Modern medicine is stuffed full of egregious waste. Whether unnecessary imaging for lower back pain, scandalous improper use of cardiac stents, or the administrative and regulatory burden on clinicians, there is ample opportunity to improve. However, no part of care should cause us greater shame than our incurable addiction to antibiotic prescribing for benign, self-limited conditions. Astoundingly, four years of medical school and three years or more of specialty training have not yet proven sufficient to prevent clinicians from choosing wrongly in the most basic ambulatory complaints—bronchitis, pharyngitis, and sinusitis.
Explore This IssueACEP Now: Vol 33 – No 09 – September 2014
The treatment for acute bronchitis, for example, is very clearly laid out by the Agency for Healthcare Research and Quality and the National Quality Measures Clearinghouse in the Healthcare Effectiveness Data and Information Set.1 The correct treatment rate for adults ages 18 to 65 who have no comorbid respiratory condition is zero. We should never be prescribing antibiotics in this situation. This is not a surprising or novel recent medical innovation. Uncomplicated acute bronchitis has been established for 40 years as a self-limited condition for which antibiotics have conferred no benefit.2 However, clinicians in the United States—both ambulatory outpatient and emergency department—prescribe antibiotics between 65 percent and 80 percent of the time, a rate that has held steady over the last two decades.3 With literally a million visits to EDs for bronchitis each year, we are causing profound injury to society from the raw costs of antibiotics, adverse reactions to medication, and increased bacteria resistance; this is all completely avoidable.
Uncomplicated acute bronchitis has been established … as a self-limited condition for which antibiotics confer no benefit.
Acute pharyngitis, likewise, is grossly overtreated with antibiotics. The prevalence of pathogenic group A Streptococcus (GAS) in acute pharyngitis is approximately 10 percent, and other concerning pathogens—Fusobacterium and Neisseria, for example—represent a tiny additional fraction.4 There is a widely available rapid antigen test for GAS, and besides, GAS is an otherwise self-limited condition for which antibiotics confer minimal symptom relief. Might it be reasonable to expect prescribing rates would be low? It would. However, 60 percent of visits for uncomplicated acute pharyngitis result in antibiotic prescriptions. If this excessive rate is justified based on prevention of subsequent complications, the rate cannot be justified, as the concern is unfounded. It has been estimated that as many as 4,000 patients need to be treated with antibiotics for GAS infection to prevent a single case of peritonsillar abscess.5 Rheumatic fever, the scourge of previous generations, has been eliminated in the United States, with multiple hypotheses, including simple improved hygiene, changes in host factors, and decline in rheumatogenic strains, thought to be the cause.6 David Newman, MD, even makes a very reasonable case for cessation of treatment of GAS with antibiotics, estimating it requires more than 100,000 patients to be treated to prevent a single case of rheumatic fever.7 This rate of complications is far lower than the expected rate of anaphylactic and adverse reactions from antibiotic treatment; therefore, antibiotics for strep throat may do more harm than good. At minimum, however, testing and treatment should be guided by validated clinical criteria and use of rapid antigen testing, which should dramatically decrease the rate of prescribing in acute pharyngitis.