Room to improve on antibiotic prescribing

Primary care clinicians are often caught between a rock and hard place. Antibiotic prescribing offers a classic example. The rock – patients often want antibiotics for common infections, are happier with their PCP if she or he gives them antibiotics, and the visit length tends to be shorter when antibiotics are prescribed since less patient education is needed. The hard place – most of the common infections for which antibiotics are prescribed are viral; patients tend towards skepticism if their PCP won’t prescribe antibiotics, especially when “they’re the only thing that works for me;” and the visits take longer since the reasons not to prescribe antibiotics take time to explain.

Two recent studies highlight the ongoing squeeze between these unyielding forces. JAMA Internal Medicine recently published a “research letter” looking at the relationship between the time of the office visit and the rate of antibiotic prescribing for low-risk acute respiratory infections. For early morning visits, the rate of antibiotic prescribing was 26%. For late afternoon visits, the antibiotic prescription rate was 35%. The authors indicate this may be due to “decision fatigue” as the day wears on. Decision fatigue is a concept developed by some psychologists who had extra time on their hands and were looking around for something to do. They determined that judges are less likely to grant parole later in the day, since denying parole is easier than granting it. My take on the JAMA Internal Medicine paper’s findings is that while decision fatigue may well be an issue, other factors are at work. In late afternoon, the number of patients waiting in the waiting room is higher, clinicians are further behind schedule, the stack of messages needing to be addressed is taller, and the number of test results needing to be reviewed is peaking. In any case, for whatever reason or reasons, we PCPs are apparently not practicing a consistent standard of medicine throughout the course of the long office day. At least when it comes to antibiotics.

The other paper was just published in JAMA Pediatrics. It showed both a continuing high rate of antibiotic prescribing for pharyngitis in children (60% of all visits), but more alarmingly, it showed a steady increase in the prescribing of broad-spectrum antibiotics. Pharyngitis in kids is uncommonly bacterial. But when it is, the culprit is almost always Group A strep. Group A strep is almost always sensitive to penicillin or amoxicillin. So, if we are going to inappropriately prescribe antibiotics for kids with sore throats, let’s at least prescribe the appropriate inappropriate antibiotic.

The squeeze is on. I don’t mean to make light of how challenging it is to get through the long clinic day, treat each patient and family member with empathy and respect, avoid missing serious problems, and try to improve the health status of the people coming to our door. But hopefully we can continue to work on gradually reducing the inappropriate use of antibiotics.

Richard Fleming, MD

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