Snake oil or sound medicine - Letter to the Editor

Journal of Family Practice, Oct, 2002 by Charles G. Young

TO THE EDITOR:

I was a bit dismayed by the article by Arroll and colleagues (1) and the editorial by Little (2) in the April issue of the Journal of Family Practice promoting delayed prescriptions as a way of decreasing usage of antibiotics for viral upper respiratory infections. I certainly applaud any effort to reduce unnecessary use of antibiotics; but is this the right method?

When patients seek medical care they should reasonably lye able to expect that the physician will use his or her best judgment in prescribing the most appropriate care. To let the patient decide is just an abdication of responsibility by the physician. To say, "You don't need a prescription for an antibiotic, but here is your prescription for an antibiotic" sends a mixed message to the patient. I believe a mixed message is worse than no message. Each time an antibiotic is proscribed for a cold, either immediately or delayed, it will only reinforce that behavior and make it that much more difficult lot the next physician the patient sees to prescribe rationally.

Although prescribing appropriately can be difficult sometimes, it is now easier than before. Guidelines for appropriate treatment of respiratory infections were published in the Annals of Internal Medicine in March 2001. (3) Since the publication of these guidelines I have followed them as closely as possible. I have been surprised how few patients object to symptomatic treatment of their colds when I spend just a few extra moments explaining the rationale of my decision to not prescribe antibiotics. For patients very resistant to my views, they are often convinced if I explain that better guidelines are now available for prescribing antibiotics for respiratory infections than in the past, and I offer to provide the literature reference if they are interested.

Arroll and colleagues (1) reported that by giving delayed prescriptions for antibiotics to patients with common colds, antibiotic use was reduced from 89% to 48%. At the risk of appearing too simplistic, may I point out that if only those physicians had done their duty, antibiotic use would have been reduced to 0%.

Promoting the irrational use of antibiotics makes us no better than the snake oil salesmen of years ago. Actually, it makes us worse. Many of the snake oil salesmen believed their remedies worked, but we know better.

Charles G. Young, MD
McKinley Health Center
University, of Illinois at Urbana-Champaign
E-mail: cgyoung@mhc.uiuc.edu

REFERENCES

(1.) Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce the use of antibiotics for the common cold? A single blind controlled trial J Fam Pract 2002; 51:324-8.

(2.) Little P. Where next with antibiotics and respiratory tract infections? J Fam Pract 2002; 51:337-8.

(3.) Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use [or treatment elf acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med 2001; 134:479-86.

DRS LITTLE RESPOND:

Is delayed prescribing irrational and the stuff of snake charmers? Unlike with snake charmers' wares, a body of emerging evidence supports the judicious use of delayed prescribing. In some situations, delayed prescribing can be useful:

In response to patient pressure and expectation. If a physician believes antibiotics are of little benefit, then he or she should advise against using them, and discuss their disadvantages. However, if patients are adamant that they want antibiotics, then the delayed prescribing approach combined with a discussion of patients' concerns and expectations can be a useful way to avoid long, antagonistic, and counterproductive encounters with patients, and to convey the message that antibiotics may not be essential. Good evidence has suggested that if physicians use a delayed prescription, patients' beliefs in the importance of antibiotics and their subsequent reconsultation rate are the same or better than if nothing is prescribed, (1) and only a minority use their prescriptions. (2)

Where the evidence is not clear cut. For most respiratory tract infections--rhinosinusitis, bronchitis, sore throat, and otitis media (ie, the vast majority of RTIs)--the evidence is not simple: systematic reviews in the Cochrane library suggest a modest benefit from antibiotic use on average, and most patients' symptoms will settle quickly, but a proportion do benefit. Furthermore, we cannot easily identify patients with bacterial infections, infections that will not settle quickly, or the few patients who go on to develop complications. Should all patients be offered antibiotics or none? In face of this uncertainty, it is perfectly reasonable and safe to advise patients that their symptoms are extremely likely to settle during the next few days, that it is wise not to use antibiotics unless absolutely necessary, and only if severe symptoms persist then to use antibiotics. Such clear guidance to patients does not therefore need to give mixed messages and has been applied successfully in large cohorts3 (as in the Dutch guidelines for antibiotics in otitis media) and several recent trials. (2,4)