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The Antibiotic Stewardship Experiment

The antibiotic stewardship battle is no different from the surgery battle, the work-note battle, or the opioid battle. Most clinicians face these and some have a better system for it while others drown in it. Yet others have almost completely given into it.

While moonlighting in residency I came across a lot of patients wanting antibiotics for their cold and flu symptoms. I came from a residency program that had a nearly religious dogma when it came to antibiotics prescribing. I was so convinced by this attitude that I never hesitated to say no during residency and when moonlighting.

When I started practicing in the community at my first job at Kaiser Permanente, I saw a huge spectrum of prescribing styles. I gravitate more towards those clinicians who rationed antibiotics because they also seemed to practice better medicine overall as well.

After a few years, sometime in 2011, I realized how time-consuming and emotionally exhausting it was to have the same discussion and argument with damn near every patient. It became a grind and has remained a grind up until a few months ago.

Antibiotic Stewardship

One part of the discussion is avoiding antibiotics for seemingly viral symptoms. As physicians we have a hard time admitting that we actually have no idea what it is we are dealing with when we see it.

A sudden seasonal allergy attack can present with low-grade fevers, headaches, and green nasal snot. So can adenovirus, parainfluenza virus, rhinovirus, H1N1, and Streptococcus Pneumoniae.

1st Layer of Stewardship

The first layer of antibiotic stewardship is to not prescribe antibiotics for viral-appearing infections and instead look for the hallmarks of a bacterial infection and treat those.

The medical community and society as a whole will have your back when it comes to this first layer.

The only downside is that you’ll spend a much longer time in the exam room or on the phone with patients to convince them of your viral assessment. Even your patients satisfaction scores could be hurt by this.

2nd Layer

The second layer is to choose a narrow spectrum antibiotic instead of medications such as ciprofloxacin, azithromycin, or Augmentin.

The medical community will have your back here. Plenty of data showing that azithromycin is a much more problematic choice than amoxicillin for Acute Sinusitis.

3rd Layer

The third layer is to ignore the vague recommendations by various medical societies and even in light of possible bacterial infections consider managing the patient conservatively.

Seriously, who the shit believes that the 10-day mark is the signs of a bacterial infection? I’d be embarrassed to publish that if I was a physician at the IDSA (pdf).

The key concept that’s missed by many even seemingly intelligent attendings is that it doesn’t matter even if you are treating a real bacterial infection, the side effects of biome genocide and antibiotic resistance still apply.

Treating sinus infections, even bacterial ones, with antibiotics, treating ear infections in peds with antibiotics, pneumonias in peds, simple skin and soft tissue infections, and simple strep throat is ass-backwards. With all the data that we have it makes very little sense to treat uncomplicated bacterial infections in low-risk patients.

What does make sense is monitoring the patient, see how they do, watch for them getting worse, taking cultures, following serum markers if needed, and adjusting their lifestyles and diets to aid in resolution of the infection.

Side effects of antibiotics:

  • increased risk of cancer
  • increased risk of sepsis in peds
  • increased risk of hypertension
  • risk of diabetes
  • future need for antibiotics
  • yeast infections
  • C. Difficile colitis
  • IBD/IBS
  • chronic diarrhea
  • lupus

In this 3rd layer you will be completely on your own. Not the medical community nor our society will stand behind you. Even though this is absolutely necessary for the long-term health of patients, it doesn’t matter how many unproven benefits you provide – it’s that one septic or cerebral abscess patient from inadequately treated Acute Sinusitis who will drag you through the medical-legal system.

Worth The Battle?

Of course no clinician knows for certain if a patient has a bacterial or viral infection though there are a few clinically significant signs for either presentation.

Over the years, I have had a few cases where I was certain it was viral and I was painfully proven wrong.

I am sure I treated viral infections with antibiotics with no obvious resolution of symptoms. Though the drug manufacturers design their medication and market them with enough anti-inflammatory properties to make the patient feel better after starting them.

The potent anti-inflammatory effects of certain tetracyclines and macrolides have been demonstrated in multiple studies. They have been used to treat low-grade malignancies, arthritis, colitis, cysts, and pain.

My General Spiel

My spiel always starts the same, build a rapport with the patient and then discuss their symptoms. I give them my impression and come up with things they can try in order to help them get over their miserable symptoms. I talk to them about all the various side effects and risks of taking antibiotics and discuss what makes an infection viral and what makes it bacterial.

I have halfway decent patient satisfaction scores and though I stand my ground when it comes to overtreating patients, I believe that I come across nice about it – stern, sometimes, but caring and attentive and only rarely dismissive.

There is no navigating around patients who are absolutely convinced that I am the worst doctor in the world because I refuse to give them the antibiotics they believe they desperately need. These are rare, fortunately, but incredibly tiring.

The Experiment

A couple of months ago I decided to try an experiment. I build the rapport, I review the patient’s symptoms with them, I give them my impression with a brief explanation of why I believe it is viral, allergies, or bacterial. Then I discuss what things they can do based on what they have tried already.

If they insist on antibiotics then I review the general side effects of antibiotics and quickly acquiesce.

Project Just Give In.™ has been going on for nearly 6 months and I’m happy to report that my job satisfaction and unnecessary energy expenditure are both much improved.

Experiment Results

The final outcome of my experiment is that my patients are happier because they don’t feel that they no longer have to battle me for antibiotics.

With my documentation and the current practice standards, I feel protected from any poor outcomes or investigations by the medical board.

Earning More Money

I spend less time with the patient = I can see more patients = I earn more money.

At my old Kaiser job I wasn’t paid for productivity. The average throughput in the Urgent Care has been 1.7 pph while mine was 3.3. For me this meant more risk and less income per patient.

With telemedicine and being per diem, I get remunerated for my competency instead of being punished.

Job Satisfaction

I don’t recall medicine having felt this easy in a long, long time. Just thinking of the many instances patients requested antibiotics and the tiresome back-and-forths we’d have makes me feel irritable and exhausted.

I ran my experiment results by peers, thinking I would get a verbal flogging. In fact, my peers who practice Urgent Care agree with this method:

  1. inform the patient of what they have
  2. make your recommendations to the patient
  3. discuss the risks of their antibiotic request
  4. give up, give in, and give the Rx

Should Doctors Be The Stewards Of Antibiotics?

On the surface, it appears that doctors should be the ones who should scientifically ration out medical resources, specifically antibiotics. Obviously, the main reason being to avoid long-term side effects in patients and prevent antibiotic resistance.

If that’s all a busy physician would have to deal with and could make the call without having to deal with patient, parent, or supervisor protests, then it would be the right system to follow.

If no major grievance could be filed for any missed antibiotic prescribing then it certainly should be the clinician’s job to take on the antibiotic stewardship.

The only complaints I have ever heard were from patients who were upset that I didn’t give them antibiotics and that they had to return multiple times to the Urgent Care to eventually get the antibiotic from someone else.

A Terrible Outcome

I got complaints and an investigation into why I didn’t give a healthy woman Tamiflu for her cold/flu symptoms which ended her up in the ICU with respiratory failure. I recall the case quite well and I stood my ground and she didn’t see the point in arguing with me but it took some convincing – after all, she was healthy and the risk of respiratory failure was incredibly low.

I am not justifying my practice in that case. But reflecting back on it I wonder how many Tamifus I would have to give out to prevent that one episode of respiratory failure.

The Patient’s Well Being

Are we practicing in the patient’s best interest? If that was the case then we wouldn’t do gastric bypass surgeries because their overall outcomes are abysmal.

We would also stop giving out statin drugs as much as we are because they are as ineffective as many of the stents which are placed in patient hearts.

After a decade of practicing medicine I am ready to admit that I am in a customer service role. I have been practicing retail medicine and those patients who truly are concerned about their wellbeing avoid MD/DO’s all together as do I for my personal health. They seek out Naturopaths, Herbalists, or wise old minds who can tell what to do without causing harm.

Causing harm is what I do because that’s what pays the most. I may not be causing the kind of harm that you can see but I’m causing molecular harm  – should I disregard that because society as a whole is too unschooled in recognizing molecular harm?

You’ll have to answer that question for yourself. Perhaps I’ll change my answer many times over my lifetime. For now, I’ve tasted what practicing medicine can be like – absolute heaven.

Enjoying The Wins

There are occasional wins in antibiotic stewardship and those are absolutely delightful.

Yesterday I spoke to 2 different individuals doing telemedicine, the first a middle-aged woman and the second a man in his 30’s. Both with influenza symptoms and both appeared to genuinely care about my medical opinion regarding their need for Tamiflu. In both cases I didn’t see the need, they thanked me for my opinion, we discussed conservative options and some return precautions – I loved it.

Getting Over My Antibiotic Ego

I had this conversation with my mom a few months ago and it takes your mom to set you straight sometimes.

I recognize my overbearing ego when it comes to medicine, particularly in dispensing antibiotics. That’s the whole reason I needed to write this post. It’s something I try to work on because unless you’re a scientist not much good comes from mixing ego in with patient care.

Moving forward I have decided to continue practicing the results of this experiment by prescribing antibiotics to patients who insist on it and avoid resisting. 

This will make the patients happier, it will decrease the amount of ego that I inject into the patient visit, it will increase my hourly wage, and it will make my work so much easier and far more pleasant.

Measuring Antibiotic Stewardship

We’ve all seen how closely some clinical metrics are followed and have received feedback as to how we compare to others whether it’s our antibiotic stewardship, MRI utilization, or internal referrals.

It was 2012 when I first started seeing real measurements of medication and imaging utilization.  It was a sizable wave that has persisted.

However, its consequences are as weak as predicted. No metrics or Medicare scoring will get in the way of pushing medications and imaging and procedures on patients. Preventing disease doesn’t make money – battling disease does.

Yes, you’ll get emails saying that you prescribe a little more amoxicillin compared to you colleagues who apparently do a better job with antibiotic stewardship. But as long as you aren’t giving it out for Bronchitis or Upper Respiratory Tract Infection, nobody really cares.

Since my experiment I have learned to ignore these metrics and over these past few months during my experiment I have realized that even though I receive these metrics, nobody actually cares; least of all the patients or the medical group who is able to retain and recruit happier patients because of higher customer satisfaction scores.

“10 days of worsening unilateral sinus pains with now developing fevers and worsening mucopurulent discharge” is all that you need to justify that amoxicillin. Who will argue against that? Who could argue against that?

You can feel good about yourself because you at least avoided the broad spectrum antibiotics and you gave the patient just a smidgen of a spiel about why you think they would be better off without the antibiotic despite their eventual choice to take it.

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