Medicine For People!

March 2014

Technology Marches On: Your Lab Costs Decrease

Technology Marches On:   Your Lab Costs Decrease

Fifty Years of Overuse

Like Toad who was mad for motorcars in the book "The Wind in the Willows," some doctors have that same irrational gleam in their eyes when it comes to antibiotics.   My first published article on a medical topic was a plea for moderation and sanity in antibiotic use -- as you can see from this article published in the Northwest Passage in 1973.

Heal Thyself

Amazingly, the problem persists.   I write again because just a few months ago the Journal of the American Medical Association reported that about 60 percent of the time that patients went to their healthcare provider with a sore throat, they received an antibiotic.[1]   The authors also pointed out that that just 10 percent of people who go to the doctor with a sore throat actually have a strep infection.   One out of ten, not six out of ten, needed an antibiotic.

Many Sore Throats – Very Little Strep

Here's what a strep throat looks like.[2]

Sore Throat

 

This is the only kind of sore throat that an antibiotic can help.   Trust me, 60 percent of people who come into a medical office with a sore throat do not look like this[3].   Even more amazingly, JAMA researchers noted that about one in six were given a prescription for the broad-spectrum antibiotic azithromycin rather than the first line strep drug, penicillin.   After some 70 years of exposure, the group A beta-hemolytic Streptococcus bacteria has proven itself nearly 100 percent susceptible to penicillin. Yet it only took approximately 20 years for one in six Streptococci to become resistant to azithromycin. In addition, azithromycin has much more important uses, uses endangered with every unnecessary prescription.   So, half the time you seek help for a painful throat you're going to get an antibiotic you don't need?   And some of the time for this wrong diagnosis you're going to get the wrong antibiotic?     Be still, my heart!

Bronchitis – Usually Goes Away on Its Own

Another common reason for an unnecessary antibiotic prescription is bronchitis.   There are a few occasions in which a person will benefit from antibiotic treatment for bronchitis, such as emphysema, an immune deficiency, or infections caused by Mycoplasma or Chlamydia.  However 98 percent of the time an individual is best treated in other ways. And yet, of the 3.4 million people who consulted a healthcare provider in 2010 for cough symptoms, a full three quarters were given a prescription for an antibiotic.   Authorities estimate the cost of all of these unnecessary prescriptions in the billions of dollars.   While the rate of noticeable and immediate side effects with antibiotics is low, certainly many hundreds of thousands of people among those 3.4 million who took antibiotics suffered from nausea, diarrhea, yeast infections and other adverse effects.   

These unnecessary prescriptions benefit only the providers who write them and the pharmaceutical industry.   They hasten the development of antibiotic resistant bacteria.    And over 20,000 Americans die each year from infections caused by those antibiotic resistant bacteria.

How Bacteria Become Resistant

As you learned from this newsletter in 2009, you and everyone else comprise an ecosystem of thousands of types of bacteria.   When you are given an antibiotic you do not need, some of your friendly bacteria die, to be replaced by bacteria resistant to that antibiotic.

Here's how often that happens.   British doctors reviewed research on antibiotic resistance after people were given antibiotics. In the first month after antibiotics were given, 3 to 10 percent of these individuals developed bacteria in their respiratory or urinary tracts that were resistant to the antibiotic. In many of these individuals, these resistant bacteria persisted at least a year[4].

Much is known about bacterial resistance to antibiotics.   Bacteria learned long ago to destroy penicillin using enzymes.   As well, bacteria can pump antibiotics out of themselves fast enough to avoid damage.[5]

Bacterium

 

This diagram[6] shows a bacterium doing just those things: both pumping and destroying- either one is sufficient.

And once a bacterium has developed this resistance, it not only can pass this genetic information on to its progeny, but it can also pass it on to neighboring bacteria.   It can even pass this ability on to bacteria of a different species than itself![7]

Bacterium Pumping and Destroying

 

This diagram[8] shows this process in action.   Parental discretion advised!

These are not theoretical problems.    When treating some infections, such as tuberculosis, the bacteria accomplish these defensive maneuvers so fast that, even if the bacteria were susceptible when we started treatment, by the time we're finished, they've become resistant.   This is why tuberculosis treatment now often requires two drugs at once.

Antibiotics in Our Food

Antibiotics used in agriculture can engender resistance in bacteria living in that domestic animal, and those bacteria, even though they pass through our intestine without causing direct harm, can transfer that resistance to our resident intestinal bacteria.[9]  

The result is, when someone falls ill with an infection of the colon, such as diverticulitis, we require more dangerous antibiotics than we used to.

Why Doctors Prescribe What You Don't Need

Researchers have looked at why providers prescribe unnecessary antibiotics.  

  • The symptom, most often a cough, has lasted a long time.[10]
  • The provider overestimates the patient's desire for a prescription.[11]   In fact, surveys show that people usually want three things when they consult a doctor for a sore throat, namely pain relief, a diagnosis, and knowledge of what they can expect over the next few days.[12]   Of thirteen concerns voiced in this survey, desire for an antibiotic ranked 11th.
  • When the insurance company will pay for a prescription, the provider is more likely to prescribe an antibiotic,[13] even when the patient does not need the antibiotic.
  • One group of researchers found that providers often misinterpreted symptoms and physical examination findings, mistaking a viral infection for a bacterial infection.[14]
  • About a quarter of physicians do not think that antibiotic use increases the risk of future infections with resistant organisms (it does) or that excessive antibiotic use increases the prevalence of resistant infections in their community (it does).[15]

Your Needless-Antibiotics Danger Zone

Patients with these common conditions frequently walk out of a medical clinic with an unnecessary antibiotic prescription.

  • Acute purulent rhinitis:   a nasal infection with green, brown or yellow discharge.   Analysis[16] of several studies showed that of ten people treated with antibiotics, one will benefit. As many as one in twenty had an adverse consequence severe enough to consult a physician.
  • Acute bronchitis: most coughs are due to bronchitis, discussed above. Viral bronchitis results in a cough that lasts from two to four weeks, with an average of 2½ weeks.   Coughs producing sputum average a couple of weeks in duration.[17]  Antibiotics, no matter how broad-spectrum, do not change this.  
  • Sinus infection: even with colored nasal discharge and an abnormal sinus X-ray, numerous studies have proven beyond any doubt that people do not recover more quickly with antibiotics.[18]   
  • Upper respiratory infection: sinusitis, nasal drainage, sore throat, with or without green, brown, or yellow sputum, does not respond to any antibiotic.[19]   Sore throat all by itself is a different story; about ten percent of these do require an antibiotic.
  • Acute otitis media:   middle ear infection.    The British reported in the early 1980s that most children recovered as quickly with a placebo as they did with an antibiotic.   Numerous subsequent studies have confirmed this.   As of 2004, researchers estimated that about half the children with this diagnosis were still being given antibiotics.   More disturbing was that about half the time, the children were not given the first-line drug.[20]     And most disturbing was that the US had the highest rate of antibiotic misuse when compared with the rest of the world.[21]

Old Habits Need the Wooden Stake

A final serious problem with the unnecessary antibiotic prescription is that it takes the doctor's mind away from remedies that might actually help.   There are too many specific situations and remedies to cover in this newsletter.

Believe me, medical authorities are working hard to correct over-prescribing, and are learning one thing: old habits tend to persist.  

When patients do express a strong wish for antibiotics that do not seem necessary, doctors who take the time find that a briefing on antibiotic overuse, accompanied (only when necessary) with a prescription for the patient to use if needed after hours or on weekends, often helps the patient avoid using antibiotics for that particular episode.[22]

The media bring us constant news of breakthroughs that turn out to be merely hype.   I've nothing against breakthrough, but what we really need is better execution of what we do know today.

What You Can Do

1.   If you do not have a temperature above 100 degrees, you are very unlikely to have an acute bacterial infection.   You may need treatment for some other problem, but that treatment will rarely require an antibiotic.   If you feel dangerously ill, forget your temperature; see your doctor.

2. Do not suggest to the doctor that you think you might need an antibiotic.   Many will take this as a request.

3. Quiz your doctor as to the diagnosis.   Tell them you only want antibiotics for a bacterial infection.  

4. If you do take antibiotics, take a probiotic to replace beneficial bacterial killed by the drug.  

5.  Choose meat labeled antibiotic-free.  This reduces the influx of resistant bacteria into your intestinal tract.  

Technology Marches On:   Lower Lab Costs at the Rienstra Clinic

In medical school, I worked in clinical laboratories in my off hours to pay the bills.   In those years the large bulk-processing laboratory analyzers did not run at night, so measuring blood sugar (just one of the tests we might do) involved a test tube with a bulb on the bottom, several additions of chemical reagents, a timer and a Bunsen burner.   Had technology not advanced in the intervening decades, you'd be paying a month's rent just to get a minimal blood panel.

Fortunately, lab technology today provides more accurate values at ever decreasing cost.   Labcorp has again significantly streamlined their technology.   Here is an example of the kinds of savings you can now expect.   Whereas in the past someone with long-standing fatigue needing, for diagnosis, a standard panel, a vitamin D level, a c-reactive protein, and tests for diabetes, B-12 deficiency and gluten sensitivity would have paid $720, they can now obtain the same tests for $315.  

Endnotes

[1] JAMA Nov 27, 2013 page 2135

[2] http://sphweb.bumc.bu.edu/otlt/mph-modules/eh/eh_immunity_b/eh_immunity_b_print.html

[3] http://sphweb.bumc.bu.edu/otlt/mph-modules/eh/eh_immunity_b/eh_immunity_b_print.html

[4] BMJ 2010;340:c2096       Antibiotic overuse

[5] Image at http://textbookofbacteriology.net/themicrobialworld/bactresanti.html

[6] http://textbookofbacteriology.net/themicrobialworld/bactresanti.html

[7] Image at http://textbookofbacteriology.net/themicrobialworld/bactresanti.html

[8] http://textbookofbacteriology.net/themicrobialworld/bactresanti.html

[10] J Gen Intern Med 23(10):1615–20

[11] Murphy et al. BMC Family Practice 2012, 13:43

http://www.biomedcentral.com/1471-2296/13/43

[12] Ann Fam Med 2006;4:484-485.

[13] Arch Intern Med. 2010 August 9; 170(15): 1308–1314.

[14] BMC Family Practice 2005, 6:6

[15] Can Fam Physician 2001;47:521-527.

[16] BMJ, doi:10.1136/bmj.38891.681215.AE (published 21 July 2006)

[17] Ann Fam Med 2013;11:5-13.

[18] Ann Fam Med 2006;4:484-485.

[19] J Gen Intern Med 1999   14:151

[20] Arch Intern Med. 2012 October 22; 172(19): 1465–1471.

[21] BMC Health Services Research 2006, 6:75

http://www.biomedcentral.com/1472-6963/6/75

[22] British Journal of General Practice 2010; 60: 907–912.

 

 

story: 

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.