Blog | Wednesday, September 19, 2012

Overuse from flu to you

Antibiotic overuse is a big problem: it contributes to antibiotic resistance, changes the distribution of beneficial bacteria within our bodies, and, more generally, is an example of a wider problem, treatment that doesn't work which many people continue to expect anyway and thus ends up prescribed on a wide scale.

Some common circumstances in which antibiotics are given when they shouldn't be include upper respiratory infections. A fascinating piece of research in the latest issue of the Annals of Internal Medicine addresses a question relevant to those infections and antibiotic overuse: Does the context of a patient's illness, that is, the other illnesses that the doctor might have seen around the same time, affect the likelihood of prescribing antibiotics for febrile illness? The answer is a qualified yes: that is, as the number of cases of febrile illness that a doctor had seen during the previous week increased, their likelihood of prescribing antibiotics for the case seen decreased. In other words: if the doctor was exposed to more cases of what were likely flu, or flu-like, they were less likely to give antibiotics.

As interesting as the article itself was the accompanying editorial, which talked about the multiple factors contributing to antibiotic overuse. Sometimes patients want them even when the doctor thinks they don't work; sometimes the doctor thinks they would work when they wouldn't; and sometimes the doctor isn't sure what the true diagnosis is, and prescribes the antibiotic just in case the illness is bacterial.

The last paragraph of the editorial hits the nail on the head: How exactly [does] knowledge about the [flu] pandemic enter into interactions between patients and clinicians? This is a relevant question because antibiotic prescriptions for respiratory illnesses are usually the result of a verbal negotiation between a patient (or parent) and clinician, during which different perceptions of the illness and appropriate course of treatment may be at play. ... On-the-ground observations not only produce ... nuanced explanations of clinical priorities and practices, they can also disentangle the complex interplay of tacit knowledge, social norms, economic pressures, and broader cultural trends--all of which shape patients' perceptions, clinical reasoning, and prescribing decisions.

Even more relevant: antibiotic overuse is just one kind of overuse. As we become more attuned to the general problem of overuse of multiple diagnostic tests and therapeutic modalities, we should try to understand the culture of overuse underlying all of it.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.