American College of Physicians: Internal Medicine — Doctors for Adults ®

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President's Column

How ACP-ASIM is working to combat the growing overuse of antibiotics

From the October 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

Imagine a typical workday for a practicing internist. You've got a full schedule of office visits, with each patient allotted just 15 minutes "to increase productivity." All of your "work-in" slots have been filled with physicals for patients who joined the new HMO. Between patient encounters, while you're checking phone requests from patients, you find the following note at the top of the pile:

"Ms. Doe: sore throat, runny nose and congestion for two days. Big party this weekend, 'can't be sick.' Wants 'that new antibiotic' she heard about on TV that 'kills everything.' Too busy preparing for the party to come in. Wants a prescription called in to her pharmacy."

As you stop in your cluttered office to call in the prescription, the latest literature from the College on combating antibiotic-resistant bacteria catches your eye. Suddenly, you ask yourself: Is an antibiotic really needed here?

The College's efforts

That is the question that ACP-ASIM wants to bring to the mind of every internist whenever a patient demands an antibiotic. The College this year began a campaign to educate physicians and the public about antibiotic overuse and its contribution to emerging antibiotic resistance, which presents a serious threat to public health. ACP-ASIM has released "What you can do to reduce the threat of antibiotic resistance," a document that explains how parents, patients, physicians and organizations can work together to reduce the development and spread of antibiotic-resistant diseases. (A copy of the document is available on the Web at www.acponline.org/ear/whatyou.htm.)

The document is part of the College's first-ever clinical theme, Emerging Antibiotic Resistance: Appropriate Use of Antibiotics and Immunization, and was developed in collaboration with the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality and the Infectious Diseases Society of America. Working together, we can address a tangible clinical problem facing patients and practitioners.

A growing problem

How big a problem is antibiotic resistance? In a recent year in the United States, 50% to 66% of the 51 million visits for colds, upper respiratory infections and bronchitis resulted in a prescription for antibiotics. Yet we all know that antibiotics are ineffective for infections of viral origin.

It is no accident that a female patient is involved in the above hypothetical scenario. A study in the July 18, 2000, issue of Annals of Internal Medicine found that young, white females are more likely than other segments of the population to receive an antibiotic prescription.

The overuse of antibiotics is a problem of our own making. Unless the situation is corrected, an even worse problem is on the horizon. The Annals study suggests that increasing rates of drug-resistant, invasive infections correlate directly with recent increases in antibiotic overuse.

The CDC estimates that 30% of streptococcus pneumoniae are now resistant to penicillin. This is particularly sobering because the organism causes most cases of bacterial pneumonia, meningitis and ear infections.

This trend has already moved from the office to the ICU. Disturbing CDC data show that 28% of hospital-acquired infections result from bacteria resistant to the preferred antibiotic.

While nearly all staphylococcus aureus infections are penicillin-resistant, many are now found to be methicillin-resistant as well. Previously, vancomycin had been uniformly effective against methicillin-resistant staphylococcus aureus. Since 1997, however, strains with decreased susceptibility to vancomycin have been reported in Japan and the United States.

This trend causes real problems for patients and the health care system. These antibiotic failures could turn back the clock 60 years and recreate a world in which some infections are untreatable. The U.S. Office of Technology Assessment estimates that at least $1.3 billion of the nation's annual health care costs are associated with this wave of drug-resistant, hospital-acquired bacterial infections.

As antibiotic use and costs have soared (to $15 billion per year in the United States alone), these miracle drugs of the 1940s are becoming the dismal failures of the new millennium. When our wonder weapons lose their luster, we will have no one to blame but ourselves.

How to help

There is hope, however. Studies in Annals and elsewhere suggest that decreasing antibiotic use can indeed reduce the prevalence of antibiotic-resistant bacterial infections. As the mainstream media give attention to this issue, our patients may become ready to approach routine bouts of illness in a new way.

What can you do? First, share the College's information about this issue with your patients. Second, resist the temptation to perpetuate the myth that a prescription for an antibiotic is the ultimate way to end the office visit. Third, tell patients about the problems of antibiotic-resistant strains and ask them to do their part to avoid unnecessary use of antibiotics. Fourth, don't be afraid to end an office visit by giving patients an "unprescription," or information about why they don't need an antibiotic.

If we internists do our job, the campaign can be successful. Our goal should be to change routine patient requests from, "Doctor, I need an antibiotic," to "Doctor, can we manage this without antibiotics?" When this happens, patients, the public and the health care system will be better for it.

—Sandra Adamson Fryhofer, FACP

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