Preventing antibiotic resistance
The problem of evolving antibiotic resistance can be addressed from three different angles: (1) avoiding antibiotics altogether when they are not clearly indicated; (2) using the right antibiotic; and (3) using the antibiotic for an appropriate length of time.
When are antibiotics not indicated? As noted earlier, the etiology of most cases of bronchitis is viral. Numerous studies over the past 30 years have shown that these infections are for the most part self-limited and improve over time or with a bronchodilator. Bronchodilators are underused and should be prescribed for any patient with bronchitis (not just those with known asthma).
Patients with asthma do not need an antibiotic. These patients need oral or inhaled steroids and bronchodilation. Patients with a short-lived cold need a decongestant, lozenge, or analgesic and not an antibiotic (the color of their nasal discharge notwithstanding).
Despite all these caveats, it is important to remember that for the individual patient, the infection is not just a cold or viral illness. Recognize that the infection must have interfered enough with work, sleep, or leisure to drive the patient to your office or ED.
Writing instructions on a prescription pad seems to validate many patients’ concerns and serves to fulfill the unspoken wish for a prescription. For example, write out a detailed “viral” prescription of rest, fluids, OTC analgesics, and albuterol. At the same time, write out a backup plan informing patients that if their condition does not improve by a specific date, they should call the office and you will prescribe an antibiotic. Even if the prescription is never filled, patients will leave the office happier and more satisfied.
Backup prescriptions intended to be filled only under certain conditions (e.g., the patient is no better after 48 hours, temperature goes over 100°F, etc.) demonstrate that the clinician cares and seem to reassure patients, especially those who are anxious about work or travel. One study showed that more than half of such backup prescriptions were never filled,15 while another suggested that they could significantly reduce the rate of inappropriate antibiotic use.16
What antibiotics are best avoided and when? Azithromycin is popular because it is easy to prescribe and use, but its prolonged half-life, which results in slowly falling serum levels over many days, is the perfect setup for the emergence of resistant strains. Doxycycline and TMP/SMX may be much better choices for acute bronchitis. Amoxicillin is far preferable for ear infections or sinusitis. For streptococcal pharyngitis, penicillin and cephalexin are still the drugs of choice.
How long should common RTIs be treated? Shorter courses of antibiotics are becoming increasingly popular and have not been associated with higher failure rates. These treatments are less expensive, equally effective, and associated with a lower resistance rate than traditional longer courses of treatment.17,18 There are exceptions, however. Streptococcal pharyngitis should be treated for a full 10 days,19 and sinus infections may require several weeks to clear. On the other hand, a five-day course for a middle-ear infection is acceptable and has the advantage of increased patient compliance.