{"id":953,"date":"2016-01-22T16:31:16","date_gmt":"2016-01-22T16:31:16","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=953"},"modified":"2017-08-21T11:06:49","modified_gmt":"2017-08-21T11:06:49","slug":"primary-care-corner-with-geoffrey-modest-md-antibiotic-overprescribing-and-acute-respiratory-infections","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/01\/22\/primary-care-corner-with-geoffrey-modest-md-antibiotic-overprescribing-and-acute-respiratory-infections\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Antibiotic Overprescribing and Acute Respiratory Infections"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>In my\u00a0never-ending pursuit of protecting the microbiome, and also decreasing further development of antibiotic resistance, there was a helpful\u00a0clinical guideline from the American College of\u00a0Physicians and the CDC (see\u00a0doi:10.7326\/M15-1840). Nothing new here, but it really reinforces both the remarkable overuse of anti-bacterial\u00a0antibiotics for nonbacterial conditions and the\u00a0very common conditions when this is happening (the lowest-hanging fruits), which if implemented should decrease bacterial resistance, decrease antibiotic-associated adverse events including lots of deaths, and save lots of money (and the microbiome).<\/p>\n<p>Background:<\/p>\n<ul>\n<li>Antibiotics are prescribed in &gt;100M adult ambulatory care visits in the US\/yr, with cost of $10.7 b(as in, billion)\u200b\u00a0in 2009, with $6.5 b in the community setting<\/li>\n<li>41% of prescriptions are for respiratory conditions<\/li>\n<li>There are\u00a0&gt;2M antibiotic-resistant illnesses and 23K deaths in US\/yr, with cost of $30\u00a0b<\/li>\n<li>Higher rates of\u00a0multi-drug resistant pneumococcal disease occur\u00a0in places where there is more prescribing of broad-spectrum antibiotics, esp extended-spectrum cephalosporins and macrolides<\/li>\n<li>And, antibiotics as a group are responsible for the largest number of medication-related adverse events, including 20% of ER visits for adverse drug reactions<\/li>\n<li>Adverse drug reactions range from mild to serious: an\u00a0estimated 5-25% of patients on antibiotics have adverse events, and 1 in 1000 have a serious one. E.g.: c difficile causes 500K infections and 29,300 deaths\/year in the US, with an\u00a0estimated $1 billion in extra medical costs<\/li>\n<li>An\u00a0estimated 50% of outpatient\u00a0antibiotics are considered unnecessary, with a direct\u00a0cost of $3 b<\/li>\n<li>Although (the good news) antibiotic prescriptions have decreased 18% in people&gt;5\u00a0yo in the past decade, (the bad news) prescriptions for broad-spectrum fluoroquinolones and macrolides have increased &gt;4-fold<\/li>\n<\/ul>\n<p>Recommendations:<\/p>\n<ol>\n<li>Acute uncomplicated bronchitis (self-limited inflammation of bronchi with cough, which may or may not be productive),\u00a0lasting up to 6 weeks.<\/li>\n<\/ol>\n<ul>\n<li>\u200bHas 100M outpatient visits\/yr (10%!! of total), and <strong>&gt;70% result in antibiotic prescription!! &#8212; the largest cause of inappropriate antibiotic prescriptions<\/strong><\/li>\n<li>\u200bNeed to differentiate from pneumonia (in adults &lt;70\u00a0yo, pneumonia unlikely in absence of all of: tachycardia with HR&gt;100, tachypnea with RR&gt;24, fever with T&gt;38C, and abnormal findings on chest exam (rales, egophony, or tactile fremitus)<\/li>\n<li>Meta-analysis of 15 RCTs found limited benefit of antibiotics but a\u00a0trend to increased adverse events. and no clear decrease in days to cough resolution<\/li>\n<li>There may be benefit from cough suppressants (dextromethorphan or codeine), expectorants (guaifenesin), first-generation antihistamines (diphenhydramine), decongestants (phenylephrine), b-agonists (albuterol), though data to support specific therapies are limited and b-agonists don&#8217;t seem to help unless there is underlying asthma or COPD [by the way, I think there are lots of scripts for the more selective antihistamines, such as loratadine, which have limited effectiveness for viral infections]<\/li>\n<li>\u200bThere are some cases of antibiotic-sensitive causes (mycoplasma, chlamydia, B pertussis), though these are uncommon and should be considered in cases where transmission in the community is reported [no comment here that it is hard to know of transmission in the community if these are not tested for&#8230;.., but in broad strokes, treating people\u00a0indiscriminately with antibiotics\u00a0does not seem to help]<\/li>\n<li>So, <strong>do not perform testing or give antibiotics in patients with bronchitis unless pneumonia is suspected<\/strong><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ol start=\"2\">\n<li>Pharyngitis (benign self-limited illness with sore throat, worse when swallowing, with or without constitutional symptoms<\/li>\n<\/ol>\n<ul>\n<li>12M outpatient visits\/yr (1-2% of total). <strong>60%\u00a0get antibiotics<\/strong><\/li>\n<li>No further testing indicated if likely viral: associated symptoms of cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, oropharyngeal ulcers\/vesicles<\/li>\n<li>Those with symptoms suggestive of strep should get rapid strep test, throat culture or both: e.g. symptoms of persistent fever, rigors, night\u00a0sweats, tender lymph nodes, tonsillopharyngeal exudates, scarlatiniform rash, palatal petechiae, and swollen tonsils.<\/li>\n<li>\u200bThe Centor criteria are often used (fever, tonsillar exudates, tender anterior cervical nodes, absence of cough), BUT\u00a0because\u00a0the positive predictive value for group A strep\u00a0is so low, the IDSA (Infectious\u00a0Diseases Society of America) only suggests using these as a means to do no further\u00a0testing or prescribing\u00a0antibiotics\u00a0if there are &lt;3 criteria.<\/li>\n<li>Some patients present with severe signs\/symptoms, such as\u00a0difficulty swallowing, drooling, neck tenderness\u00a0or swelling, and should be evaluated for peritonsillar abscess, parapharyngeal abscess, epiglottitis, Lemierre syndrome<\/li>\n<li>If strep found on testing, then treat with appropriate narrow-spectrum antibiotics, which decreases\u00a0duration of sore throat by 1-2 days, but may also\u00a0decrease risk of acute rheumatic fever (more common in kids and teens), peritonsillar abscess, and spreading the infection.<\/li>\n<li>No need to treat asymptomatic carriers of strep, since low likelihood of spreading it and low potential for complications<\/li>\n<li>\u200bNot do tonsillectomy in adults just to reduce frequency of recurrent strep infections<\/li>\n<li>Treat adults with analgesics (aspirin, acetaminophen, NSAIDs), throat lozenges. Little data on salt water, viscous lidocaine [or, I would add, tea with honey or lemon, as is preferred by many of my patients]<\/li>\n<li>\u200bSo, <strong>test patients with symptoms suggestive of Group\u00a0A\u00a0strep pharyngitis, and treat only if confirmed strep<\/strong> [and use narrow-spectrum antibiotics, my addition]<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ol start=\"3\">\n<li>Acute rhinosinusitis (self-limited viral infection, allergy, or irritant which causes inflammation in nasal or paranasal sinus cavity. Lasts 1-33 days with most resolving in a\u00a0week. Can be associated with nasal congestion, purulent discharge, maxillary tooth pain, facial pain\/pressure, fever, cough, hyposmia\/anosmia, ear pressure, headache, hallitosis.<\/li>\n<\/ol>\n<ul>\n<li>&gt;4.3 M adults have diagnosis annually,<strong> &gt;80% get antibiotics<\/strong>, mostly macrolides, and most unnecessarily so<\/li>\n<li>No role for radiologic imaging &#8212; does not reliably differentiate bacterial from viral causes<\/li>\n<li>Bacterial cause more likely if symptoms persist &gt;10 days without improvement, symptoms are severe (fever &gt;39C, purulent nasal discharge, or facial pain &gt;3 days), or if new onset fever, headache, increased nasal discharge after a viral URI was improving<\/li>\n<li>If treating, preferred agent per IDSA is amoxacillin-clavulanate,with doxycycline or respiratory fluoroquinolone as alternative; the Am Acad of Otolaryngology emphasizes initial management of watchful waiting regardless of symptom\u00a0severity; some medical\u00a0societies recommend amoxacillin (no direct evidence\u00a0that amoxacillin-clavulanate\u00a0is clinically\u00a0superior). In fact\u00a0rhinosinusitis\u00a0is usually self-limited even if caused by bacteria. A meta-analysis found that the number-needed-to-treat was\u00a018 for 1 patient to have a more rapid cure, but the number-needed-to-harmfrom adverse antibiotic effects was 8<\/li>\n<li>Nasal saline irrigation and intranasal steroids may alleviate symptoms and\u00a0decrease likelihood of antibiotic use. Other supportive therapies include analgesics for pain, systemic or topical decongestants, mucolytics, and antihistamines<\/li>\n<li>\u200bSo, <strong>reserve antibiotics unless patient has persistent symptoms &gt;10\u00a0days, onset of severe symptoms\/signs of\u00a0fever &gt;\u00a039C and purulent nasal discharge or facial pain for &gt;3 consecutive days, or worsening of symptoms after a viral illness that lasted\u00a0&gt;5\u00a0days and was initially improving<\/strong><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ol start=\"4\">\n<li>URI<\/li>\n<\/ol>\n<ul>\n<li>\u200b37 M ambulatory\u00a0care visits (3%), <strong>30% get antibiotics<\/strong><\/li>\n<li>Complications include acute bacterial sinusitis, asthma exacerbation, and otitis media. Antibiotics play NO ROLE in preventing these.<\/li>\n<li>\u200bBest means to prevent transmission: handwashing<\/li>\n<li>Symptomatic therapy, though advise patient that symptoms can last 2 weeks. antihistamine-analgesic-decongestants work. Zinc supplements help if given within 24 hours. no evidence for vitamins\/herbal remedies<\/li>\n<li>So, <strong>do not prescribe antibiotics for patients with the common cold<\/strong><\/li>\n<\/ul>\n<p>As many of you know, I have sent out many blogs on this. In particular:<\/p>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2014\/07\/11\/primary-care-corner-with-geoffrey-modest-md-whos-remarkable-scary-report\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2014\/07\/11\/primary-care-corner-with-geoffrey-modest-md-whos-remarkable-scary-report\/<\/a> \u00a0highlights the worldwide emergence of antibiotic-resistant bugs<\/p>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/antimicrobial-resistance\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/antimicrobial-resistance\/<\/a> includes a slew of blogs on antimicrobial resistance, including long-term changes in the gut microbiome after even a single dose of antibiotics, importance of antibiotic use in food industry in creating very threatening changes in microbial sensitivity, effects of international travel on changes in microbial sensitivities in the gut microbiome, and the real importance of using the narrowest-spectrum antibiotics in treating pneumonia\/strep pharyngitis<\/p>\n<p>So, I do realize that it can be difficult to dissuade some patients from getting antibiotics. I frequently hear &#8220;but my (cough, bronchitis, cold&#8230;) is bad and in the past whenever I get antibiotics it goes away right away&#8221;. Though, I have noted over the years that fewer patients are so insistent (perhaps relating to my sense that it is the dying breed of\u00a0older patients who are more insistent than younger ones). In any event, I have had some success in stating over-enthusiastically that &#8220;the good news is that you do not have a bacterial\u00a0infection, do not need antibiotics, but I can give you some medicines to help relieve the symptoms.&#8221; Or, if pushed, &#8220;antibiotics really don&#8217;t help this type of infection, which gets better on its own. And there is a very real chance you could get a very serious side-effect. So I really think it is important not to take antibiotics&#8221;. And in my experience (perhaps augmented by my gray hair), these are usually successful and lead to a satisfying encounter, without antibiotics being prescribed.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Antibiotic Overprescribing and Acute Respiratory Infections  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/01\/22\/primary-care-corner-with-geoffrey-modest-md-antibiotic-overprescribing-and-acute-respiratory-infections\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-953","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/953","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=953"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/953\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=953"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=953"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=953"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}