Credit CDC Get Smart Campaign
# 7021
One of the most common ailments seen by family physicians and emergency departments is the ARI, or acute respiratory infection.
Typically the result of a viral infection (e.g. influenza, rhinovirus, adenovirus, coronavirus, parainfluenzavirus, etc.) – conditions that do not respond to antibiotics – they can occasionally progress into a life threatening bacterial pneumonia.
For that reason many patients insist on having a round of antibiotics `just in case’. A practice of long-standing that has been linked to the rapidly growing problem of increased antibiotic resistance.
Caught in between are busy doctors who must quickly balance each individual patient’s needs (based on patient age, history, frailty - and sometimes - just how `sick’ they look), against prudent public health policy.
To avoid a protracted discussion, all-but-predictable disgruntled patient returns – and the remote, but real possibility of a patient progressing to a bacterial pneumonia – doctors will often oblige and prescribe a course of prophylactic antibiotics.
Today, we’ve a reassuring study appearing in the Annals of Family Medicine, that helps to quantify the risks of not prescribing antibiotics for acute nonspecific respiratory infections (ARIs).
Researchers in the UK used cohort of more than 1.5 million adult patient visits with ARI visits to their primary care provider over a 20 year period (1986-2006). Of these 65% received antibiotics.
Patients receiving antibiotics saw an overall small decrease in the rate of bacterial pneumonia hospitalizations – roughly 8.16 fewer per 100,000 (95% CI, –13.24 to –3.08; P = .002) than those not prescribed antibiotics.
First a link to the study and then a Reuters report, after which I’ll be back with more.
Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study
Sharon B. Meropol, MD, PhD, A. Russell Localio, PhD and Joshua P. Metlay, MD, PhD
RESULTS The cohort included 1,531,019 visits with an ARI diagnosis; prescriptions for antibiotics were given in 65% of cases.
The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events (95% CI, −4.52 to 2.38; P = .54) and 8.16 fewer pneumonia hospitalizations (95% CI, −13.24 to −3.08; P = .002).
The number needed to treat to prevent 1 hospitalization for pneumonia was 12,255.
And this report from Reuters Health.
Antibiotics not worth risk in most chest colds: study
By Andrew M. Seaman
NEW YORK | Thu Mar 21, 2013 4:12pm EDT
(Reuters Health) - Doctors need to give antibiotics to more than 12,000 people with acute respiratory infections to prevent just one of them from being hospitalized with pneumonia, according to a new study.
And that small benefit is outweighed by the very real risks that go along with antibiotics - both from serious side effects and the promotion of resistant "superbugs," researchers say.
The practice of medicine is still very much an art, dependent upon the skill and yes, the intuition, of the health care provider. Patients are not statistics, and a one size-fits-all policy for dispensing antibiotics is neither practical or desirable.
But despite decades of warnings, the persistent overuse of antibiotics has led us to the precipice, and we now face an uncertain and potentially frightening future where previously curable infections may run rampant.
A few recent warnings include:
UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’
MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)
CDC HAN Advisory: Increase In CRE Reports In The United States
PNAS: Abundant Antibiotic Resistance Genes In Chinese Swine Farms
The bottom line is that our antibiotic development pipeline is pathetically inadequate, and that bacteria are rapidly learning to evade our current arsenal.
If we fail to control the rise in antibiotic resistance, and our current antimicrobial armamentarium fails, the decision whether to give – or not give – antibiotics will eventually become moot.
While it is unlikely to sway many patient’s opinions, hopefully today’s study will provide doctors with a little more reassurance when they opt not to prescribe antibiotics for routine ARIs.
For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors) Superbug: The Fatal Menace of MRSA.
And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.
