The following originally appeared on The Upshot (copyright 2014, The New York Times Company).
The best way to prevent transmission of Ebola in the United States is to identify and quarantine those with the disease as soon as possible. However, the first Ebola patient in this country was, unfortunately, released after going to an emergency room, even though he had symptoms indicative of the disease. He was sent home on antibiotics.
The antibiotics were, of course, of no use in treating Ebola. They’d be of no use for any viral infection, for that matter. Even if the patient had actually had a sinus infection, as his doctors initially believed, antibiotics probablywouldn’t have done much for that either.
Yet antibiotics are regularly prescribed in this manner. Cases like this highlight a real, but often ignored, danger from their overuse: a false sense of security.
As a pediatrician and a parent, I’ve seen many protocols and procedures that require the use of antibiotics for a number of illnesses that may not necessitate them. These plans are in place, ostensibly, to protect other children from getting sick. They rest on the idea that someone on antibiotics is no longer contagious.
This is, tragically, often not the case. If you’ve had a small child with pinkeye, you know that few diseases can get your toddler banned from preschool faster. Most of the time, he will not be able to return to school until he has been on antibiotic drops for 24 hours.
This assumes, of course, that the pinkeye is caused by bacteria. Often, it is not. Up to 20 percent of conjunctivitis can be caused by adenovirus alone. Pinkeye caused by a virus will be completely unaffected by any antibiotic drops; children will be infectious long after receiving them. Moreover, physicians are pretty much unable to distinguish between bacterial and viral conjunctivitis.
Even if we were, there’s little evidence than 24 hours of antibiotic drops do much of anything to render a child noncontagious. Most of the outcomes studied include things like “early microbiological remission,” which means eradicating the infection by Day 2 to 5 of therapy. However, some children still haven’t achieved this outcome even by Day 6 to 10. Drugs simply work differently in different people.
Strep throat isn’t much better. Resistance in group A streptococcus, the cause of strep throat, is negligible. Yet even with proper therapy, it can be very difficult to eradicate the pathogen from carriers. This has led to outbreaks among family members and closed communities even when people are properly treated.
Even in the best-case scenario, being “on an antibiotic” isn’t much protection for others. And often, antibiotics offer no protection at all.
Only about a quarter of children who have acute respiratory tract infections(including sinus, ear, throat and bronchial problems) have an illness caused by bacteria. But about twice that number are prescribed antibiotics for their symptoms. These extra drugs provide no useful benefit. Although they might make the patients feel better through a version of the placebo effect, they certainly don’t prevent transmission of nonbacterial pathogens from one person to another. So if they give people a false sense of reassurance that they are no longer contagious, leading them to relax their usual precautions, the antibiotics are most likely doing harm. (This is separate from the other kind of harm usually associated with antibiotic overuse: stimulating resistance in either the bacteria you’re trying to treat, or in other bacteria that happen to be present in the body.)
Every time a patient comes to the office with an upper respiratory infection, and we prescribe an antibiotic, we imply that we’ve taken care of the problem. We give patients an incorrect impression that the drug will make them better, and will begin to kill off the germs affecting them. We also give the impression that they will be less of a risk to their friends, family and close contacts. After all, they’re “on an antibiotic.”
Confronted with this information, physicians will often fall back on the excuse that their patients “demand” it. But too often, it’s physicians, not patients or parents, who are the problem.
A study published in 1999 in the journal Pediatrics examined expectations and outcomes regarding visits to the pediatrician for a child’s cold symptoms. The only significant predictor for an antibiotic prescription was if a physician thought a parent wanted one. They wrote one 62 percent of the time when they assumed a parent expected a prescription, but only 7 percent of the time when they thought parents didn’t. However, it turned out that the doctors often guessed wrong as to what parents actually desired.
Another study, published in 2003 in the Annals of Emergency Medicine, had similar findings. Doctors were more likely to prescribe an antibiotic fordiarrhea when they assumed that patients expected it, but they correctly guessed patients’ expectations only a third of the time. Physicians were also more likely to prescribe antibiotics for patients with bronchitis and other respiratory infections if they believed patients wanted them, but correctly identified those expectations only about a quarter of the time. In yet another study, physicians even prescribed antibiotics to 29 percent of patients whodidn’t want them.
It’s time that we stopped viewing the overuse of antibiotics as a victimless crime. According to reports, Thomas Eric Duncan showed up in the emergency room with a 103-degree fever, a headache and abdominal pain. He rated that pain an 8 on a scale of 1 to 10. After receiving tests, he was thought, perhaps, to have sinusitis, and was given an antibiotic. I cannot guess what was in the physicians’ heads that day, but I think it’s likely they thought the antibiotics would do little harm, and potentially some good.
We physicians may believe that antibiotic prescriptions are what patients want, but it may be time to recognize that they are sometimes more for us than for them. Moreover, the false sense of security they provide may do more harm than good.
