gives me Augmentin for this.” So what do you think? Should this guy get an antibiotic?
The CDC panel defines ‘rhinosinusitis” as and inflammation of the mucosa of the sinuses and paranasal structures. Sinusitis involving the maxillary and ethmoid sinuses is usually self limited. However, sinusitis remains the fifth most common diagnosis for which antibiotics are prescribed. The CDC panel makes the following recommendations:
Viruses account for the majority of cases of rhinosinusitis.
- Patients with bacterial sinusitis tend to have the following:
- Symptoms for more than seven days.
- Tenderness of the face or teeth.
- Purulent nasal discharge.
- The CDC does not recommend sinus x-rays for the diagnosis of sinusitis since x-rays perform poorly compared to sinus puncture and culture. If the clinician suspects frontal or sphenoid sinusitis, CT scanning of the sinuses is prudent.
- Most cases of rhinosinusitis resolve spontaneously without antibiotics. Antibiotics should be reserved for patients with moderate or severe symptoms.
In the case of our clinic patient, the PA notes that he has had symptoms for less than seven days. He also has no significant tenderness to percussion of the face or teeth. Finally, the PA cannot find any true purulent discharge. After a discussion about the CDC’s recommendations on the appropriate use of antibiotics for rhinosinusits, the patient is discharged with analgesics but no antibiotics.
Here is the question for your facility: How much money are you paying for antibiotics prescribed for sinusitis, bronchitis and pharyngitis? I recommend that you find out by pulling all of the charts with one of those diagnoses over the past couple of months and adding up the antibiotic costs. Then, I highly recommend that these CDC guidelines be required reading for all the prescribing clinicians in your jail or prison.