Patient Demand Drives Antibiotic Overuse
Patients demand antibiotics for viral infections like the common cold, and some doctors still prescribe the drugs unnecessarily.
About a third of Dr. Anna Julien's patients who come in with a cold ask for antibiotics, often saying they're too busy to be sick.
Julien, who is trained in family medicine and works in an urgent-care clinic, is among the majority of physicians who know that antibiotics don't cure viral infections, and that their increased use has led to the evolution of drug-resistant bacteria.
"I have had full-on arguments with people about antibiotic resistance and why I will not be prescribing an antibiotic for their viral cold. Generally, as soon as I tell them that antibiotics are ineffective against a virus and a waste of money, they calm down and I can offer them symptomatic treatment," Julien told Healthline. "Most patients leave satisfied when they have a game plan to help deal with their most frustrating cold symptoms, which I often treat with over-the-counter medications."
The American Academy of Pediatrics stresses to parents that antibiotics can't cure their children's colds and flus, and that symptoms should be treated with home remedies, including rest and fluids.
Still, every year, doctors write an estimated 100 million antibiotic prescriptions for conditions they cannot treat. In part, that's because 36 percent of Americans incorrectly believe antibiotics are an effective treatment for viral infections.
A recent study in the Journal of the American Medical Association shows that despite clear evidence antibiotics should never be prescribed for acute bronchitis—a wheezing, deep cough—about 70 percent of bronchitis patients from 1996 to 2010 received prescriptions.
"Everyone feels awful when they are sick and just wants to feel better," Julien said. "For some reason, faith in the body's natural ability to heal itself has waned, and everyone believes that an antibiotic is the only possible cure that could help."
With increased attention through public health campaigns, consumers are slowly becoming aware that the overuse of antibiotics has given rise to bacteria that have mutated defenses stronger than the toughest of these drugs.
Each year in the U.S., drug-resistant "superbugs" sicken about 2 million people and kill 23,000. Each time these deadly microbes encounter antibiotics in humans and animals, they have another opportunity to share information with one another about how to create enzymes to defeat antibiotics.
That's why organizations like the U.S. Centers for Disease Control and Prevention (CDC) have publicly announced that prescribing practices need to change.
"If we lose our antibiotics, we will lose not only the treatment of primary infections but the treatment of infections that complicate many other conditions," Dr. Tom Frieden, CDC director, said in March.
Changing Practices to Slow Bacterial Evolution
New studies show how often unnecessary antibiotic prescriptions occur.
The latest information from the CDC shows that half of hospitalized patients receive antibiotics during their stay, but researchers were surprised to learn that doctors in some hospitals prescribe three times as many antibiotics as their peers in other hospitals.
About a third of the time, using the common antibiotic vancomycin to treat urinary tract infections involved some kind of error—either the medical staff did not conduct appropriate testing or evaluation, or doctors prescribed the drugs for too long, the CDC report states.
These kinds of mistakes can lead to antibiotic-resistant C. diff, an intestinal infection linked to 14,000 deaths annually in the U.S.
"You may initially have a bladder infection, but soon you're fighting for your life from deadly diarrhea," said Dr. Michael Bell, deputy director of the CDC's Division of Healthcare Quality Promotion.
Besides resistance, the increased use of antibiotics in the first six months of a person's life has been linked to a higher incidence of asthma, eczema, and allergic hypersensitivity, according to an article in the journal Pediatrics. Also, about 140,000 people every year have serious adverse reactions to antibiotics.
Because of the pressure hospitals put on doctors to see more patients, and with patients able to visit different physicians until they get what they want, Dr. Neil Fishman said slowing prescription rates isn't as simple as it sounds.
"Patients demand antibiotics. It takes a minute to write a prescription, but it takes 15 or 20 minutes not to write a prescription," Fishman, associate chief medical officer at the University of Pennsylvania Health System, said.
As recently as the 1990s, more than 20 percent of antibiotics prescribed for adults were for colds, upper respiratory tract infections, and bronchitis, three conditions for which antibiotics have "little or no benefit," according to a study published in the Journal of the American Medical Association. This practice resulted in 12 million unnecessary prescriptions.
But in the last two decades, as drug-resistant bacteria have spread in hospitals and the broader community, educating physicians and patients about the long-term effects of antibiotic use is slowly changing old practices.
Researchers at Vanderbilt University tracked antibiotic prescription rates for acute respiratory tract infections and found that while prescribing rates for children under the age of 5 have declined by 40 percent, the use of broad-spectrum antibiotics in adults has increased by 10 percent.
Some experts found that reducing unnecessary prescriptions can be as simple as making a pledge to do so.
Researchers with the RAND Corporation and other institutions conducted an experiment in which physicians posted a large note on their office wall that featured their picture and signature, and detailed appropriate antibiotic use for acute respiratory infections. After three months, the study showed, doctors with posted letters reduced unnecessary prescriptions by 20 percent, while those without the notes increased prescriptions by 18 percent. Appropriate use, however, remained the same.
"This low-cost and easily scalable intervention has great potential to reduce inappropriate antibiotic prescribing," lead study author Daniella Meeker said.
But doctors such as Fishman acknowledge that change won't happen overnight.
"It takes time. It takes money," he said. "It is a large culture shift, and it's very difficult to change culture. And we can't underestimate the voice of the consumer."
But the costs of not changing may be just as great—the average drug-resistant bacterial infection costs up to $37,000 to treat.
Doctors also face pressure to get favorable reviews. Julien, however, said she won't give out antibiotics to patients who demand them, even if it could mean a lower online rating.
"There is pressure to please, and a large part of that stems from wanting [patients] to feel better, and some [doctors] worry about online reviews," she said. "People are very happy to Google doctor names to check out reputations, and those with bad experiences are more likely to rate their doctor than those with good experiences."
Experts say the best strategy is to tell patients that using antibiotics for a common cold may make the drugs less effective when they need them to treat something worse.
The Rise and Fall of Deadly Hospital-Acquired Infections
Spurred by shrinking government reimbursements, hospitals address infection rates.
Among the most lethal antibiotic-resistant bacteria are CRE, or carbapenem-resistant Enterobacteriaceae. CRE infections most commonly occur when a person is hospitalized. Patients at the highest risk are those who need ventilators, urinary catheters, or IVs, as well as those taking long courses of antibiotics.
CRE have been located in healthcare settings in 42 states, increasing from 1 percent to 4 percent of all hospital-acquired infections, according to the CDC.
While CRE cause only a small fraction of all infections, the CDC has dubbed them the "nightmare bacteria" because they are fatal in half of all cases.
Another serious infection is methicillin-resistant Staphylococcus aureus (MRSA). In the first-ever comprehensive look at the threat of drug-resistant bacteria in the U.S., researchers found that 60 percent of the estimated 80,461 MRSA infections in 2011 were related to outpatient hospital procedures, and another 22 percent occurred in the general community.
Still, a study published in the Journal of the American Medical Association found that since 2005, outpatient infections have decreased by 27.7 percent and hospital-acquired infections by 54.2 percent. Interestingly, infections that occurred outside the healthcare setting have decreased by only 5 percent.
The quick reduction in hospital-acquired infections since 2005 is directly related to legislation passed to lower the national deficit and reduce Medicare spending.
"Some of my colleagues will shoot me for saying this," Fishman said, "but hospital infections only got attention when they were tied to reimbursement."
According to the CDC, healthcare-associated infections cost U.S. hospitals between $28.4 and $33.8 billion annually. Infection-control initiatives could save up to $31.5 billion.
In 2005, when medical errors were costing an average of $113,280 per negligent injury in some states, President George W. Bush threatened Medicare reimbursements. Seventy percent of those unnecessary medical costs were billed to Medicare or private insurance companies, a Harvard School of Public Health study found.
With the Deficit Reduction Act, signed in 2006, the Secretary of Health and Human Services identified hospital-acquired conditions that could be avoided. Among them were urinary tract infections from catheters, vascular catheter-associated infections, and surgical-site infections.
Hospitals that continued to see high levels of preventable infections would receive less money from the federal government for care they provided patients covered by Medicare, according to a report from the National Conference of State Legislatures. Once the government told hospitals to clean up their act or face paying for their mistakes, changes began to occur, and hospital-acquired infection rates were cut in half.
Overall, there has been a 20 percent decrease in infections related to 10 types of surgical procedures and a 44 percent decrease in line-associated bloodstream infections, according to a CDC report released in March.
But a study published in the New England Journal of Medicine concluded that a policy to reduce payments for two types of catheter infections had no measurable effect in the 398 hospitals studied. The Harvard University researchers offered possible explanations, such as the infections were already being targeted, the hospitals changed their billing practices, or the financial incentives were too small.
The average hospital would have lost as little as 0.6 percent of its Medicare revenue, but preventive improvements would have been more costly, the researchers said.
While recent data from the CDC shows that hospital-acquired infections continue to decline, about one in 25 patients in American hospitals will get some type of infection. About 11 percent of those patients—most often the elderly—will die.
Sumanth Gandra, an infectious disease specialist with the Center for Disease Dynamics, Economics, and Policy (CDDEP), uses data on antibiotic use and infection rates to help countries develop policies to stop the evolution of antibiotic-resistant bacteria.
Through his work to reduce the spread of these deadly bacteria, Gandra has found that lost profits create quicker change than the negative impact on human health.
In some countries, drug-resistant bacteria affect newborn babies and delivering mothers most often. Although these infections are causing an important health crisis, Gandra said leaders pay attention only when the financial impact of doing nothing is apparent: a dwindling workforce in the future.
"The finance people never cared about infection control until they had some economic incentive if you have an infection. That's when you have people focusing on infection control," Gandra said. "Having those kinds of policies will definitely make people shake at the top level at the healthcare institution."
Why a Lack of Stewardship Can Be Costly
Preserving current antibiotics is much less costly than discovering new ones.
Ramanan Laxminarayan, director of the CDDEP, said many of those interested parties—the healthcare, pharmaceutical, and agriculture industries—suffer from "status quo bias."
Disease-prevention efforts, after all, can be costly. Those who benefit from current practices are reluctant to change because they don't have incentives to do so, Laxminarayan said.
He likened antibiotic development to oil use: Once we use up what's available, it's going to be more expensive to dig deeper to find more. He warned that without good antibiotic stewardship policies across the globe, things will get much worse.
"Nothing drives policy better than impending catastrophe," Laxminarayan said.
The next story in the series examines the shortage of new antibiotics, which ones are being developed to combat drug-resistant bacteria, and how new legislation entices pharmaceutical companies to develop new antibiotics.
Continue to the next article »