Photo Credit – CDC
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One of the most common dilemmas that doctors face is whether or not to prescribe an antibiotic for a patient presenting with an FRI (Febrile Respiratory Illness) often defined as a fever > 38C accompanied by a cough, sore throat, or runny nose.
While these illnesses are often caused by a simple viral infection, there is always the possibility that the patient may have (or may subsequently develop) a bacterial infection.
Since there is little in a patients physical appearance that can help distinguish between a viral and a bacterial respiratory infection, many doctors will decide to err on the side of caution and prescribe an antibiotic, “just in case”.
The problem is that the over-prescribing of antibiotics is viewed as one of the main forces driving the continual growth of antibiotic resistance.
Guidelines (created by the CDC in cooperation with other medical organizations) have been developed to assist the doctor in the prescribing of antibiotics for upper respiratory infections (Adult Treatment Guidelines, Pediatric Treatment Guidelines).
The CDC has also prepared patient education information on when antibiotics are appropriate (see the CDC’s GET SMART ABOUT ANTIBIOTICS website).
But in the end, it often comes down to the primary care provider’s gut feeling whether or not to prescribe an antibiotic. According to a study that appeared yesterday in the Annals of Internal Medicine, Epidemiological Context – not just patient appearance - can be one of the factors that influences this decision.
The study is called:
The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness: A Cohort Study
Courtney Hebert, MD; Jennifer Beaumont, MS; Gene Schwartz, MD; and Ari Robicsek, MD
The authors undertook a 5.5 year retrospective cohort study on the prescribing of antibiotics to patients seen by a network of Midwest primary care providers during influenza seasons between 2006 and 2011.
Their results, compiled from 28,301 patient encounters with signs of an FRI – seen by 69 physicians across 26 practices - is illuminating.
- They found that during the pandemic flu season (April to June 2009 - Sept 2009 to March 2010) antibiotic prescribing dropped significantly over that seen during non-pandemic flu seasons (39.2% versus 47.5%)
- Furthermore, they found the odds that a doctor would prescribe an antibiotic decreased as the number of FRI cases that they had seen in the previous week increased.
In other words, the more viral illness that a doctor perceives to be circulating in their community, the less likely that doctor is to prescribe an antibiotic.
Perhaps more surprising was the range of antibiotic script writing by doctors across this limited geographic region.
Overall, antibiotics were prescribed in just under half (45.2%) of all FRI cases, but among individual clinicians that number ranged from a low of 17.9% to a high of 83.7%.
While there may be other factors not readily apparent from these numbers, there does appear to be a surprising diversity of opinion among clinicians over the appropriateness of prescribing of antibiotics for FRIs.
Although limited in both size and scope, this study suggests that finding ways to keep doctors better informed on what illnesses are currently circulating in their community might help moderate the unnecessary prescribing of antibiotics.
You’ll also find an accompanying editorial in the same issue of Annals Of Internal Medicine, that stresses it is important to not only determine which external factors affect clinician’s decisions, “but how and why”.
The Context of Antibiotic Overuse
Sara Ackerman, PhD, MPH; and Ralph Gonzales, MD, MSPH
For more on the importance of proper antibiotic usage, you may wish to revisit these earlier blogs.
Chan: World Faces A `Post-Antibiotic Era’
Get Smart About Antibiotics Week
IDSA: Educational Guidelines Lower Antibiotic Use
And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.
And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.
