Antibiotic Use: An Update

A Look at the Usage

The introduction of antibiotics, once hailed as "miracle drugs" in the 1940’s is reminiscent of the words of William Heberden when he wrote 200 years ago that "new medicines, and new methods of cure, always work miracles for a while" ⁽¹⁾. Today, the widespread and often inappropriate use of antibiotics within the last 50 years has contributed to the emergence of bacteria that are resistant to not just one but several types of antibiotics. As a result, parents and healthcare professionals alike are confronted with challenges to diagnosis and treatment options, rising healthcare costs and an increased risk in patient morbidity and mortality particularly with the very young and the very old.

An informed public, the medical profession and non-allopathic healthcare practitioners recognize the disturbing trends in antibiotic resistance and now feel a sense of urgency in addressing the problem. For the medical profession, there is the recognition that antibiotic prescribing by its practitioners are often inappropriate. For example, it has been estimated that approximately 20-50 percent of antibiotic prescriptions in hospital (with 190 million defined daily doses annually) and community (with 145 million defined doses annually) settings are believed to be unnecessary.

The resulting resistant pathogens are staphylococci, enterococci and gram-negative rods, pneumococci, gonococci, group A streptococci, E. coli and mycobacterium tuberculosis ⁽²⁾. Schwartz et.al. ⁽³⁾ attributed these prescribing patterns to unreasonable patient demands and expectations, inadequate time to explain to parents why antibiotics are unnecessary and misdiagnosis of nonbacterial infections. Another study by Butler et.al. ⁽⁴⁾ found that even when physicians know that the use of antibiotics has marginal efficacy (if any), antibiotics are still prescribed to maintain good relationships with their patients. Harrison and Lederberg ⁽²⁾ summarized the factors responsible for inappropriate antibiotic prescribing by medical doctors.(See Fig.1)

After reviewing the factors, I was not surprised by the reasons associated with inappropriate antibiotic prescribing by medical doctors. I see lack of patient education ⁽⁵⁾, selfish personal and professional incentives as well as a general lack of confidence in their ability to provide adequate care for their patient as reasons why medical doctors inappropriately depend on and prescribe antibiotics.

Perhaps the challenges faced by the medical profession with respect to the problem of antibiotic-resistant pathogens is reflective of the problems faced by the medical profession in general. It is beyond the scope of this paper to address all the patient conditions treated in a family practice setting wherein antimicrobial agents may be prescribed inappropriately. The following information is a sampling of the problem and is provided for the reader so that they may be better informed.

Respiratory Tract Infections

In cases of uncomplicated upper respiratory tract infections, the symptoms resolve in most patients within 7-10 days. The patient may experience mild sinusitis-like symptoms such as facial pressure and colored nasal discharges. Symptomatic management in terms of hydration with fluids, vitamin C and rest along with removing interference to the nerve system with chiropractic adjustments is all that's needed. Research has failed to demonstrate the therapeutic benefits from antibiotic therapy in viral upper respiratory tract infections.

Take for example, the following findings:

• Antibiotics do not improve the clinical course of maxillary sinusitis ⁽⁶⁾

• In the management of acute sinusitis, there is an increasing problem with antibiotic-resistant Haemophilus influenza and S. pneumonia, providing further support for avoiding inappropriate antibiotic use ⁽⁶⁾. •Cases of pharyngitis are viral in nature and therefore antibiotics are not indicated.

• Antibiotics have not been shown to be efficatious in the treatment of acute uncomplicated bronchitis. Most cases of acute bronchitis are viral in nature and tend to be self-limiting and benign. Treatment should mostly be directed at the symptoms of cough ^(8-10).

• For the common cold, a recent study concluded that there is not enough evidence of important benefits from the treatment of upper respiratory tract infections with antibiotics to warrant their routine use in children or adults and there is a significant increase in adverse effects associated with antibiotic use in adult patients ⁽¹¹⁾

Acute Otitis Media

In 80 percent of cases of acute otitis media in children, the condition resolves in 7 to 14 days without treatment and with observation alone compared with 95% of patients receiving antibiotic therapy ⁽¹¹⁾. Given its modest if not minimum impact on this condition as well as the risk of adverse reactions, antibiotic use is questionable to say the least. In some European countries, a "watchful waiting" or withholding of antibiotic therapy is a popular course of action.

What role for the Chiropractor?

For Doctors of Chiropractic, the situation provides us the opportunity to educate our patients on our paradigm of health: That health comes from within; that establishing function in the body allows for a state of health to express. In making informed health care choices, parents need to realize that simple preventive measures can go a long way in maintaining health and preventing dis-ease and that treating symptoms merely covers up the underlying cause. My next article will examine the role of the chiropractor in the care of patients exhibiting a number of these conditions.

Figure 1

Patient-Parent Factors:

• Anxiety
• Misconceptions about:what antimicrobials do
• Fever requiring antibiotics
• Belief in the healing power of the physician
• Economic concerns for patients (i.e., missing work)

Physician-Provided Factors:

• Real or perceived patient-parent pressure
• Economic concern for self (loss of clientele)
• Litigation concerns
• Physician fallibility:
• Inadequate knowledge
• Cognitive dissonance (i.e., knowledge but failure to act on it)

Managed Care Factors:

• Cost-saving pressures to substitute therapy for diagnostic tests
• Productivity incentives, reduced appointments time per patient, less explanation time
• Monitoring of rates of return visits to obtain prescription for antibiotic
• Responsiveness to patient complaints about "inadequate antibiotic use"

Cost-saving pressures to substitute therapy for diagnostic tests:

• Productivity incentives, reduced appointments time per patient, less explanation time
• Monitoring of rates of return visits to obtain prescription for antibiotic
• Responsiveness to patient complaints about "inadequate antibiotic use"

Sept - Oct 2002

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