Should patient requests for an antibiotic be considered when prescribing?

Issue: April 2016

In this month’s cover story, Infectious Diseases in Children addressed the dangerous trend of antibiotic overuse across the entire continuum of care. Over the years, unnecessary prescriptions have diminished antibiotic efficacy against certain infections, prompting WHO, the CDC and other leading health organizations to call for a renewed focus on overprescribing across all areas of health care. Click here to read commentary from several experts in different specialties about the factors driving antibiotic overuse and the interventions designed to curb its impact.

Harms of inappropriate prescription take priority over patient requests

Antibiotics can do harm to the individual taking them, as they could lead to allergic reactions, alteration of the beneficial microflora of the GI tract or predisposition to Clostridium difficile. This is similar to other types of medicines, such as insulin, antihypertensives or chemotherapy, which also can have adverse effects. A physician would not give chemotherapy to someone who did not have cancer or insulin to someone who was not diabetic. Similarly, physicians should not give antibiotics to patients who do not have a bacterial infection.

There might be situations, however, when the use of antibiotics is considered optional or conditional; for example, a skin infection might be just on the border of “should be treated with antibiotics” vs. just incision and drainage, and the patient cannot return for follow-up. Similarly, antibiotic prophylaxis to prevent traveler’s diarrhea or antibiotics to treat traveler’s diarrhea that is moderate, might or might not be given. Perhaps in this case, patient preference as well as the patient’s situation and general health might be considered.

Moreover, unlike other drugs, whose use in one patient does not potentially compromise their use in another (insulin, antihypertensives), the use of antibiotics in a patient can proliferate antibiotic resistance, both in the infecting bacteria and in the “bystander” bacterial flora. This then poses a potential risk to others if such organisms spread. For the community, as well as the individual patients, I would encourage physicians to not consider, in most instances, patient preference.

Barbara E. Murray, MD, is the director of the infectious diseases division at the University of Texas Medical School, and a former president of the Infectious Diseases Society of America. Disclosure: Murray reports previous relationships with AstraZeneca, Cubist Pharmaceuticals, Forest Laboratories, Merck and Theravance.

Understanding patient preferences for antibiotics is important to providing optimal care

We increasingly recognize that care should be patient-centered. The Institute of Medicine, in its seminal report, Crossing the Quality Chasm, defined patient-centered care as being “respectful of and responsive to individual patient preferences, needs and values.” While this does not mean that a request for antibiotics should drive clinical decision-making, it does emphasize the need to share the rationale behind these decisions and understand what the patient really wants. Some may want reassurance, to know that their condition is not serious and will improve. Others may ask for antibiotics because of the misperception that antibiotics will make them feel better faster, which is an opportunity for patient education.

Understanding the root cause of the request can be challenging. In a busy clinic, it takes more time to explain why an antibiotic is not indicated than it does to write an antibiotic prescription. Not providing an antibiotic prescription may also be perceived as causing lower patient satisfaction. Providing reassurance is a skill that must be developed, as it requires several steps to be successful.

Patients often ask for, and receive, antibiotics for syndromes that are typically viral. Practice patterns vary widely. Some providers prescribe antibiotics for more than 95% of patients with acute respiratory tract infections regardless of symptoms, but others in less than 40%. As part of its Get Smart initiative, the CDC has provided education materials to help structure the conversation with patients, including a “prescription” for supportive care for viral illnesses.

Sir William Osler declared, “One of the first duties of the physician is to educate the masses not to take medicine.” We should listen to our patients and then engage them into a conversation that sometimes less is more. The lack of an antibiotic prescription does not equate to lack of care. Indeed, it often reflects better care.

References:
CDC. Get Smart: Know When Antibiotics Work. http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html. Accessed February 1, 2016.
Coenen S, et al. PLOS One. 2013;doi:10.1371/journal.pone.0076691.
Hwang TJ, et al. Lancet Infect Dis. 2015;doi:10.1016/S1473-3099(15)00235-2.
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. http://www.nap.edu/html/quality_chasm/reportbrief.pdf. Accessed February 1, 2016.
Jones BE, et al. Annals Intern Med. 2015;doi:10.7326/M14-1933.
Sapira JD. Ann Intern Med. 1972;doi:10.7326/0003-4819-77-4-603.

Jesse T. Jacob, MD, is an associate professor of medicine at Emory University School of Medicine. Disclosure: Jacob reports no relevant financial disclosures.