What If It Is Really Bacterial?
Uncertainty about a patient's diagnosis and whether antibiotics are truly necessary is a common theme among clinicians' comments to the Medscape antibiotic prescribing survey, with good reason. In a study of adults presenting with acute cough, clinicians expressed diagnostic uncertainty in 16% of the visits.
"It is an uncomfortable reality," admits Dr. Bartlett. "Clinicians take the safe road -- it might not be the right road, but it's safe. They are weighing the probability of an adverse reaction to antibiotics against the consequences of an erroneous diagnosis, and choosing the safe side."
Dr. Robert Glatter, Attending Physician in the Department of Emergency Medicine at Lenox Hill Hospital in New York City, acknowledges that diagnostic uncertainty could be behind the tendency to overprescribe. "Several recent high-profile cases of sepsis in young children have heightened our awareness that subtle presentations can mask serious illness. Unfortunately, this tends to have the opposite effect on prescribing. Instead of scaling back, these horrific cases prompt clinicians to prescribe antibiotics when they might not be indicated. Other times, it's the complications that we fear. If we don't treat the sore throat, is it going to turn into a peritonsillar abscess?"
Embedded in the issue of uncertainty is the challenge of having timely laboratory evidence to show whether the patient's symptoms are caused by a virus or a bacteria. "One can't always be certain, short of doing unnecessarily invasive tests," argues a pediatric clinician. "Guidelines are vague. Persistent bacterial bronchitis has recently been described, but no one has clear guidelines for diagnosis. So I sometimes prescribe on the basis of unusually prolonged or severe symptoms." Dr. Glatter agrees that we need "better ways to pick up bacterial infection early on. Such markers of infection as C-reactive protein and procalcitonin may have a role here, and PCR tests that can distinguish bacterial DNA are on the horizon."
A family nurse practitioner also deals with uncertainty about the ability to ensure that the patient's outcome is good without antibiotics. "If I am uncertain whether the patient will follow up if more severe symptoms develop -- for example, an unreliable parent, a drug-dependent patient, or an elderly person with transportation issues -- I will sometimes prescribe sooner than I would have otherwise."
For some clinicians, uncertainty is closely tied to litigation concerns. An orthopedic surgeon confesses that at times he prescribes antibiotics "to treat my own uncertainty. If I am uncertain about the probable course of the patient's illness, I will treat with antibiotics and avoid the repercussions if the end result turns out bad."
"Malpractice reform would help," adds a gastroenterologist. "If there is a 1-in-100 chance of sepsis upon admission, the patient will receive antibiotics. If there is a 1-in-100 chance of bacterial infection in the outpatient setting, the patient will receive antibiotics. The nation cannot improve healthcare quality without addressing malpractice reform as an important driver of abuse/overuse of diagnostic tests and treatments, including antibiotics. Will policymakers and academic medicine step up to the plate?"
A family practice physician agrees. "No one at an urgent care center or the ED will discharge a patient who demands antibiotics, without giving him a prescription. Not only [would] your patient satisfaction score take a hit [if you didn't prescribe antibiotics], but if something does happen [to the patient], it is guaranteed that you will be blamed."
On the other hand, Russell Steele, MD, Head of Pediatric Infectious Diseases at the Ochsner Health Center for Children in New Orleans, Louisiana, does not believe that clinicians should equivocate on this issue, even if it means severing ties with the patient. "We have to draw the line here. We are committed to practicing good medicine. It's inappropriate from a patient care standpoint to prescribe antibiotics when they are not indicated. There may be times when the physician has to say, 'This is the way I practice medicine.' We are essentially firing the patient because they are not allowing us to practice good medicine."