Antibiotic XI did a consultation today about a dog that illustrates some of the practical challenges to reducing antibiotic use. It was an older dog with a test result that could be consistent with an infectious disease, but one that is also common in healthy animals. The signs of illness that the dog had would have been pretty atypical for the infectious disease in question, but the signs and some other testing were also highly suggestive of a (bad and untreatable) non-infectious cause. The owners weren’t willing to pursue any more diagnostic testing.

So, this is a case where an infectious disease is unlikely but it can’t be completely excluded, and where there’s no chance of getting more info. At what point does antibiotic use go from a reasonable outside chance of being effective to inappropriate?

It’s pretty grey.

Another interesting example can be found in a great commentary in JAMA Internal Medicine (Kavanaugh, 2014). To make an interesting story short:

  • The writer is a physician who was attending a conference (ironically, about antibiotic resistance).
  • The day after, he woke up with a sore throat and fever, and was concerned about strep throat. At the same time, he didn’t want to take an antibiotic unnecessarily.
  • He went to a “doc-in-the-box” clinic and a group A strep test was negative.
  • However, the physician recommended antibiotics, despite the negative test. The patient-physician said he didn’t want antibiotics but the attending physician persisted. He then prescribed azithromycin, which is an unusual choice for strep throat.
  • The patient-physician says he knew he shouldn’t take an unnecessary antibiotic (especially an antibiotic that would be the wrong choice in the unlikely event this was strep throat). Yet, he also felt like he was in a dependent position as the patient, and gave in.
  • After leaving (and no longer being under the physician’s sway) he decided not to fill the prescription, something that was good in this case but not something that is recommended in general.
  • The sore throat resolved on its own in a few days, as expected.

He concluded: “Looking back, my own willingness to go along with “doctor’s orders,” or at least not argue with him when he wrote a prescription, gave me a glimmer of insight into how hard it is for patients to express concerns when in the presence of a figure of authority on whom they are dependent. In my home state of Kentucky, we have the highest rate of prescribing antibiotics to outpatients in the nation. Had I filled the prescription and taken the medicine, I may have contributed to the serious and growing problem of antibiotic resistance. All the conferences in the world will not put a dent in antibiotic overuse unless the medical profession owns the problem and changes its own habits. “

Interesting insight.