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.

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.

Lastly, the final upper respiratory scourge, acute sinusitis. The prevalence of bacterial infection during acute sinusitis is estimated to be only 2 percent to 10 percent, yet more than 80 percent of the 4 million annual outpatients who visit for acute sinusitis receive antibiotics.⁸ Sinusitis is, understandably, frustrating for patients and clinicians, with persistent symptoms lasting several weeks in many cases. However, antibiotics simply don’t provide much value. In clinical trials, only half of patients improved within the first week, and nearly 30 percent continued to have symptoms past 14 days.⁹ However, allocation to the antibiotic group did not increase overall cure versus placebo, and antibiotics decreased the duration of symptoms for only one in 20 patients. Considering there are no reliable clinical signs specific for bacterial versus viral etiologies, and it is challenging to select patients for whom intervention will substantially increase the chance of cure, antibiotics are best used judiciously for only the most exceptional cases.

Further compounding all these sins, physicians are persistently using a nuclear antibiotic arsenal for these extraordinarily straightforward conditions, which is akin to smashing a teacup with a sledgehammer. For each of these conditions, in the vanishingly small subset where antibiotics are indicated, narrow-spectrum antibiotics are absolutely sufficient. The first-line antibiotic for each of these conditions is penicillin or an equivalent beta-lactam antibiotic, yet these classes represent fewer than 20 percent of antibiotic prescriptions for sinusitis. Group A Streptococcus is universally susceptible to penicillin, but despite this, penicillin’s use in acute pharyngitis continues to drop. Extended-spectrum macrolides, such as azithromycin, and fluoroquinolones are experiencing corresponding increases as penicillin falls out of favor. Azithromycin, in particular, has such a long half-life that its unfettered use is responsible for a rapid rise in macrolide-resistant Streptococcus pneumoniae.¹⁰ It is estimated that more than $250 million in direct and indirect costs in the United States alone are associated with clinical treatment failures secondary to macrolide-resistant pneumococcus.¹¹ Fluoroquinolones, on the other hand, are bactericidal antibiotics with a broad spectrum of activity. The resulting effect on the natural symbiotic flora of the human body predisposes patients to such overgrowth of pathogens such as Clostridium difficile along with other adverse effects such as tendinopathies and delirium in the elderly. Antibiotic spectrums of activity are part of the basic preclinical medical school curriculum; sadly, many, if not most, clinicians have forgotten this portion of their education.

If you’re routinely prescribing for these conditions, please stop. If you supervise residents, nurse practitioners, or physician assistants, ensure they stop as well. Institute a quality-improvement program at your facility to track and provide feedback on antibiotic prescribing rates. Create educational materials targeted at patients to reduce the expectation of antibiotics.

The status quo is unacceptable and, frankly, embarrassing.

Dr. Radecki is assistant professor of emergency medicine at The University of Texas Medical School at Houston. He blogs at Emergency Medicine Literature of Note (emlitofnote.com) and can be found on Twitter @emlitofnote.

References

1. National Committee for Quality Assurance. Avoidance of antibiotic treatment in adults with acute bronchitis: percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Agency for Healthcare Research and Quality Web site. Available at: http://www.qualitymeasures.ahrq.gov/content.aspx?id=47167. Accessed August 11, 2014.
2. Smith SM, Fahey T, Smucny J, et al. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;3:CD000245.
3. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014;311:2020-2.
4. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Emer Med. 2001;134:509-17.
5. Petersen I, Johnson AM, Islam A, et al. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335:982.
6. Olivier C. Rheumatic fever—is it still a problem? J Antimicrob Chemother. 2000;45:13-21.
7. Newman DH. Antibiotics for strep do more harm than good. Emergency Physicians Monthly Web site. Available at: http://www.epmonthly.com/columns/ in-my-opinion/antibiotics-for-strep-do-more-harm-than-good. Accessed August 11, 2014.
8. Fairlie T, Shapiro DJ, Hersh AL, et al. National trends in visit rates and antibiotic prescribing for adults with acute sinusitis. Arch Intern Med. 2012;172:1513-4.
9. Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;10:CD006089.
10. Dias R, Caniça M. Emergence of invasive erythromycin-resistant Streptococcus pneumoniae strains in Portugal: contribution and phylogenetic relatedness of serotype 14. J Antimicrob Chemother. 2004;54:1035-1039.
11. Reynolds CA, Finkelstein JA, Ray GT, et al. Attributable healthcare utilization and cost of pneumonia due to drug-resistant streptococcus pneumonia: a cost analysis. Antimicrob Resist Infect Control. 2014;3:16.