According to a report released last week by the Centers for Disease Control and Prevention (CDC), more than half of all hospitalized patients receive antibiotics. In some hospitals, doctors prescribe three times as many antibiotics as in others.
According to the report, (and as we’ve often blogged), “Antibiotics save lives, but poor prescribing practices are putting patients at unnecessary risk for preventable allergic reactions, super-resistant infections and deadly diarrhea. Errors in prescribing decisions also contribute to antibiotic resistance, making these drugs less likely to work in the future.”
Reducing the use of high-risk antibiotics by 30%, the CDC says, can reduce the incidence of deadly diarrhea infections by more than one-quarter.
So except for possible cases of sepsis (see our blog from earlier this week, “Boy’s Death from Misdiagnosis Points Up CDC’s Inadequate Sepsis Information”), why are doctors so keen to prescribe drugs that can undermine good health, for both the individual and the hospital community?
According to a commentary published in JAMA Internal Medicine by Drs. Scott Flanders and Sanjay Saint of the University of Michigan Medical School, one reason is the “chagrin factor” – that’s when it’s not immediately clear if a patient has an infection, so caretakers make a certain treatment decision because they don’t want to learn days later that they were wrong.
But it’s basic to doctoring that you “do no harm,” and if covering your … options just because you’re not confident of your diagnostic skills does harm, maybe it’s time to reassess your clinical judgment in general.
As explained on the news site of the University of Michigan, the CDC wants hospitals to evaluate their antibiotic practices in order to curb their overuse.
According to the CDC report, which is included in its Vital Signs consumer newsletter, the most common types of infections for which hospital clinicians wrote antibiotic prescriptions were lung infections (22%), urinary tract infections (14%) and suspected infections caused by drug-resistant Staphylococcus bacteria, such as MRSA (17%).
About 1 in 3 prescriptions for urinary tract infections and prescriptions for the critical and common drug vancomycin included a potential error – the drugs were given without proper testing or evaluation, or given for too long.
Patients given powerful, broad-spectrum antibiotics (those that treat a wide range of infections) are as much as three times likelier to get another infection from an even more resistant germ.
“In medicine, there’s a tendency to think there’s no harm in erring on the side of caution – but in this case, it may sometimes put patients at risk,” Flanders said.
“U.S. physicians,” Saint said, “tend to place the interests of their patients above the broader interests of society. We need to provide physicians with strategies that are viewed as both benefiting the patient and society.”
He’s being gentle with his profession, of course; we believe that it is the job of a physician to see the big, as well as the small, picture, because one’s health does not exist in a vacuum. We are a social species.
Although medical consumers too often ask for antibiotics as a “just in case” (but inappropriate) treatment for problems like a cold or flu, many are just creatures of habit or ignorance. But a doctor is obliged to know better.
Flanders and Saint offer several suggestions how hospitals can, and should, improve their use of antibiotics. Some of them seem like common sense, some are measures we’ve heard before and all should be taken seriously by medical institutions:
- Hospitals and doctors should work together to develop antimicrobial guidelines and implement them to optimize antibiotic use.
- Doctors should document antibiotic use better in their notes, and share them with other providers caring for the same patient throughout his or her hospital stay, and after discharge.
- Doctors should take an “antibiotic timeout” 48 to 72 hours after a patient has been taking antibiotics to re-assess their use.
- Treatment and its duration should conform with evidence-based guidelines; hospitals should make the appropriate duration of treatment clear to all practitioners.
- Improved diagnostic tests should be available to physicians.
- Diagnostic errors should be addressed by improving how physicians think when considering whether to provide antibiotics.
- Performance measures should be developed so that common conditions in which antibiotics are overprescribed are highlighted.