By Sarath Malepati, MD – Medical Director, PPC Group
With the 2015 cold and flu season approaching, I wanted to discuss a subject that, in some ways, has become my professional mission; the appropriate use of antibiotics.
When I was a medical student in the early 2000’s, nosocomial methicillin-resistant Staph. aureus (MRSA) was a novel thing to hear about and see on the wards. You would every once in awhile see staff donning gloves and ‘gowning up’ in yellow gowns to go into a room where a patient had MRSA.
By the time I graduated, it seemed like there were yellow gowns everywhere, with whole MRSA-only units designed to reduce the inadvertent spread to other patient wards. The concept that MRSA was going to become a community-acquired infection existed then, but wasn’t the reality it is today.
Similarly, infections like C. diff colitis were small paragraphs in textbooks. The end spectrum of C. diff, toxic megacolon, was a rare presentation that could be cured by total colectomy. As time went on into my residency training and practice, managing infections like MRSA and C. diff became increasingly dominant features. In the case of C. diff, as the incidence increased, so did the aggressiveness of the infections. Over time, more patients needed stronger antibiotics and more patients ultimately required surgical intervention. As the number of septic toxic megacolon cases grew, the number of deaths increased as well.
My experience was consistent with the 2015 CDC data, which showed that the number of deaths from C. diff doubled from 14,000 to over 29,000 between 2007 and 20111. We now have over 2 million drug resistant infections in the US annually2 and it is now estimated that at our current rate, global death from drug resistant infections will surpass that from cancer by 20503.
Unquestionably, inappropriate antibiotic use across many layers of our healthcare system is a primary contributor to this complex emerging global problem. As clinicians, we must work together to support and educate each other as well as our patients to do the right thing as well as do no harm.
In the primary and ambulatory care settings, upper respiratory infections (URIs) broadly are among the most common diagnoses for which a patient receives an antibiotic. It is also among the biggest areas of inappropriate antibiotic use. URIs are the most common disease in humans, with 80% of these illnesses being viral and not amenable to antibiotic treatment4. Yet depending on the study, anywhere from 46-86% of URIs that receive antibiotics do not meet clinical criteria to warrant one5,6.
In a WebMD study last year, 95% of prescribers surveyed admitted to writing antibiotics when unclear of their necessity at least some of the time7. The number one cited reason was, as you may have guessed, patient expectation.
So what do we do?
1)     Don’t be pressured by patients to do the wrong thing. We have lost the art of conversation within the continued erosion of the art of medicine. Ultimately, more than the treatments you prescribe or recommend, patients want to know and feel that their provider understands that their concerns are valid and that they’ve been acknowledged. This is half the battle in channeling patient’s expectations for what they want into what they need.
2)     If it’s not antibiotics, what does the data support? Review the literature and consider your own clinical experiences within the context of those of your colleagues and peers. Determine in your own professional opinion what treatments work and what do not.
3)     Accessorize. Patient educational materials are often overlooked tools in clinical practice. You may know all of the answers. But your patients don’t. Arming them with knowledge that they can physically hold and walk out of your office with reinforces your counseling and education.
My own professional mission is to help improve the knowledge transfer between clinicians and patients around the appropriate use of antibiotics. In the global village we now live in, we must all work together towards expanding awareness that when it comes to infectious diseases, responsible decision making with our own personal health is critical to our collective public health as well. As health care providers, patients want to leave our presence knowing that we care about them and that we are playing our professional role in supporting their health.
About the Author: Sarath Malepati, MD is the Founder and Medical Director of the PPC Group, a California-based health product design team focused on improving knowledge transfer between clinicians and patients through the design of simple solutions for common health care problems. 


References 
1. N Engl J Med. 2015 Feb 26;372(9):825-34. doi: 10.1056/NEJMoa1408913.
2.  http://www.cdc.gov/drugresistance/
3.  http://amr-review.org/

4 – National Health Interview Survey, 1996. Vital Health Statistics, 10, 200, 1-203
5 – Fam Pract. 2015 Aug;32(4):401-7. doi: 10.1093/fampra/cmv019. Epub 2015 Apr 24.
6 – Ann Intern Med. 2015 Jul 21;163(2):73-80. doi: 10.7326/M14-1933.
7 – http://www.medscape.com/viewarticle/827502


*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.