Case Scenario

In my walk-in office I see many patients with respiratory ailments, and I usually have reasonable and successful conversations with them about antibiotic use. However, the patients that I find most difficult to deal with are those who are looking specifically for an antibiotic prescription because they claim to “know their bodies” and know what they need.

Typically, patients who claim to know what they need have had many similar bouts with sinusitis or bronchitis and know they are going to need antibiotics because the condition “never clears up without them.” Or, they may claim that only one specific antibiotic (usually one that is expensive and broad spectrum) works for them. For example, a patient may refuse amoxicillin because of previous episodes that did not respond to amoxicillin but that eventually subsided after taking a broad-spectrum drug. I sometimes try to explain that the amoxicillin probably didn’t work because no antibiotic would have worked, and that the broad-spectrum antibiotic seemed to work because, by the time it was prescribed, the infection had resolved on its own. Of course, this argument is not only time-consuming, it is also convoluted. How should I manage these encounters? What is the best way to educate patients about resistance to antibiotics?

Commentary

Multiple studies^1–6 have demonstrated that patients who seek care for respiratory ailments often expect to receive antibiotics, and that patients or parents who expect antibiotics receive them more often than those who do not.

Interactions with patients who claim to “know their bodies” and know what treatment is best for them are common. A study of audiotaped office visits⁷ for respiratory ailments identified several communication elements that were associated with high antibiotic prescription rates. These elements included those that appealed to specific life circumstances (e.g., “I’m getting married this weekend”) and those that were related to experiencing previous benefit from antibiotics for a similar illness.

Implicit in the scenario described above is the more specific question: how do I minimize unnecessary prescribing of antibiotics while maintaining patient satisfaction? Several studies^1,4–6 show that patient satisfaction with the care received for respiratory ailments is more closely related to how much time the physician spends explaining the illness, rather than the physician simply writing a prescription for an antibiotic. However, because most of these reports were from observational studies, patients who had strong expectations for antibiotics probably always received prescriptions for them. Encouragingly, we found that there was no change in patient satisfaction or the number of return office visits in a primary care practice where antibiotic prescribing for uncomplicated acute bronchitis had been reduced by 50 percent through provider and patient educational intervention.⁸

Major determinants of patient satisfaction, regardless of the illness, are based on the patient’s perception that the physician spent enough time with him or her, explained the illness coherently, and treated him or her with respect. Specific to respiratory ailments, it is unusual for patients to seek care only for reassurance that they are not seriously ill. Therefore, physicians should evaluate the severity of the illness, keeping in mind that the illness has affected the patient’s activities enough for him or her to seek care. A physician should focus treatment discussions on alleviating symptoms while being realistic about the time required for symptom resolution (e.g., a typical cough illness lasts 10 to 14 days). The doctor also should ask patients which components of their illnesses are most bothersome to them and recommend a therapy accordingly. Physicians should advise patients when to return to the physician’s office. The exact symptoms and signs will vary by illness, patient, and season; in general, fever beyond four or five days, shortness of breath, nausea and vomiting, severe headache, and increasing fatigue should prompt the patient to contact the physician’s office.

Choosing an over-the-counter cough and cold remedy at the local supermarket or pharmacy can be an onerous task for patients, given the wide variety of single and combination therapies available. Congestion and cough tend to be the most common chief complaints for which I would offer simple recommendations to patients. Decongestants that contain pseudoephedrine are moderately efficacious at reducing nasal congestion and should be considered the key therapy for treating rhinosinusitis.⁹ The literature evaluating antitussive treatments is more problematic, because the efficacy of these agents seems to be dependent on the etiology and duration of the cough.¹⁰ My own synthesis of this literature is that, for patients with acute bronchitis whose average duration of cough is two to three weeks, cough preparations containing dextromethorphan or codeine, as well as albuterol therapy, probably have some beneficial effect on cough severity and duration during the protracted phase of illness, although the evidence on this is conflicting.¹⁰

As pointed out in the scenario, these recommendations are usually enough for most patients. However, when patients specifically request antibiotics for viral infections, physicians should discuss the risks and the lack of benefit from antibiotics for their specific illness. In addition to the well-known risks of gastrointestinal effects, vaginitis, skin eruptions, and anaphylaxis from antibiotics, physicians should briefly explain to patients the growing problem of antibiotic resistance. It is important to personalize the risk of antibiotic use for each patient because appeals to public health concerns in general are often insufficient. When talking to patients about antibiotic use, try to convey the following four points:

1. Adults, particularly those with young children or those who work in child care or health care settings, are continuously exposed to antibiotic-resistant bacteria.

2. Our body’s “healthy bacteria” are useful because they help prevent colonization with new bacteria. However, the use of antibiotics (whether appropriate or inappropriate) kills many of our healthy bacteria and creates a more favorable environment for colonization with antibiotic-resistant bacteria.

3. Although these antibiotic-resistant bacteria alone usually don’t make us sick, we can remain colonized for months and spread resistant bacteria to our family members and close contacts. Then if we do get sick, we often require much stronger antibiotics to get better.

4. Taking antibiotics unnecessarily during the winter months creates a “double whammy” effect, because we increase our likelihood of being colonized with resistant bacteria when we also are more likely to spread these germs via coughs and colds.

The scenario also raises the issue of time. In a busy clinical practice, how does a physician handle these encounters expeditiously? In intervention trials, and in our walk-in clinic, my colleagues and I have found that providing patient education on antibiotic resistance and on appropriate antibiotic use for respiratory tract infections greatly facilitates these discussions. Brochures placed in the waiting room help patients move beyond their preconceptions about antibiotics. In addition, we have posters in each examination room that specifically address the issues related to antibiotic use. Physicians have told us in focus groups that these posters are helpful in “objectifying” the decision about antibiotic treatment and in laying the groundwork, if necessary, for a quick discussion about the relationship between antibiotic use and antibiotic resistance. These posters and brochures, as well as other reference materials on antibiotic use are provided in English and Spanish and can be downloaded from the Web site: http://www.getsmartcolorado.com.