Do the Right Thing – Hold the Inappropriate Antibiotics
Recently I saw an 18 month old girl on her second course of antibiotics for an “infection”, according to the mother. The child initially had symptoms of fever associated with nasal congestion and cough and sore throat. How she or the treating physician determined she had a sore throat will always be an enigma for me. OK I guess if she was drooling or grimacing when attempting to drink, I will give them that (not so, per mom).
The “astute” physician at the local clinic did a rapid strep test and back up culture and according to this well-educated mother, prescribed Amoxicillin for “strep negative” tonsillitis. She remained febrile and now had a rash 3 days later, so mom brought her back to this clinic and she was switched to Azithromycin for “now she was suspected to be allergic to the Amoxicillin”. Her fever persisted for another 3 days, the rash would come and go, and for the past 2 days her eyes were injected. When I saw her, she had now 7 days of fever, rash, conjunctival injection and I appreciated her hands and feet were edematous. It was quite clear to me; she was on her second course of antibiotics for Kawasaki’s Disease.
A colleague recently reported receiving a transfer of a quite moribund child with Stevens Johnson Syndrome who had been receiving antibiotics for “likely bronchiolitis”. “Hope she lives”, he wrote with a sullen tone. Lately, it is my perception, I am seeing more and more examples of inappropriate use of antibiotics for conditions such as a strep negative or “weakly positive” (not even certain what that means!?) swab, or antibiotics for cough or a sinus infection in a very young infant. How often I see babies on antibiotics for classic bronchiolitis or simply fever (per the family, the doctor gave me the prescription “in case the fever was from a bacterial infection”).
Yes, we are all under pressures to provide high quality care and this is not limited to the ED. Certainly, the stress of managing an ED treating lots of patients simultaneously, all who are patients “new to our practice” is high. Costs and co-pays are high, and there is always an undercurrent and potential fear of legal recourse. Yet we all should have known this when we voluntarily chose to practice emergency medicine.
Yet I would submit our true obligation to the patient (and parent) remains to not perform unneeded tests and certainly to not prescribe medications “because that is what they want”. What parents want is for us to allay their fears, be truthful when we know what may be wrong and more so when we don’t, and only really do a test when it will help aid in making or supporting a diagnosis.
There have been numerous publications in the last 15 years in both medical and lay literature on inappropriate use of antibiotics for upper respiratory infections in outpatients and our need to be judicious in our prescription practice. As I allude to here, it is not solely about antibiotics, but other prescriptions for unnecessary meds (e.g. oral steroids often prescribed for cough or localized hives) or excessive testing – chest xrays for simple coughs; strep tests CBCs for uncomplicated fevers; and don’t get me started on how often I see patients either having had or being requested to get CT Scans for unnecessary indications such as nonspecific headaches or abdominal, back or pelvic pain. And these are only a few examples.
We need to test and prescribe less and listen, reassure, and hence treat more. Simple as it may sound we need to get back, once again, to basics and remember when we stood and recited the Hippocratic Oath. Of which, my take home remains, “Do the Right Thing” for all our patients. It’s why I am here and hope all of us are too.