Physicians are being called on to change patient expectations about antibiotic use, and experts say it’s about communication.
Antibiotic resistance is one of the world’s major public health challenges, according to the Centers for Disease Control and Prevention. While medical providers are heeding the call, patient pressure about receiving antibiotic prescriptions remains a significant influencer, says the National Committee for Quality Assurance.
It’s the crux of the problem and a serious communications challenge for physicians-patients expect to receive antibiotics for cold or upper-respiratory symptoms, regardless of whether it’s to treat a bacterial or viral infection. When physician’s refuse to prescribe in cases when an antibiotic is probably not warranted, it often strains this relationship.
Over the last 15 years physicians started reducing the number of prescriptions they write for antibiotics for patients with many viral illnesses, but it still has not stopped patients from asking for them. And the problem of antibiotic resistance has been getting much more attention by the mainstream media and national medical organizations in an effort to safeguard the effectiveness of these drugs.
In recent months, NCQA issued a report calling for more restraint in prescribing for acute bronchitis for routine treatment.
The American Academy of Pediatrics’ Committee on Infectious Diseases recently issued a policy statement on this issue, “Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics.”
This report provides a framework for clinical decision-making regarding antibiotic use. It emphasizes the importance of using stringent and validated clinical criteria when diagnosing acute otitis media, acute bacterial sinusitis, and pharyngitis caused by group A streptococcus. It also reviews situations in which antibiotics are not indicated, in particular for viral respiratory infections.
The power of communication
But much of this issue revolves around physician-to-patient communication and redirecting his or her treatment expectations.
Mary Anne Jackson, MD, one of the authors of the statement, says that in her experience, having conversations with parents about not giving antibiotics does not have to be difficult.
“Parents want to do what is best for their child,” she says. “Many parents now realize the potential for harm of antibiotics and that they are not always the answer.”
Not only won’t antibiotics help a child with a viral infection, but they increase the risk of the child becoming colonized with antibiotic-resistant bacteria and developing adverse reactions such as diarrhea, which occurs in two out of every 10 kids, she says. Children who carry antibiotic-resistant bacteria can transmit them to other children, at home or at school or day care.
When possible, be specific about what virus you are diagnosing, Jackson says, using in-office testing to confirm viruses such as respiratory syncytial virus or influenza.
For bacterial infections such as strep throat, the diagnosis should always be confirmed with a “rapid strep test” before administering antibiotics. With a firm diagnosis in hand, the decision about antibiotics becomes clear, she says.
“I learned a long time ago that saying ‘it’s only a virus’ will never work for you. Some viruses make children very sick,” she says.
Instead, be careful, cautious, and complete in making a diagnosis, and have a good discussion with the family so that they understand under what circumstances you want to see a child for a return visit.
Acknowledging patient expectations
In the past, physicians taught patients to expect antibiotics when they presented with cold symptoms, and today’s physicians have to undo that teaching, Molly Cooke, MD, FACP, president of the American College of Physicians and professor of medicine at the University of California-San Francisco.
“Make them feel heard and cared about,” Cooke says. “Replace what they thought they were going to get with other suggestions.”
“I will sometimes apologize to patients,” she says. “I tell them that I suspect they came in expecting that I would give them antibiotics. I say I am not going to, but I will spend time explaining why not. I tell them that if I thought antibiotics would do them the least bit of good, I would happily give them. This isn’t about withholding an effective therapy due to cost or anything else, but the fact that antibiotics will not help in this situation.”
Cooke says she sometimes appeals to patients’ common sense by asking them if they called their mom and described their runny nose, scratchy throat, and cough, what would she say? Most acknowledge that mom would tell them to drink hot tea, get some sleep, suck on a lozenge, and expect to feel better in a few days. She tells them, “Your mom is all over this.”
“Anything to decrease the sense that the doctor and patient are in a tug of war,” she says.
What Cooke finds doesn’t work is offering up the public health argument. Patients don’t care about the big picture when they are ill. “It’s way too abstract,” she says.
She focuses instead on what patients can do so they don’t feel like they came in for nothing. She offers advice on symptom relief and ways to help prevent the rest of the family from getting sick, such as thorough hand washing.
The value of a relationship
Wanda Filer, MD, MBA, a board member of the American Academy of Family Physicians, finds that most patients know that physicians no longer give antibiotics for colds and other viruses, but they seem less aware of the newer trend against using them with ear and sinus infections.
Most patients do not push her too hard once she educates them about viral versus bacterial illnesses, she says. She often stresses to them that not giving antibiotics not only avoids the risk of unnecessary side effects but also saves them having to make a copay. Having good rapport with the patient really helps in these situations.
“One of the advantages of being a family physician is that I have a relationship with a lot of my patients and have taken care of them more than just today,” she says.
For example, she knows which patients are at significant risk of developing lung disease and therefore might give them an antibiotic more readily.
Jackson agrees that trust and relationship are vital to the success of conversations in which you are not giving the patient what they think they need.
“Development of trust with your patient population depends on how good you are at communicating all of this information. A lot of this falls back on the doctors,” she says.
Don't give in
Cooke acknowledges that in this era of direct-to-consumer advertising, it can be easier to just give patients what they want. Some caregivers might be tempted to hand over a prescription since they believe if they don’t, another physician will. But she doesn’t think that many people will actually try to get a prescription from another doctor.
“Patients’ time is valuable. They have already taken half a morning off to wait for their appointment with me, and they are probably not in a big hurry to spend the same amount of time in someone else’s office,” she says.
For patients who are truly miserable, all three experts suggest asking the patient to call you, or calling the pateint yourself a few days after the appointment to find out how they are doing. Often when that call occurs, patients feel better and they appreciate that you cared enough to follow up.
If the pateint’s condition doesn’t improve, however, it could be an indication that the illness has become more acute, such as a sinusitis, and may now warrant treatment.
A nurse or medical assistant could make that call if you are too busy, they note. “Just because they have left the office, they haven’t left the practice,” Filer says. “I always assure them they haven’t wasted my time by coming in.”
In fact, she sees acute visits as a “window of opportunity” to review a patient’s overall health and touch base on other issues such as the status of their vaccinations.
Prescribe with caution
Even when antibiotics are warranted, however, there are still issues that need to be resolved, Jackson says. For the most common forms of pneumonia, for example, azithromycin is frequently prescribed but is not always effective. The guidelines offered in the Judicious Use document are a valuable resource for making the right choices.
“We give antibiotics empirically if we think there is an infection while we are waiting for cultures to come back. We give them for definitive infections and sometimes we give antibiotics prophylactically,” Jackson says.
For example, animal bites can warrant the use of preventative antibiotics for 2 to 3 days, but most physicians mistakenly prescribe them for 7 to 10 days for these patients.
“We did a calculation based on how many days of inappropriate antibiotics we might see in this case. The economic cost was significant. We exposed the child longer than was necessary, and possibly missed the diagnosis of going from prevention to infection, which should be treated differently,” Jackson says.
She also stresses that it is important for physicians to warn parents about the possible side effects of all prescription medications, including antibiotics. Physicians need to be sure they are using the right antibiotic at the right dose for the right length of time, Jackson warns.