Publication Date: Wednesday Apr 8, 1998

Resisting the antibiotic urge

At the first sign of the sniffles, fever, chills, or a deep chest cough, many people rush to their doctors hoping for prescription for antibiotics to curb the infection.

Yet, many doctors say for most upper respiratory infections or bronchitis--at least in otherwise healthy people--antibiotics will do little good. And, as these valuable disease-fighting tools become too common, bacteria are learning to resist them.

"There are ramifications of giving antibiotics. Patients will start harboring more resistant bacteria," said Dr. Meg Durbin, a family practice physician at the Palo Alto Medical Foundation.

Since the discovery of penicillin in 1928, killer diseases like tuberculosis have been virtually quelled in modern society. The fallout, however, is that bacteria have been treated with the same antibiotics for so long that the germs, to some extent, have become resistant. Consequently, doctors are increasingly reluctant to prescribe antibiotics for run-of-the-mill sicknesses out of fear of increasing that resistance. Medical experts are trying to learn to save their ammunition for the most serious of battles.

Durbin and two associates have conducted a study within the clinic to determine the prevalence of antibiotics prescriptions being written by clinic doctors for patients with upper respiratory infections (not including strep throat) or bronchitis. The good news is the clinic's antibiotic prescription rate for bronchitis is about one-third the national average.

According to a study published in the Journal of the American Medical Association, 12 million prescriptions for antibiotics, or 21 percent of all prescriptions, were written for colds, upper respiratory tract infections, and bronchitis in 1992.

A total of 51 percent of patients diagnosed with colds, 52 percent with upper respiratory tract infections, and 66 percent of patients diagnosed with bronchitis were treated with antibiotics.

"Although antibiotics have little or no benefit for colds, upper respiratory tract infections or bronchitis, these conditions account for a sizable proportion of total antibiotic prescriptions for adults," the study concluded.

While the Palo Alto Medical Clinic's average is less than the national, Durbin says there is still much room for improvement.

"It's not just the Palo Alto clinic, it's everywhere," she said. "What makes doctors prescribe antibiotics (often) is patients have come in with expectations. Doctors rightly or wrongly assume the patient wants antibiotics."

For example, she said, a patient who has waited for an hour or so in an urgent care facility to see a doctor, only to have that doctor send them home to rest, with no medication, will often feel their visit was futile if they don't leave with a prescription.

"Doctors and patients may misunderstand each other," Durbin said. "The doctor may assume that because the patient is there, they want an antibiotic."

But the fact is that with or without antibiotics, people will generally recover from most upper respiratory infections within 14 days, Durbin said. And, if patients have prescriptions for antibiotics and don't finish them, the last remaining, strongest bacteria could get a chance to multiply uncontrollably.

Studies have found that even when an illness has a bacterial cause, patients with bronchitis may take the same amount of time to get well, whether or not they are taking antibiotics.

Not only is it important to change patients' expectations, Durbin said, but to change doctors' culture as well. "If you put 10 doctors in a room, and show them 10 case histories, you'll get 100 different opinions."

"The challenge we face in trying to change physician behavior are the same everywhere," Durbin said. The clinic will be creating an overall plan to tackle patient education, and also to work with advice nurses, doctors, and urgent care personnel about ways to assess the need for prescribing antibiotics.

Stanford University Hospital and Clinics has also formed a multidisciplinary committee to monitor antibiotic use in the hospital. "In the hospital, we have decreased our use of antibiotics," said clinical pharmacist Lana Witt. The hospital has worked to shorten the time that surgical patients are on antibiotics, and has tried to narrowly tailor antibiotics for specific bacteria.

Durbin said patients can take it upon themselves to ask their doctors if antibiotics are really necessary for their illness. "The patient should clearly state their symptoms, to be able to give a good history."

Durbin added that contrary to popular opinion, the color of mucus secretions associated with an illness does not necessarily dictate prescribing an antibiotic. "Nobody knows what it really means, (even though) we all ask that," she said.

Patients should maintain an open mind about therapies for their illnesses other than antibiotics. Inhalers, for example, can be beneficial. These devices "can counteract the body's response to infection," Durbin said, and are often underprescribed by physicians.

Last, she said, both doctors and patients could do well to remember this: "There are illnesses that just take time to heal," she said. 

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