Monday, August 25, 2008

Antibiotics and the common cold

While everyone knows that antibiotics are over-prescribed for the common cold, and doctors are regularly reminded to limit their use, the practice continues. Why are doctors habits slow to change? Why do patients frequently request antibiotics from their physicians? The lack of a real discussion in society about the forces in play is a significant reason for the ongoing problem.

Everyone has had the common cold. It’s miserable. Fatigue, aches and pains, a runny nose, a post nasal drip, a cough, pressure over the sinuses, a sore throat… On top of all that, you can’t sleep, you’ve been up half the night caring for your child who is also sick, work is as busy as ever, and you have a critical meeting later in the week a few time zones away.

“I can’t afford to be sick.”

The pressures at home and at work are enormous. Doctors, realizing these pressures and faced with ill patients, everyday scour their brains for answers to the common cold but only come up with ways to relieve symptoms. Simple measures like fluids, rest, saline rinses, acetaminophen as needed and a tincture of time are generally all that doctors have to offer.

“Doc, you’re telling me I can put my hard drive on my keychain, but there isn’t anything for the common cold?”

Despite all the advances of modern medicine, there is still nothing to cure the common cold. Antibiotics kill bacteria, but they don’t kill viruses like the common cold. Unlike bacteria, viruses are not living things or cells. Viruses are merely particles that hijack the body’s cells. Bacteria and viruses are separate entities, and taking an antibiotic to kill the common cold is analogous to using cooked pasta to hammer a nail – humorous but ineffective.

“But I’m sure what I have is bacterial.”

Unlikely but possible. Nothing in medicine is absolute and doctors are sometimes wrong. Ascertaining as to when, even if rarely, antibiotics might be indicated can be difficult. Because even a simple illness can change, doctors always insist on being called if symptoms are worsening or the illness is not resolving.

While patients may understand this complexity and uncertainty, patients are also the ones feeling miserable and under pressure to return to their busy lives. It’s a very difficult position in which to find themselves and increases the chance that they might consider their illness to be bacterial or consider antibiotics.

Fear of being wrong, however, also drives a doctor’s prescription habits. Gradually, without a doctor realizing what is happening, the range of signs and symptoms for which he prescribes antibiotics begins to expand.

“Are you sure I don’t have a sinus infection?”

Possibly, but determining whether a sinus infection is viral or bacterial is difficult, and guidelines generally recommend that doctors (once they have ruled out anything serious) wait at least 7-10 days before prescribing antibiotics. Unfortunately, also, no symptom or test clearly distinguishes those who need antibiotics. Doctors, however, often deem one-sided facial pain with dark mucus, a toothache, or pain on bending, or a two-staged illness in which the symptoms are worsening after initially improving, as considerations to treat with antibiotics.

“Yet antibiotics have always worked for me in the past.”

Patients who have frequently taken antibiotics for the common cold may understandably develop a false association between improving and taking antibiotics. Patients usually wait a few days before calling the doctor, and when they then start the antibiotics and improve they relate the two events. Unknown is whether they would have otherwise improved had they not taken the antibiotics. A common understanding among doctors is that patients generally improve in a week with antibiotics or seven days without. It is also one reason for the importance of randomized, controlled trials in medicine.

Analogous to falsely associating antibiotics with improvement is to observe that every morning when the rooster crows the sun rises and then to attribute the sun rising to the rooster crowing. Similarly college students have been known to misattribute feeling sick after a long night of drinking to the nuts at the bar rather than to the excess number of drinks they consumed.

“I never had problems with antibiotics in the past.”

The reasons to minimize antibiotic use are often undervalued. One is simply that side effects from antibiotics are common and unpredictable, including nausea, vomiting, diarrhea, rash, and others that can compound a patient’s misery. There is also the potential for interactions with other medications that are being taken. An increase in antibiotic resistance with the liberal use of antibiotics is a serious problem both for individual patients and the rest of society. One day available antibiotics may not even be effective in treating simple conditions. More serious side effects from antibiotics are less common, but if they happen to you, particularly when they are life threatening, they suddenly don’t seem so uncommon and antibiotics don’t seem so benign.

“My other doctor always gave me antibiotics.”

Often even the best intentioned doctor after being asked multiple times for antibiotics will relent. Again, doctors are human. It takes a strong will to resist a patient’s repeated entreaties in the face of the possibility, even if remote, that the doctor is wrong. Being wrong, despite part of being a doctor, opens the doctor up to emotional tumult of his own, finger-pointing by others, and malpractice lawsuits. In addition, doctors rationalize that the patient will just see another doctor who will prescribe the antibiotics anyway.

This idea of not losing a patient to another doctor is one of the financial pressures to prescribe antibiotics that a doctor faces. Unintentionally, insurance companies also indirectly pressure doctors to use antibiotics by limiting visits to fifteen minutes, including writing the note. Explaining to patients and reassuring them why antibiotics are not needed is time consuming, and a doctor will sometimes choose to give a patient antibiotics rather than spend the time as the waiting room quietly fills with the next patients. Patients, of course, fear the financial impact of missing work, and doctors understand that as well.

Hopefully this look at the over-prescribing of antibiotics clouds the picture enough to open the discussion.