Waiting for Superbugs: Patient expectations drive dangerous overprescription of antibiotics

The 1928 discovery of penicillin, the first general antibiotic, was a medical breakthrough credited with saving untold numbers of lives. But your doctor is unlikely to prescribe penicillin today because it is often ineffectual against modern bacteria, which have evolved immunity against it through natural selection. Drug resistance has become a major public health problem in recent years because of consistent over-use of antibiotics. A recent study at the Geisinger Health System in Pennsylvania found that patient expectations are a driving factor in this overuse: sick patients typically expect to be prescribed antibiotics even when they are ineffectual.

As a 2013 Centers for Disease Control and Prevention (CDC) report notes, “Antibiotics are a limited resource. The more that antibiotics are used today, the less likely they will still be effective in the future.”

The problem is several-fold: doctors overprescribe antibiotics, patients take them incorrectly, and antibiotics are routinely fed to livestock animals to help them grow faster, among other reasons. Every time an antibiotic is applied to bacteria, it kills those susceptible to it and encourages the growth of those that have mutated to survive it.

The rapid growth of “superbug” bacteria resistant to antibiotics—such as the nearly untreatable MRSA, which now kills over 11,000 in the US each year—have prompted several pharmaceutical companies to restrict the use of their antibiotics in livestock farms. In addition, the Food and Drug Administration is widely expected to recommend against the common inclusion of triclosan, an antibiotic, in consumer soaps and other products.

Given the large body of research on why antibiotic resistance occurs, it’s difficult to understand why behavior is so difficult to change. The study by Sara Ackerman et al. in BMC Health Services Research investigates one specific problem: the routine prescription of antibiotics for patients with bronchitis. According to the authors, most bronchitis is caused by viruses—not bacteria—so antibiotics have no effect other than to increase bacterial resistance. Yet fully 90 percent of patients with bronchitis are incorrectly prescribed antibiotics.

The study enrolled fifty-five doctors at primary care practices in Pennsylvania, who varied by how often they prescribe antibiotics for bronchitis, and divided them into test and control groups. The researchers provided physicians in the test group with diagnostic aids, including a large and colorful poster visible to patients, clearly stating the (rare) conditions under which antibiotics might be appropriate for patients with respiratory infections (some practices used electronic diagnosis tools, and their doctors were provided with electronic aids instead). Patients were also provided with brochures about antibiotic use. The researchers then collected data on how frequently all the doctors (test and control) prescribed antibiotics for bronchitis, and finally administered a survey to the doctors on why they believe overprescription occurs.

The most interesting finding is that two-thirds of doctors in the test group did not reduce antibiotic prescriptions for bronchitis, even though they were aware of the study’s purpose and of the medical guidelines. The doctors cited patient expectations as the primary reason for this: 79 percent agreed with the statement, “My patients really want and expect antibiotics when they come in,” and 38 percent even said that “It’s easier to just give the patient antibiotics than to explain that they don’t work.” Doctors feel that, when patients clearly have a respiratory infection, they can be reluctant to leave the doctor’s office without a prescription in hand.

The physicians gave other reasons for overprescribing, like medical liability concerns, but none were nearly as universal as patient expectations. Furthermore, every single physician surveyed acknowledged that his or her individual decision to prescribe antibiotics contributed to antibiotic resistance. The posters and brochures, however, were universally seen as ineffectual in changing patient expectations. Doctors were divided on whether the poster helped them avoid overprescribing; some found it useful both in making their diagnoses and in explaining to patients why antibiotics were inappropriate, but others found it an intrusion on their authority.

Decades of attempts to reduce overprescriptions have plateaued, and antibiotic resistance has reached the level of a “serious health threat” that directly kills at least 23,000 Americans each year, amounting to $20 billion in healthcare costs alone (CDC). If one barrier is patient expectations, as this study suggests, then we may be in need of strong policy solutions like public education campaigns. Otherwise we may soon revisit the age before penicillin was discovered, when a routine bacterial infection was often fatal.

Feature Photo: cc/(Shenin Liu)