It happens almost everyday- a patient will call and say
“I have a (insert malady here) can you please just call me in something? I don’t have (Time, copay, a ride) to come in and see you”
And my answer is 90% of the time, “No, you need an appointment to be evaluated”
The reason? We for lack of a better one is we are running out of antibiotics and my giving you one without checking to make sure that your “infection” is bacterial, well is causes more harm than good. Besides if you just have a cold (which is viral) you probably won’t finish the antibiotic anyway, and stash it over your sink for the next time that you get the sniffles, leaving behind what was once a harmless bacteria, a stronger resistant one.
Misuse of antibiotics leaves behind the stronger bacteria which makes it more difficult to fight next time that there is an infection. Sadly there has not been a new antibiotic class discovered since the 1980s. But how can that be?
Figure 18: The Antibiotic Discovery Void
Source: World Economic Forum, adapted from Silver, L.L. Challenges of Antibacterial Discovery.
In Clinical Microbiology Reviews, 2011, 24:71-109.
Is is a matter that drug companies can’t make enough money at it? IF only. Sadly, it isn’t. They continue to look for ways to fight infection, however today we encounter the ever increasing resistant bugs. Currently, 100,000 Americans die each year from resistant bugs, while small compared to the numbers who die from heart disease and cancer, this number is only going to grow.
One reason, is the way we treat patients at the nursing home. I routinely get calls to have a urine done on a patient. Often what returns is a contaminated mess that the nurse is just sure needs to be treated. This is an endless repetition of calls saying either, “No wait for the culture” or “No get a cath or a clean catch sample, that is full of contamination” or in the most extreme nurse going to tell family “Your doctor just doesn’t care about the infection, so they won’t treat it.” prompting the family to immediately change to a doctor who will treat said contaminated sample or a trip to the ER so that they can be “properly” treated. Or in the case of a patient with a chronic infection, endless arguments and sending 5 copies of the consultation from the urologist saying “don’t treat that mess, you are just causing increased resistance.” And that is just for urines, coughs at nursing homes are often treated with a z-pack thrown at them, because it is easier than having them carted to the office for an evaluation. Is it any wonder that c.difficile at the nursing home is almost considered normal.
The other reason for this resistance? Patients out in public- All of you who decided you were filling better on day 5 of a 10 day course of amoxicillin. So you kept the rest in your medicine cabinet above the sink (probably the worst place to store pills by the way) and then the next time you are feeling bad, well you started to take them. Sadly after 5 days of old pills, you still are not feeling better, so you go into your doctor. Unfortunately you have now confused the picture. What might have been a cold, and needed only decongestants can’t be differentiated from a half treated bacterial infection. And now, I am stuck with given possibly unnecessary antibiotics or not giving antibiotics and now that you have half treated yourselves you have caused resistant organisms only to survive.
Another scenario, patient goes to Doctor number 1 and they tell patient, it is viral after doing the appropriate exams and tests, and that no antibiotics are needed. Patient then says “If I go to Dr #2 he will give me an antibiotic.” Dr #1 has two choices, to practice good medicine in a day of decreasing reimbursement and risk losing patient, or the give into patient and practice “good business”
Add to that the routine use of antibiotics in livestock feed, and we are about to face a drug resistance epidemic that we never thought possible. Resistant bacteria can be transferred from livestock to humans, and resistant bacteria has contaminated our water supply so much that they have found resistant strains as far away as Antarctica.
Some even wonder if our obsession in this country on controlled substances is misdirected and that maybe we need to worry less about the improper prescribing of hydrocodone and more about the improper prescribing of antibiotics. While both could potentially have horrible consequences, the antibiotic misuse is more dire for the population as a whole.
Patients often ask me what do I do when either I or my children get sick. Funny enough, the last time I was sick before this past December was 3 years ago. Mine did happen to be bacterial and I finished my antibiotics. My oldest son, hasn’t taken an antibiotic since he was in second grade 2 years ago when he had strep. My youngest, its hard to remember, its been longer than that. We spend considerable time washing hands, and less worrying about a little dirt in the house. So yes, I practice what I preach.
Antibiotics have a role in healthcare, but we need to attempt to make sure that they are used appropriately, because despite one or two recent antibiotics that came to market in the last few years, new drugs are few and far between on the drug pipeline. It is an expensive process, and despite my remark that if only it were solely because antibiotics would have a hard time to be profitable once released, it takes on average $1 billion to get a drug to market from start to finish in this country. There does need to be some means to get back the cost of that research.
So next time you start cussing because your doctor didn’t just call you in that z-pack maybe there is a good reason and maybe you should be thankful in the future.